We conducted a cross-cultural survey using standardized questionnaires in online format (see below) via the specialized survey platform among psychotherapists from 12 European countries: Austria, Bulgaria, Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden, and Switzerland. The data collection in all the countries was parallelly conducted between June 2020 and June 2021, during the second and third waves of the COVID-19 pandemic. The online set of the study questionnaires was sent in each country to the professional psychotherapeutic associations of various therapeutic modalities, which have distributed it among their members.
Finally, 2915 psychotherapists from the 12 countries representing various psychotherapeutic modalities participated in this study. The eligibility criteria encompassed certification (or being in the process of certification) in a particular psychotherapeutic modality and psychotherapeutic practice for at least 1 year. The participants completed the online versions of the questionnaires, which were preceded by detailed sociodemographic and work-related questions, including items on how the COVID-19 pandemic impacted their practice and on potential psychological distress associated with the pandemic. In each country, participation was anonymous and voluntary, and the participants received no remuneration for participating in the survey. Informed consent was obtained from all participants of this study. The study protocol was accepted by the ethics committee of the Faculty of Psychology at the University of Warsaw in Poland. The sociodemographic and work-related variables and COVID-19-related distress among the psychotherapists from each country are presented in the Supplementary Tables. Finally, it is important to underline that this manuscript contains unique data, which has not been published in any other journal.
As can be seen in all the tables, age distributions were generally similar among all countries (M = 45.5 years, min. 21 years—max. 82 years). Regarding the participants’ sexes, female psychotherapists were overrepresented (83%) in all of the countries. A significant number of participants were also in some form of stable relationships (75%). In terms of education, most participants held psychology degrees. However, Finnish and Swedish participants were almost evenly divided between having a psychology degree or a different degree such as social work, counseling, or nursing. In all 12 countries, most psychotherapists worked with adult clients. Nonetheless, a significant number of Polish and Bulgarian psychotherapists also worked with children. Having a private workplace was almost universal for therapists in all countries. Most psychotherapists in all the countries had already undergone their own psychotherapy. Supervision was provided once a month to the participants in most of the countries. However, Austrian psychotherapists used supervision quarterly, and most Spanish therapists did not use it at all. The results regarding therapeutic modalities varied across countries. Cognitive-behavioral therapy seemed to be the more common therapeutic approach in Cyprus, Spain, Poland, and Romania. Next, psychodynamic therapy was the dominant modality in Bulgaria, Norway, and Sweden. Austria and Switzerland seemed to favor Gestalt therapy. Finally, integrative psychotherapy was the most common approach in the United Kingdom. On average, psychotherapists in Bulgaria, Cyprus, Finland, Poland, Romania, and Serbia had between 6 and 11 years of experience in the profession. On the other hand, psychotherapists who were working in Austria, Spain, Norway, Switzerland, Sweden, and the United Kingdom had between 12 and 18 years of experience. In eight of the included countries (Austria, Cyprus, Finland, Spain, Norway, Romania, Switzerland, and the United Kingdom), most psychotherapists reported having a psychology certification (80% or more). The numbers appeared lower in Bulgaria, Poland, Serbia, and Sweden, with only approximately 35–65% of psychotherapists obtaining a certificate. Psychotherapists worked anywhere between a couple of hours a week and more than 20 h a week. More specifically, the average weekly workload in Bulgaria, Cyprus, Romania, and Serbia was between 1 and 10 h. In Sweden and the United Kingdom, the average was between 10 and 20 h a week. Psychotherapists who worked for more than 20 h a week were from Finland, Norway, and Poland. Austrian, Spanish, and Swiss psychotherapists were evenly divided between the last two workload categories. Finally, a general trend in working partially online during the COVID-19 pandemic was observed, with this being the case for psychotherapists in 11 countries (Austria, Bulgaria, Cyprus, Finland, Spain, Norway, Poland, Romania, Serbia, Switzerland, and Sweden). At the time of data collection, UK therapists were still mostly providing their services online only.
To assess burnout, we used the Maslach Burnout Inventory-Human Service Survey (MBI-HS)6. All 12 language adaptations of the MBI-HS were bought from Mind Garden, the official distributor of the MBI-HS. The MBI-HS consists of 22 items and evaluates burnout and its three components: (1) Emotional Exhaustion (EE), nine items; (2) Personal Accomplishment (PA), eight items; and (3) Depersonalization (DP), five items. For each item, the respondent indicated the frequency of symptoms on a Likert-type scale from 0 (never) to 6 (every day). ). All the summed responses form an overall index, higher values of which indicate higher burnout. We decided to use the MBI-HS in our study for two reasons: First, it is the most popular and widely used burnout inventory focused especially on helping professions, which was the case in our research7,38. Second, the MBI-HS is the only tool available for the assessment of burnout with a wide spectrum of different language adaptations; as such, it is valuable in cross-cultural studies38.
To measure cultural values, the participants completed a revised version of the Portrait Values Questionnaire (PVQ-R) developed by Schwartz et al.24. The PVQ-R consists of 57 short, sex-matched, verbal portraits of different people, each depicting a goal that is important to some person. For each portrait, respondents highlight how similar the person is to themselves on a 6-point Likert-type scale defined as follows: 1—not like me at all, 2—not like me, 3—a little like me, 4—moderately like me, 5—like me, and 6—very much like me. The participants’ values are inferred from the values of the other people they described as similar to themselves. For example, a respondent who underlines that a person described as “Enjoying life’s pleasures is important to her” is similar to herself, and probably attributes importance to hedonistic values. The PVQ-R assesses 19 values that can be combined into higher-order values, which was the case in our study: self-transcendence (universalism-nature, universalism-concern, universalism-tolerance, benevolence-care, and benevolence-dependability), self-enhancement (achievement, power dominance, and power resources), openness to change (self-direction thought, self-direction action, stimulation, and hedonism), conservation (security-personal, security-societal, tradition, conformity-rules, and conformity-interpersonal). All the language versions of the PVQ-R were provided by the author of this tool, S. Schwartz.
COVID-19 related distress was assessed via short, but reliable operationalization of this variable based on some other studies published at the time, when we started our research39,40. Namely, we asked participants on a Likert 1–5 point scale how stressful they found the situation in their role as psychotherapists caused by the COVID-19 pandemic. The answers varied between 1 (“not at all)” to 5 (“very much”). We also examined the issue of changes in psychotherapy settings (i.e. online setting) imposed by the pandemic situation.
Data analysis
The data obtained had a two-level structure with persons (2915 units) nested within countries (12 units); thus, a cross-sectional multilevel model was adopted41. The explained variable was the burnout level among the psychotherapists, which was operationalized as the global burnout indicator. The explaining variables at Level 1 were the four higher-order values assessed by each person (see Measures section), centered on their means (centering on the group mean). The Level 2 variables were aggregates of the individual person’s scores on four higher-order values to form a country mean of each value, which was then centered on the mean for all countries at a given value (see, centering on the grand mean). The maximum likelihood (ML) estimation method was used. For random effects (the random intercept model), the covariance structure of the variance components (VC) was assumed.
Unconditional (i.e., intercept only) modeling was the first step of the analysis. It was also used to obtain the interclass correlation coefficient (ICC)42, which informs about the proportion of variance in the burnout level explained by a grouping variable, that is, a country in which a participant is a psychotherapist. ICC values as low as 0.01 were treated as non-trivial43. Next, sociodemographic and work-related characteristics and COVID-19-related distress were added to the model. Continuous variables were centered on the group mean (e.g., age, work experience, and pandemic-related stress), whereas categorical variables were transformed into two dummy-coded categories (sex: female = 0, male = 1; relationship status: single = 0, in a stable relationship = 1; weekly workload: 0 = less than 20 h, 1 = 20 h and more; supervision: 0 = quarterly or less, 1 = once a month or more). In subsequent steps, only the variables found to be significantly related to the explained variable were taken into account44. In the third step, the Level 1 personal values were added, followed by the introduction of the Level 2 aggregates of these values for each country in the fourth step. Finally, the cross-level interactions of all values were tested45,46. For significant cross-level interactions, simple slopes, regions of significance, and confidence bands were established using the computational tools developed by Preacher et al.47. Statistical analysis was performed using IBM SPSS Statistics version 2748. Only the final hypothesis-testing models are presented in the article.
For model comparison, deviance statistics, based on χ2 distribution with the degrees of freedom equal to the difference in the number of parameters estimated in nested models, and the Akaike Information Criterion were used41.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
