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Burnout among psychotherapists:
a cross‑cultural value survey
among 12 European countries
during the coronavirus disease
pandemic
Angelika Van Hoy1*, Marcin Rzeszutek1, Małgorzata Pięta1, Jose M. Mestre2,
Álvaro Rodríguez‑Mora2, Nick Midgley3, Joanna Omylinska‑Thurston4, Anna Dopierala5,
Fredrik Falkenström6, Jennie Ferlin7, Vera Gergov8, Milica Lazić9, Randi Ulberg10,
Jan Ivar Røssberg10, Camellia Hancheva11, Stanislava Stoyanova12, Stefanie J. Schmidt13,
Ioana Podina14, Nuno Ferreira15, Antonios Kagialis16, Henriette Löer‑Stastka17 &
Ewa Gruszczyńska18
The aim of this study was to examine cross‑cultural dierences, as operationalized by Schwartz’s
rened theory of basic values, in burnout levels among psychotherapists from 12 European countries
during the coronavirus disease (COVID‑19) pandemic. We focused on the multilevel approach to
investigate if individual‑ and country‑aggregated level values could explain dierences in burnout
intensity after controlling for sociodemographic, work‑related characteristics and COVID‑19‑
related distress among participants. 2915 psychotherapists from 12 countries (Austria, Bulgaria,
Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden, and Switzerland)
participated in this study. The participants completed the Maslach Burnout Inventory‑Human Service
Survey, the revised version of the Portrait Values Questionnaire, and a survey questionnaire on
sociodemographic, work‑related factors and the COVID‑19 related distress. In general, the lowest
mean level of burnout was noted for Romania, whereas the highest mean burnout intensity was
reported for Cyprus. Multilevel analysis revealed that burnout at the individual level was negatively
related to self‑transcendence and openness‑to‑change but positively related to self‑enhancement
and conservation values. However, no signicant eects on any values were observed at the country
OPEN
1Faculty of Psychology, University of Warsaw, Stawki 5/7, 00-183, Warsaw, Poland. 2University Institute of
Sustainability and Social Development (INDESS), Jerez de la Frontera, Universidad de Cádiz, Department of
Psychology, Puerto Real (Cádiz), Spain. 3Child Attachment and Psychological Therapies Research Unit (ChAPTRe),
Anna Freud Centre for Children and Families, 4-8 Rodney Street, London N1 9JH, UK. 4School of Health and
Society, University of Salford, Frederick Road Campus, Broad Street, Salford M6 6PU, UK. 5School of Psychology,
University of Lincoln, Brayford Pool, Lincoln LN6 7TS, UK. 6Department of Psychology, Linnaeus University, SE-351
95 Växjö, Sweden. 7Linköping University, 581 83 Linköping, Sweden. 8Department of Psychology and Logopedics,
Faculty of Medicine, University of Helsinki, P.O. Box 63, 00014 Helsinki, Finland. 9Department of Psychology,
Faculty of Philosophy, University of Novi Sad, 2 Dr Zorana Đinđića, 21101 Novi Sad, Serbia. 10Insitute of Clinical
Medicine, University of Oslo, Blindern, P.O Box 1171, 0315 Oslo, Norway. 11Department of Psychology, Head of
Center for Psychological Counselling and Research, Soa University “St. Kliment Ohridski, 15 Tsar Osvoboditel
Blvd., 1504 Soa, Bulgaria. 12Department of Psychology, Faculty of Philosophy, South-West University “Neot
Rilski”, 66 Ivan Mihaylov Street, 2700 Blagoevgrad, Bulgaria. 13Department of Clinical Child and Adolescent
Psychology, Institute of Psychology, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland. 14Faculty of
Psychology and Educational Sciences, University of Bucarest, 90 Panduri Street, sector 5, 050663 Bucharest,
Romania. 15Department of Social Sciences, School of Humanities and Social Sciences, University of Nicosia, 46
Makedonitissas Avenue, 2417 Nicosia, Cyprus. 16Department of Psychiatry, School of Medicine, University of
Crete, 715 00 Heraklion, Greece. 17Department of Psychoanalysis and Psychotherapy, Medical University Vienna,
Währinger Gürtel 18-20, 1090 Vienna, Austria. 18Faculty of Psychology, SWPS University of Social Sciences and
Humanities, Chodakowska 19/31, 03-815 Warsaw, Poland. *email: angelikahoun@psych.uw.edu.pl
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level. Male sex, younger age, being single, and reporting higher COVID‑19‑related distress were
signicant burnout correlates. Burnout among psychotherapists may be a transcultural phenomenon,
where individual dierences among psychotherapists are likely to be more important than
dierences between the countries of their practice. This nding enriches the discussion on training in
psychotherapy in an international context and draws attention to the neglected issue of mental health
among psychotherapists in the context of their professional functioning.
Since Freud’s1 early observation of the danger of analysis for the analyst, subsequent empirical studies have
shown that psychotherapists may be vulnerable to burnout (see reviews and metanalyses2,3. Although this highly
emotionally taxing helping profession should be a textbook example of a job with a high risk of burnout4–7, stud-
ies on burnout among psychotherapists are much less prevalent than those on burnout in other similar health
professions such as physicians or nurses (see reviews and meta-analyses8–12). us, the issue of burnout in this
occupation was and is still largely understudied in the elds of clinical psychology and psychotherapy, which
are traditionally focused on the clients of psychotherapy rather than on psychotherapists13,14. However, several
authors have observed that burned-out psychotherapists not only lose their ability to maintain their therapeutic
relationship with clients and manage the whole therapeutic process15–18 but also experience a substantial decline
in their well-being, accompanied by various somatic and psychological complaints19–21. Until now, the most
commonly studied burnout risk factors among psychotherapists were either work-related (e.g., caseload and
years of experience) or sociodemographic (sex and age)3. Much less attention was paid to the interpersonal and
intrapersonal characteristics of therapists22. In addition, several studies found vast discrepancies in burnout
prevalence among psychotherapists from various countries, ranging from 6%–54%3. To date, however, the cul-
tural context has only been examined from the perspective of client outcomes, not how it potentially relates to a
psychotherapist’s functioning and well-being23. In our study, we followed the basic cultural values in the rened
Schwartz value theory24,25 to assess burnout dierences among psychotherapists from 12 European countries
during the coronavirus disease (COVID-19) pandemic. To combine both individual and cultural perspectives,
we employed the multilevel approach, which allowed us to evaluate burnout at dierent levels of this hierarchy
simultaneously26,27. is approach may provide new insight into the fundamental question of whether burnout
is a multidimensional phenomenon or unitary, single-factor syndrome consisting of interrelated symptoms27. In
our study, we wanted to verify whether, among psychotherapists from these 12 countries, dierences in profes-
sional burnout were associated with individual and country-aggregated Schwartz’s values, aer controlling for
sociodemographic and work-related characteristics as well as the COVID-19 distress.
According to Schwartz28, values are “desirable trans-situational goals, varying in importance, that serve as
guiding principles in the life of a person or other social entity.” e recently rened theory of basic values24,25
highlights 19 basic values, which can be grouped into four higher-order values (self-transcendence, self-enhance-
ment, openness to change, and conservation; see Measures section). ese values were recognized in all major
cultures29 and are associated distinctively with human attitudes, behaviors, and demographic variables. e
main important assumption in this theory relates to a circular motivational continuum of values, which shows
motivational conict or compatibility across distinct values30,31. In other words, values can be compatible if
decisions and behaviors that express the goals of one value also correspond to the goals of the other value. By
contrast, values conict if decisions or behaviors that express the goals of some values do so at the cost of other
values. However, one of the still unresolved research questions is to what extent one may observe high within-
country similarity and signicant between-country variability in the culture as a shared meaning system32–34.
is problem becomes even more interesting if there is a mismatch between individual values declared by a
citizen of a particular country and a country-aggregated level of these values32. For example, Stephens etal.35
observed that a culturally mismatched environment can be associated with signicant psychological distress,
which can even impact the biological functioning of the person experiencing such mismatch. In the issue of
psychotherapists, existing reviews and meta-analyses have revealed that the link between burnout and work-
related factors may be modied by cultural dierences, which shape not only the organizational characteristics
of this profession but even the types of therapeutic relationships formed with clients2,3,9. Nevertheless, those
cultural factors have never been explicitly measured in previous studies. erefore our study is the rst to apply
a well-established theoretical model to interpersonal and cross-cultural comparisons of values and their potential
impact on burnout among psychotherapists. Finally, we also took into account the most recent and thus, much
understudied potential burnout risk factor among psychotherapists, which is the psychological distress during
the COVID-19 pandemic36,37. In light of the COVID-19 pandemic, psychotherapists were faced with many new
challenges and obstacles regarding their therapeutic practice. Many psychotherapists either stopped working
altogether or changed their practices in some form. One of the main challenges encompassed switching entirely
or partly to providing psychotherapy in an online format. e above-mentioned factors were responsible for
elevated levels of depression, anxiety and loneliness in this particular sample36. However, till now no studies
have been conducted on how the COVID-19 pandemic could be related to burnout among psychotherapists
employing cross-cultural comparisons.
Present Study
e main aim of this study was to examine the cross-cultural dierences in burnout intensity among psy-
chotherapists from 12 countries during the COVID-19 pandemic. We focused on the multilevel approach to
investigate if individual- and country-aggregated level values, as operationalized by Schwartz’s rened theory of
basic values24,25, could explain dierences in burnout aer controlling for sociodemographic and work-related
characteristics and COVID-19-related distress. We formulated the following hypotheses at the individual and
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country-aggregated levels to determine whether burnout in that specic occupation is more an individual syn-
drome or mostly shaped by the between-country dierences in values declared by psychotherapists. To the best
of our knowledge, no studies have been conducted on burnout in this group of participants using such a concrete
model of culture and methodological design. us, our study is mainly explorative.
Hypothesis 1 Burnout among psychotherapists is signicantly related to individual-level values (self-transcend-
ence, self-enhancement, openness to change, and conservation) aer controlling for sociodemographic and
work-related characteristics and COVID-19-related distress.
Hypothesis 2 Burnout among psychotherapists is signicantly related to country-aggregated values (self-tran-
scendence, self-enhancement, openness to change, and conservation) aer including all the variables from
Hypothesis 1.
Hypothesis 3 Burnout among psychotherapists is related to cross-level interactions in a way that a higher level
of burnout is associated with a higher mismatch between the values declared at the individual- and country-
aggregated levels.
Methods
Participants. 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, Bul-
garia, Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden, and Switzerland. e
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. e 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. e eligibility criteria encompassed certication (or being in the process of certica-
tion) in a particular psychotherapeutic modality and psychotherapeutic practice for at least 1year. e partici-
pants 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. e study protocol was accepted by the ethics committee of the
Faculty of Psychology at the University of Warsaw in Poland. e sociodemographic and work-related variables
and COVID-19-related distress among the psychotherapists from each country are presented in the Supplemen-
tary 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 = 45.5years,
min. 21years—max. 82years). Regarding the participants’ sexes, female psychotherapists were overrepresented
(83%) in all of the countries. A signicant number of participants were also in some form of stable relation-
ships (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 dierent degree such as social
work, counseling, or nursing. In all 12 countries, most psychotherapists worked with adult clients. Nonethe-
less, a signicant 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. e 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 11years of experience in the profession. On the other hand, psychotherapists who were working in Aus-
tria, Spain, Norway, Switzerland, Sweden, and the United Kingdom had between 12 and 18years 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 certication (80% or more). e numbers
appeared lower in Bulgaria, Poland, Serbia, and Sweden, with only approximately 35–65% of psychotherapists
obtaining a certicate. Psychotherapists worked anywhere between a couple of hours a week and more than 20h
a week. More specically, the average weekly workload in Bulgaria, Cyprus, Romania, and Serbia was between
1 and 10h. In Sweden and the United Kingdom, the average was between 10 and 20h a week. Psychotherapists
who worked for more than 20h 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 work-
ing 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.
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Measures. 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 ocial distributor of the MBI-
HS. e 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), ve 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 dierent 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 Question-
naire (PVQ-R) developed by Schwartz etal.24. e PVQ-R consists of 57 short, sex-matched, verbal portraits
of dierent 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 dened 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. e
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. e 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 pro-
vided 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. e 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. e data obtained had a two-level structure with persons (2915 units) nested within coun-
tries (12 units); thus, a cross-sectional multilevel model was adopted41. e explained variable was the burnout
level among the psychotherapists, which was operationalized as the global burnout indicator. e 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). e 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). e maximum likelihood (ML) estimation
method was used. For random eects (the random intercept model), the covariance structure of the variance
components (VC) was assumed.
Unconditional (i.e., intercept only) modeling was the rst step of the analysis. It was also used to obtain the
interclass correlation coecient (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 20h, 1 = 20h and more; supervision: 0 = quarterly or less, 1 = once a month or more). In
subsequent steps, only the variables found to be signicantly 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 signicant cross-level interactions, simple slopes, regions of signicance, and condence bands
were established using the computational tools developed by Preacher etal.47. Statistical analysis was performed
using IBM SPSS Statistics version 2748. Only the nal 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 dierence 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.
Results
Descriptive statistics. Table1 presents descriptive statistics on burnout levels and the four higher-order
values for each national sample of therapists.
Figure1 illustrates the mean burnout levels at the country level. e lowest mean was noted for Romania,
whereas the highest mean was reported for Cyprus. However, the ICC equals 0.09; thus, only 9% of the variance
of burnout level in the study sample of psychotherapists was related to the country level.
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Country nMean SD Range Kurtosis Skewness
Burnout
Austria 151 32.21 14.26 9–76 0.89 1.05
Bulgaria 217 38.36 15.26 8–105 0.97 0.79
Cyprus 202 42.50 17.74 10–85 − 0.72 0.47
Finland 254 31.32 12.52 8–82 0.84 0.89
Norway 225 42.12 16.27 11–89 0.13 0.60
Poland 340 37.38 14.28 10–122 4.19 1.22
Romania 202 26.50 13.51 8–74 0.73 1.06
Serbia 237 31.39 14.28 8–79 0.68 0.89
Spain 320 35.61 16.03 8–90 0.41 0.85
Sweden 275 40.53 16.00 9–106 0.61 0.74
Switzerland 205 33.90 12.95 9–74 0.44 0.77
United Kingdom 287 42.14 17.19 10–103 0.46 0.76
Self-transcendence
Austria 150 4.83 0.77 1–6 1.49 − 1.17
Bulgaria 217 4.48 0.79 1–6 − 0.80 1.19
Cyprus 202 4.91 0.65 2–6 1.32 − 0.93
Finland 254 4.86 0.55 3–6 − 0.66 0.05
Norway 225 4.82 0.63 1–6 3.23 − 1.20
Poland 340 5.01 0.50 3–6 1.03 − 0.64
Romania 202 4.82 0.68 1–6 5.43 − 1.63
Serbia 237 4.38 0.64 2–6 1.91 − 1.13
Spain 320 5.09 0.55 3–6 0.88 − 0.88
Sweden 275 4.83 0.57 3–6 − 0.52 − 0.40
Switzerland 205 5.10 0.54 3–6 0.00 − 0.63
United Kingdom 287 4.90 0.58 2–6 0.67 − 0.73
Self-enhancement
Austria 151 3.02 0.75 1–6 − 0.47 0.25
Bulgaria 217 3.14 0.81 1–6 − 0.46 0.22
Cyprus 202 3.64 0.85 1–6 − 0.14 − 0.27
Finland 254 2.67 0.89 1–6 0.46 0.84
Norway 225 3.29 0.93 1–6 − 0.44 0.44
Poland 340 2.88 0.83 1–6 0.50 0.62
Romania 202 3.37 0.81 1–6 0.70 0.11
Serbia 237 3.71 0.69 2–6 0.13 0.22
Spain 320 2.88 0.80 1–6 0.42 − 0.22
Sweden 275 2.88 0.85 1–6 0.16 0.78
Switzerland 205 2.94 0.76 1–5 − 0.31 0.39
United Kingdom 287 3.24 0.74 1–6 − 0.30 0.28
Openness to change
Austria 151 4.53 0.73 2–6 0.39 − 0.58
Bulgaria 217 4.31 0.79 1–6 0.64 − 0.47
Cyprus 202 3.64 0.66 2–6 0.74 − 0.54
Finland 254 3.98 0.60 2–6 − 2.94 − 0.22
Norway 225 4.25 0.62 1–6 − 0.82 2.56
Poland 340 4.56 0.57 2–6 0.28 − 0.37
Romania 202 4.63 0.69 1–6 3.43 − 0.99
Serbia 237 4.42 0.70 2–6 0.96 − 0.92
Spain 320 4.76 0.56 2–6 0.07 − 0.35
Sweden 275 4.26 0.59 2–6 − 0.31 0.11
Switzerland 205 4.74 0.58 2–6 0.12 − 0.50
United Kingdom 287 4.41 0.63 2–6 − 0.19 − 0.23
Conservation
Austria 151 3.66 0.65 2–6 − 0.07 − 0.04
Bulgaria 217 3.79 0.75 1–6 0.78 − 0.21
Cyprus 202 4.31 0.70 1–6 1.10 − 0.61
Continued
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Hypothesis testing. e results of the hypothesis testing are presented in Table2.
For Hypothesis 1, the test revealed that the psychotherapist-reported self-transcendence and openness-to-
change values that were higher than the typical values for a national sample were related to the lower overall
burnout levels of the psychotherapists. On the other hand, the higher-than-typical self-enhancement and con-
servation values were related to higher overall burnout levels. Moreover, we observed signicant associations
of burnout with some of the sociodemographic and work-related characteristics as well as COVID-19-related
distress. e burnout correlates were male sex, being single, younger age, and reporting more intense pandemic-
related stress than typical for the national sample.
For Hypothesis 2, aer controlling for all the variables mentioned in Hypothesis 1, the dierences in values
at the country-aggregated level were not signicant for burnout.
Finally, with regard to Hypothesis 3, we observed signicant cross-level interaction between openness-to-
change values reported at individual- and aggregated country-level (B = − 3.81, SE = 1.92, t = 1.98, p < 0.05). e
analysis of simple slopes is presented in Fig.2. As can be observed, the openness-to-change values were more
negatively related to burnout among psychotherapists in the countries with aggregated openness-to-change values
higher than the cross-country average (Β = − 3.47, SE = 0.70, z = − 4.98, p < 0.001) in comparison to the countries
for which these aggregated values were lower (Β = − 1.72, SE = 0.68, z = − 2.55, p < 0.05). us, the protective eect
of being individually highly localized on openness-to-change values in the national sample was further ampli-
ed by originating from a country with aggregated openness-to-change values higher than the average for all
12 studied countries. Referring these results to the condence bands of the aggregated values (− 61.83, − 0.29),
inside which the simple slopes were equal to zero, we conclude that there was no relationship between personal
openness-to-change values and burnout only for psychotherapists from Finland (Β = − 0.75, SE = 1.05, z = − 0.73,
ns), which at the country level has the lowest openness to change among the studied countries. However, this
result should be interpreted with caution as a model including interaction is not signicantly better tted to the
data than a model including only main eects.
Country nMean SD Range Kurtosis Skewness
Finland 254 3.77 0.72 2–6 − 0.57 0.00
Norway 225 3.89 0.72 1–6 0.35 − 0.42
Poland 340 3.69 0.70 1–6 − 0.50 0.31
Romania 202 3.91 0.66 1–6 1.81 − 0.84
Serbia 237 4.28 0.66 2–6 0.55 − 0.60
Spain 320 3.98 0.80 1–6 − 0.13 − 0.20
Sweden 275 3.57 0.71 1–6 − 0.21 0.21
Switzerland 205 3.69 0.67 1–6 − 0.39 − 0.02
United Kingdom 287 3.70 0.73 1–6 − 0.51 0.05
Table 1. Descriptive statistics for overall burnout level and personal values in the study sample of
psychotherapists (N = 2915) according to country of origin.
Figure1. Burnout mean levels values per country. A black line indicates a grand mean.
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Discussion
e results of our study were in accordance with our hypotheses at the individual level rather than at the coun-
try-aggregated level of analysis. At the individual level, burnout was negatively related to the self-transcend-
ence and openness-to-change values but positively related to the self-enhancement and conservation values.
Although Schwartz’s30 theory of basic human values has been used in hundreds of studies and various theoretical
contexts24,25,49, it has not been applied to the issue of psychological disorders. Owing to the fact that this is the rst
study to link cross-cultural values to burnout syndrome among psychotherapists, this result is dicult to discuss
other than exploratorily. Nevertheless, it is intriguing that motivational goals expressed in higher-order values
Table 2. Results for the hypothesis testing for the overall burnout indicator in the study sample of
psychotherapists (N = 2915). ***p < 0.001, **p < 0.05.
Hypothesis 1 model Hypothesis 2 model Hypothesis 3 model
Estimate (SE) Estimate (SE) Estimate (SE)
Fixed eects
Intercept 37.11 (1.50)*** 37.10 (1.31) *** 37.14 (1.35) ***
Sex 1.70 (0.69)** 1.68 (0.69) ** 1.68 (0.69) ***
Relationship status − 1.54 (0.61)** − 1.54 (0.61) ** − 1.58 (0.61) **
Age − 0.33 (0.03)*** − 0.33 (0.03) *** − 0.33 (0.03) ***
COVID-19-related stress 4.33 (0.26)*** 4.33 (0.26) *** 4.33 (0.26) ***
Level 1 values
Self-transcendence_w -4.01 (0.56)*** − 4.01 (0.56)*** − 4.10 (0.56)***
Self-enhancement_w 1.65 (0.39)*** 1.65 (0.39)*** 1.61 (0.39)***
Openness to change_w − 2.52 (0.52)*** − 2.52 (0.52)*** − 2.57 (0.52)***
Conservation_w 0.94 (0.45)** 0.94 (0.45)** 0.92 (0.45)**
Level 2 values
Self-transcendence_b 15.88 (9.71) 15.89 (9.71)
Self-enhancement_b 12.84 (7.82) 12.84 (7.82)
Openness to change_b − 10.66 (7.81) − 10.66 (7.81)
Conservation_b − 6.42 (8.69) − 6.43 (8.69)
Cross-level interactions
Self-transcendence_w*b − 0.97 (2.08)
Self-enhancement_w*b 1.80 (1.14)
Openness to change_w*b − 3.81 (1.92)**
Conservation_w*b − 0.06 (1.82)
Random eects
Residual variance 185.20 (4.95)*** 185.21 (4.94)*** 184.71 (4.93)***
Between-country variance (intercept) 22.32 (9.49)** 17.04 (7.35)** 17.04 (7.35)**
Model parameters
Akaike Information Criterion 22,765.39 22,770.33 22,770.85
− 2LL 22,743.39 22,740.33 22,732.85
− 2 LL Δ (df ) 3.06 (4) 7.48 (4)
30
35
40
45
-1 -0.5 00.
51
BURNOUT
LEVEL-1 OPENNESS TO-CHANGE VALUES
LEVEL-2 OPENNESS TO-CHANGE VALUES
-1SDmean+1SD
Figure2. Simple slopes for cross-level interaction for openness-to-change values on burnout. For Level-2
openness-to-change values slopes are probed at a mean and one standard deviation above and below a mean.
Level-1 openness-to-change values were centered around within-country means.
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of self-enhancement (e.g. power-dominance) and conservation (tradition, conformity-rules) were found to be
burnout predictors, while motivational goals of self-transcendence (e.g. universalism-tolerance) and openness-
to-change (e.g. self-direction thought) acted as buers against burnout in this particular sample. us, our study
may be an interesting adjunct to the literature on the psychological functioning of psychotherapists, including
the neglected cross-cultural context2,3. As part of the psychotherapy training process, it is also important to
consider this latter context.
However, the most intriguing nding was somehow a null result at the country-aggregated level. At this level,
dierences in values were irrelevant to the burnout levels of the participants. is was also conrmed by the
comparisons of the eects at the individual and country levels. For example, we observed dierences in burnout
among the 12 countries, with the highest levels in Cyprus, Sweden, Norway, and the United Kingdom and the
lowest levels in Romania, Serbia, and Finland. Nevertheless, these dierences were explained almost entirely by
interpersonal dierences, as only 9% of the burnout variance was related to the country level. From a dierent
perspective, burnout among psychotherapists tends to be a transcultural phenomenon rather than a country-
specic problem. Although values do matter, their idiosyncratic aspect is more important for burnout than the
collectivist aspect, i.e. shared by a group of representatives of this profession in a given country. is may be an
important conclusion for reection on the organizational structure and training in psychotherapy in Europe13,50.
e country-level aggregated values were found to be signicant in the only observed cross-level interaction
concerning openness to change. is supports the hypothesis on the role of t between individual and collec-
tive values24,25. Namely, the protective eect of individual values was enhanced when being a psychotherapist
in a country where other psychotherapists also declared high openness-to-change values. However, this result
requires further research. Observing it only for this category of values may in fact be due to the specic circum-
stances of the study. e COVID-19 pandemic universally enforced adaptation to the "new normal". Burnout
may therefore actually aect to a lesser extent those who consider openness to change as an important value
in their lives since they have an intrinsic motivation for novelty and mastery, but this adaptation may also be
facilitated or hindered by what happens in the social environment of such a person. e attitudes represented
by one’s occupational group, especially when the external demands include major changes in the conditions
of work, are likely to become an inuential reference point to modify an individual’s appraisals and behaviors.
We found that higher burnout levels among psychotherapists were associated with sociodemographic data
(younger age, being single, and male sex) and higher levels of COVID-19-related distress. Previous studies on
burnout among psychotherapists have shown that younger psychotherapists are at greater risk of burnout than
older psychotherapists and usually more experienced colleagues15,51–53. is nding is oen explained by the fact
that young psychotherapists may have high and unrealistic expectations about their roles in this occupation, and
a subsequent reality crash may be a burnout catalyst52. Our study also showed that male psychotherapists can be
at a higher risk of burnout than female psychotherapists, but the results reported in the literature on this topic
are discrepant54,55. Our meta-analysis revealed that men and women may experience burnout in dierent ways;
for example, women score higher on emotional exhaustion, whereas men score higher on depersonalization56.
Consistent with our ndings, the psychotherapy profession may also be associated with burnout among men
due to sex-related dierences in self-ecacy, which is usually higher among females in helping professions57.
As expected, COVID-19-related distress was a signicant burnout correlate in all the countries included in the
study, which is consistent with the most recent research36,37. However, this subject is still understudied in general,
particularly in this sample. In light of the COVID-19 pandemic, psychotherapists were faced with many new
challenges and obstacles regarding their practices, clients, and their well-being.
In a more general discussion, our ndings contradict one of the main assumptions at the root of cross-cultural
psychology, which is high within-country similarity and signicant between-country variability in shared cultural
meaning systems33,34,58. is notion suggests conducting cross-country comparisons by “unpacking” cultural
dierences within the studied psychological constructs and discussing them in light of a culture-comparative
perspective33. Nevertheless, for at least two decades, attempts have been made to calculate the eect sizes of the
aforementioned within-culture consensus and cross-cultural variability in several theoretical constructs59,60.
Fisher and Schwartz32 examined values in 67 countries and observed negligible variances in value ratings that
may be associated with country dierences. Specically, they found that the cross-country dierences and within-
country consensus in values were very low in all examined countries. us, we can infer that this is not because
values are part of some shared meaning system dened as culture but because people, in general, dier in values
regardless of where they come from. We obtained a similar pattern of results in this study. However, the afore-
mentioned problem needs further examination, as we did not observe a consistent pattern of the eects of a
mismatch between individual and country-aggregate values on burnout outcomes at the cross-level interactions
(Fig.2). e clinical context in cross-cultural psychology, that is, the role of values in psychological disorders,
is, therefore, an important research gap to address in the future.
Strengths and Limitations. is study has several strengths, including its large sample of psychothera-
pists from 12 dierent countries observed during the critical period of the COVID-19 pandemic and the use
of a theoretical model for cross-cultural comparisons and a multilevel design, which make it a pioneer study
in the relevant literature. However, several limitations should be mentioned. First, for organizational reasons,
our samples of psychotherapists were heterogeneous concerning psychotherapeutic modalities and other work-
related characteristics. In addition, they cannot be considered representative of the countries in which they
were sampled. is represents a common shortcoming in the literature on the psychological functioning of this
professional group3 but is hard to avoid, particularly in international comparisons and associated dierences in
regulations for this job between countries. Second, our research shares other common limitations in burnout
studies among psychotherapists, including its cross-sectional design and precluding causal inferences2. e role
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of values in the prospective study design would be interesting to investigate to determine the stability of its eect
at the individual and country levels. Two typical shortcomings must be borne in mind in cross-cultural research,
namely the reference group eect61 and the response style eect62. e former deals with the problem of using a
self-report measure to assess cross-cultural dierences when participants compare themselves to familiar oth-
ers (e.g., Poles compared themselves to other known Poles). e latter illustrates culture-related dierences in
response styles. ese eects may also be the reason for the small eects of the country-aggregated level of analy-
sis. However, another reason may be that there are not enough units of analysis at this level. A general rule of
thumb is to have as many units at a higher level as possible63. In cross-cultural research, because of practical con-
siderations, this rule is rarely fullled64. Finally, our study was not limited in terms of the number of countries,
but also in terms of their location. e participants represented only European countries, which was due both
to organizational issues, including the course of the pandemic, but also to the sharing of the basic foundations
of psychotherapy as a profession. Future research should therefore focus on comparisons that cover a broader
spectrum of countries.
Conclusions
In light of the recent inclusion of burnout in the 11th Revision of the International Classication of Diseases65,
one should bear in mind that burnout is a global occupational phenomenon that can be observed in any
profession10, including psychotherapists3. Our data suggest that burnout among psychotherapists may be, in
some sense, a transcultural phenomenon, in which there is room for interplay between what is individual and
what is shared with one’s occupational group. However, the most important factors are the individual dierences
between psychotherapists, regardless of their cultures, at least across the studied European countries. Although
this nding should be treated with caution because of the explorative characteristics and limitations of our study,
it may be an enriching adjunct to the discussion on preventing psychotherapists’ burnout. Specically, the results
of our study call for the need to place more focus on psychotherapists’ personal values regarding their professional
and private lives, especially during the psychotherapy training process. It has been found that these are crucial
factors that promote the personal and professional quality of life in this profession66.
Data availability
All data generated or analysed during this study are included in this published article and its supplementary
information les.
Received: 3 March 2022; Accepted: 28 July 2022
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Acknowledgements
is project has received funding from the New Ideas of POB V project implemented within the scope of the
"Excellence Initiative—Research University" Program, by the Ministry of Science and Higher Education in Poland
(number PSP: 501-D125-20-5004310).
Author contributions
All authors reviewed the manuscript. All authors took part in the data collection. A.V. and M.R. prepared the
original version of the manuscript. A.V. and M.R., E.G. prepared results analysis. A.V. and M.R. prepared research
plan. A.V., M.R., M.P., and E.G. prepared all visualisation of data and its interpretations.
Competing interests
e authors declare no competing interests.
Additional information
Supplementary Information e online version contains supplementary material available at https:// doi. org/
10. 1038/ s41598- 022- 17669-z.
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