Risk factors of Secondary Traumatic Stress in psychotherapists studied during the COVID-19

Introduction: The aim of the study was: to assess the severity of Secondary Traumatic Stress (STS), to identify ST's predictors, and to assess the model of relationships between predictors of Secondary Traumatic Stress in psychotherapists working during the pandemic in Poland. Materials and methods: The research group consisted of 153 psychotherapists (130 women, 85%) aged 25-66 (M = 39.39; SD = 9.65). The following tools were used to measure the variables: Coping Inventory for Stressful Situations (CISS), Perceived Stress Scale (PSS-10), Fatigue Severity Scale (FSS), FCV-19S Fear of COVID-19 Scale (FCV-19S), Secondary Traumatic Stress Scale (STSS), Personal Inquiry, Assessment of working conditions during a pandemic. Discussion: It has been shown that 9.8% of psychotherapists working during the pandemic experienced high or very high-intensity of symptoms of Secondary Traumatic Stress. The predictors of STS turned out to be: task-induced stress during the pandemic, emotion-focused stress-coping style, and fear of COVID-19. The proposed model of moderated moderation, which assumes that COVID-19 anxiety that intensifies the emotional style of coping with stress in specialists, has an influence on the relationship between occupational tasks stress during a pandemic and the severity of symptoms of Secondary Traumatic Stress, has not been confirmed. Therefore, there is a need for further exploration of the issue. Conclusions: Research shows an increase in STSD among Polish psychotherapists during covid as well as risk factors intensifying this diagnosis.


Introduction
The COVID 19 pandemic is recognized as a collective stressor having a negative impact on the functioning, health, and life of the whole society. The prolonged restrictions make it difficult for people to satisfy their basic needs, which, in turn, contributes to the growing feeling of fatigue with the situation. Being in a state of emotional tension, loneliness, or the feeling disadaptation increases the number of people who require the support of mental health professionals in order to deal with a situation for which no one was prepared [1,2,3]. Heitzman [4] refers to the concept of a pandemic acute stress disorder being a response to the pandemic, which may be tied to the emergence of the stressor. Patients, who saw psychotherapists during the pandemic, brought up a number of problems during the meetings. They most often talked about an intensification of anxiety and depression, relationship problems resulting from being together all the time, experiencing loss and grief, abusing psychoactive substances, emerging psychosomatic disorders, and difficulties in adapting to the situation. Quarantined individuals experienced higher levels of stress, lower sleep quality, anxiety, irritability, boredom, and loneliness [5]. The study subjects experienced physical stress resulting from a lack of space for physical activity, a lack of social relations, and a fear of the effects of the infection. Many of the news reported by the media served to convey information or escalate the emotions of society [5]. People had to comply with the recommended restrictions resulting from the dynamic nature of the pandemic, e.g., maintaining social distance, wearing masks in closed spaces, adhering to the rules of quarantine, taking into account the limits on the number of people in places of culture and worship, paying close attention to the changes in regulations concerning international travel [6]. Due to an increased number of problems as well as the different ways they could be interpreted, which resulted mainly from the specific way everything functioned during the pandemic, specialists concerned with mental health support played an important role [5,7].
Swartz [8] pointed out that consulting a psychotherapist helps to cope with the psychological consequences of the COVID-19 pandemic. As much as 85% of therapy progress is attributed to client-related factors, the therapeutic relationship, and hope. The mental state of the psychotherapists impacts their job performance [9]. During the pandemic, both specialists and patients experienced anxiety related to their and their relatives' health, financial and work-related issues, and living in isolation. Helping patients to work through the difficult times in their lives, but also experiencing similar hardships of their own, required additional emotional involvement [10]. It caused a strengthened feeling of anxiety and, consequently, a depressed mood [9]. Franza, Basta, Pellegrino, Solomita & Fasano [11] showed that people working in health care, especially psychiatric care, experienced increased compassion fatigue. Direct contact of medical workers with COVID-19 patients was associated with higher levels of stress, burnout, secondary trauma, and depression [2]. In the studies conducted by Franzoi et al. [12], psychotherapists experienced fatigue and overstrain as a result of the changing way they have worked due to COVID-19. The need to adapt one's home space for remote clinical work with patients was also new [13,14]. Online psychotherapy had already been practiced before the pandemic. However, up until that point, such a mode of work was treated as a choice, not a necessity. Some therapists were forced to stop working with patients for some time due to a lack of previous experience conducting meetings over the phone or not being able to ensure patient privacy in their homes [13].
Providing assistance to people who have experienced a traumatic situation can lead to symptoms of secondary traumatic stress (STS) in specialists [15]. Starting from repeated or high exposure to the details of the traumatic event, the symptoms of this disorder are identical to those of PTSD: intrusive memories, avoidance, negative changes in the cognitive and emotional spheres, increased agitation and reactivity [16]. In addition, specialists with this disorder experience a feeling of inability to continue their work, a sense of their professional competencies being limited, difficulties in recalling information about their patients, or dissociative states [15]. Professionals, such as social workers, therapists, probation officers, doctors, nurses, or paramedics, are particularly vulnerable to the onset of symptoms of secondary traumatic stress [17].
Not every psychotherapist experiences symptoms of STS. Nonetheless, those involved in providing mental health support are at particular risk because they are frequently exposed to their patients' traumatic events [18]. There are certain factors that predispose individuals to the development of this disorder. They can be divided into environmental and therapistrelated factors. The environmental factors include workload, supporting multiple clients, long periods of working with the aforementioned clients, and exposure to patients' drastic stories [15]. The therapist-related factors comprise gender, own experiences of trauma, personal resources, high level of empathy, and lack of social support [15,19]. The factors that protect those involved in supporting others from the consequences of experiencing secondary trauma are social support, peer dialogue, active seeking of support from family members, conversation with the supervisor, the ability to create boundaries between the self and others and separating the intellectual and emotional realms [18]. The important role of supervision, raising awareness of secondary traumatic stress through participation in training, teamwork, and work-life balance is also frequently emphasized.
However, as Captari [10] notes, psychotherapists have a propensity to disregard their personal limitations. The resource mobilization strategy in a long-lasting situation may be unfavorable due to the individual's increasing susceptibility to secondary traumatic stress, compassion fatigue, or occupational burnout. Additionally, the use of immature defense mechanisms (repression, suppression, addictions) is also a risk factor.

Materials and Methods
The study was conducted on a sample consisting of 153 psychotherapists aged 25-66 (M = 39.39; SD = 9.65), including 130 (85%) women. Most of the participants (69.3%) were in a relationship (marriage or informal relationship). When it comes to 84.3% of them, they were psychotherapists, and 15.7% were therapists (e.g. school therapists, addiction therapists, etc.). Professional work experience ranged from 0.5 to 40 years (M = 8.97, SD = 7.11). The participants were most often employed in one workplace (71.2%): private practice (37.6%), healthcare (30.3%), education (18.3%), social care (9.2%), uniformed services (1.8%), other, e.g. a helpline (2.8%). The majority of therapists (69.3%) worked semi-remotely, 20.9% in traditional workplaces, and 9.8% fully remotely. When it comes to 45.1% of therapists, they experienced a difficult situation related to working during the pandemic, while 84.4% of them received support from their relatives, and only 52.5% received support from their supervisors. During this time, most specialists (92%) made use of supervision. Most often it was peer (55.5%) or professional (37.7%) supervision.
The following research tools were used to measure the variables: Coping Inventory for Stressful Situations (CISS) by Endler & Parker in the Polish adaptation of Szczepaniak, Strelau, Wrześniewski [21]. This research tool consists of 48 statements about a variety of behaviors individuals can implement in stressful situations. The results are presented on three scales: (1) Task-Oriented coping strategy; (2) Emotion-Oriented coping strategy; (3) Avoidance coping strategy. The psychometric properties of the tool are satisfactory. The stability of the test ranges from 0.73 to 0.80. In this research, the reliability was verified with the use of Cronbach's alpha. Cronbach's alpha for the Task-Oriented coping strategy was: 0.83; for the Emotion-Oriented coping strategy: 0.89; for the Avoidance coping strategy: 0.83.
The Perceived Stress Scale (PSS-10) by Cohen, Kamarck & Mermelsten in the Polish adaptation of Juczyński and Ogińska -Bulik [22] contains 10 questions about various subjective feelings related to personal problems and events, behaviors, and coping strategies. PSS-10 correlated with psychological stress r = 0.32, p <0.000. The correlation was also obtained with the number of traumatic experiences r = 0.52. Tau-equivalent reliability (Cronbach's alpha) in authors' own study was: 0.89.
The Assessment of working conditions in the pandemic Banakiewicz, Frańczyk, Kajka & Kulik -the survey contains 15 questions and statements regarding the assessment of working conditions in the pandemic period compared to the pre-pandemic period. Depending on the wording of the question/statement, the respondent's task is to mark the answer or write his own answer. Sample questions were as: "How would you rate the severity of stress in the workplace, where 1-minimal 10-extreme before/ during a pandemic" or "Do you experience support from your superiors during the pandemic?".
A total number of 199 therapists who worked during the pandemic participated in an online survey (using the Lime platform). The results of 153 observations were included in the analyses. When it comes to 42 studies, they were discarded because subjects dropped out during the completion of the kit; 4 observations were also excluded from the analyses due to extreme results of +/-3 SD. The size of the study group was estimated based on literature reports [25]. Intentional selection was made using the snowball method. Each person who consented to participate in the study received a link with an individual invitation to a psychological examination and a GDPR clause. Psychology students assisted in the recruitment of respondents by seeking out potential respondents in their area. The measures were proposed to the respondents in such an order as to reduce the possibility of commonmethod variance [26]. To avoid common-method variance, UWES was introduced. The Research Ethics Committee of the Institute of Psychology of the John Paull II Catholic University of Lublin gave a positive opinion on the project: KEBN_9 / 2021 on March 9th, 2021.
Basic descriptive statistics, i.e. mean, standard deviation, median, minimum-maximum, skewness, kurtosis, measures of normal distribution, correlations, and internal compliance calculations were calculated in SPSS PS IMAGO PRO 7.0. In contrast, double moderation regression analysis was calculated using Hayes' Macro PROCESS software (model 3). The way of filling in the questionnaires did not allow for omissions of the answers and missing data. The number of 42 studies were rejected because the test subjects dropped out while completing the kit; 4 observations were also excluded from the analysis due to the extreme results of +/-3 SD. The variables were correlated. In the testing of the regression model factors, whose correlation strength was greater than r=0.300, were included. Analysis of the VIF collinearity factors (1.18 and 2.14). showed no collinearity for each factor significantly associated with secondary post-traumatic stress. In order to verify the assumption concerning homoscedasticity of variance, the Breush-Pagan test was performed. It showed that the homoscedasticity assumption was met (the residual variance was equal), χ2 = 0.33; p > 0.05. In order to verify the normal residual distribution in the tested model, the Kolmogorov-Smirnov test was performed. Analysis with the Kolmogorov-Smirnov test showed that the residual distribution of the tested regression model was statistically similar to the theoretical normal distribution KS = 0.1; p > 0.05. Based on the regression results, a double moderation model was adopted. The analyses were performed with Hayes' Macro PROCESS software (model 3). In the case of the emotional coping variable, the results were binarized according to the point 5 sten division, while in the case of the COVID 19 anxiety variable, the division method Mean +/-1 SD(division into 3 groups) was used. Before starting the analysis, the results of individual variableswith the exception of the variable expressed on the sten scale -were transformed using the R best Normalize software package. The analysis showed that the best normalizing properties for the variable: (a) Task stress during a pandemic was returned by the Box-Cox technique, P/df = 1.71, (b) for fear of COVID 19 -arcsinh x, P/df = 1.32, (c) and for secondary post-traumatic stress -Yeo-Johnson, P/df = 1.02 (compared to other transformations).

Results
The participants evaluated their work highly and noted no change in their effectiveness during the COVID-19 outbreak (Table 1). The average weekly number of work hours did not change. However, there were individuals who stopped working, and some people whose weekly number of work hours doubled. They graded their satisfaction from interpersonal relations at work as high. They were moderately satisfied with their salary. The average results obtained in psychological tests (Table 1) indicate the average intensity of stress-coping strategies (CISS; task strategy most prominent, the least prominent -the emotional strategy), the average level of perceived stress (PSS), as well as the intensification of COVID-19 related anxiety comparable to the results of other studies in Poland [24], lower level of fatigue [27], and the average level of secondary traumatic stress [15].
The obtained results, presented in table 2, indicate that among 153 examined therapists, the possible severity of secondary traumatic stress ranged from 0 to 59. This allows the group of respondents to be divided into people who obtained results below and above the recommended cut-off point. In this study, 9.80% of psychotherapists obtained high results indicating increased symptoms of secondary traumatic stress.
The next step was to analyze the predictors of the severity of secondary traumatic stress in psychotherapists ( Table 3). The model includes task-related stress induced to work during a pandemic (SW), emotional coping style (CISS_E), perceived stress (PSS), chronic fatigue (FSS), and fear of COVID 19 (FCV19). Multivariate regression analysis showed a significant prediction for the tested model, F(5, 147) = 16.04; p <0.001. The value of the R² coefficient showed that the regression model of the included independent variables accounted for about 35% (adjusted for 33%) of the variability in the results of secondary traumatic stress. The analysis of the statistics of individual predictors in the model showed the following results: an increase in the results of the task stress variable during the pandemic was associated with an increase in the results of secondary traumatic stress; the obtained result was statistically significant (β = 0.18; t =2.49; p < 0.05). An increase in the results of the emotional coping style was associated with an increase in the STS results, the obtained result was statistically significant (β = 0.25; t = 2.76; p< 0.01). The last significant result turned out to be the fear of the COVID-19 variable. Its increase was also associated with an increase in STS, the obtained result was statistically significant (β = 0.20; t = 2.81; p <0.01).
At the last stage, it was necessary to determine whether the level of fear of COVID 19 significantly differentiates how the level of emotional coping with stress moderates the relationship between the level of task-induced stress at work of therapists during the pandemic and the severity of secondary traumatic stress. The regression model tested showed a significant prediction, F (7,145  obtained results are presented in Table 4. The number of significant predictors in the model was 3: task-induced stress during the pandemic, Emotion-Oriented coping strategy, COVID-19 related anxiety. Ultimately, it was shown that the second-order interaction between task-related stress, emotional coping style and fear of COVID does not significantly predict the level of secondary traumatic stress in psychotherapists. The model fit data and the obtained results are presented in Table 4.

Discussion
The aim of the presented study was (1) to analyze and assess the severity of secondary traumatic stress (STS) of psychotherapists working during the pandemic, (2) to identify significant predictors of this phenomenon, and (3) to assess the relationship model between them. Nearly 9.80% of psychotherapists in this study obtained high and very high results in the intensity of secondary stress. Comparing this with the percentages reported so far (8-9%), we can see a slight increase [26]. In Poland, before the pandemic, it was shown that only 7% of therapists struggled with high STS symptoms [15], while the survey taken during the pandemic indicated 9.8%. This increase can also be seen in the average results. So far, researchers have reported that they oscillated around 11.5 [15]. In this study, the average result was 13.85, with a comparable standard deviation for both measurements. This data indicates a significant negative impact of the pandemic on the mental health of specialists. This research confirms that the results obtained may be related to the stress of work-related tasks during the pandemic, emotional coping style, general perceived stress, chronic fatigue, and fear of COVID-19.
It is concluded that the higher severity of the symptoms of secondary traumatic stress was, inter alia, a result of the participation of specialists in the global pandemic that is treated as a collective stressor negatively affecting functioning, health, and life. A permanent sense of uncertainty about the future, fear, and sometimes direct contact with the risk of life or health of oneself and of relatives caused additional emotional costs [10], which could be the cause of the symptoms of the disorder. Psychotherapists are a group of people working in support [18], which is generally characterized by a higher level of empathy, and this predisposes them to experience secondary traumatic stress [15].
Due to changes in the work rules, the intensity of stress in the respondents increased during the pandemic. In our research, this was reflected in the results, and the respondents themselves communicated what difficulties they face on a daily basis. The results of these studies are consistent with the reports of other researchers,  e.g. the need to conduct online therapy from home [13], change the work organization in various spheres of professional functioning [10]. Rzeszutek, Partyka & Gołąb [28] showed that psychiatrists obtained higher severity of symptoms of secondary traumatic stress compared to psychotherapists. The researchers explained such results by the fact that psychotherapists use clinical supervision, which is not practiced by psychiatrists. In our research, the vast majority of psychotherapists used supervision (92%). It is recognized as an important protective factor [28], as is the sense of self-efficacy, which in the respondents in this project could be manifested in a positive assessment of the effects of their work with patients. Despite the encountered difficulties, in the opinion of psychotherapists, the effectiveness of their work did not change significantly during the pandemic compared to the period before the coronavirus. They were satisfied with the results they achieved. The reason for this may be the use of personal resources, which is a factor that protects against the onset of STS symptoms [15], or the use of mobilization strategies in a situation of greater strain [10].
It is worrying, however, that some therapists have increased the number of working hours, and others have abandoned their profession. Being overloaded and underloaded with work can be a source of stress [29]. In both cases, it could be a reason for using up personal resources in coping with the situation, and the results are reflected in the feeling of fatigue in 39.2% of respondents, and in the presence of increased fear of COVID-19 in 13.1%.
This research paper also attempted to analyze the mechanisms of secondary traumatic stress. A moderated moderation model was proposed, which hypothesized that the relationship between work-related task stress and the severity of secondary traumatic stress symptoms is influenced by COVID-19 anxiety, which may exacerbate psychotherapists' emotional coping styles. The final model did not confirm the abovementioned predictions. This implies that the proposed mechanism of COVID-19 anxiety and emotional coping do not adequately explain the severity of the relationship between pandemic taskrelated stress and secondary traumatic stress. The above analysis indicates that each of these factors affects STS separately, but not collectively. Perhaps the obtained results may be affected by the high intensity of protective factors (as an important moderator). This seems to be an interesting concept for further exploration. After all, what protects psychotherapists will also protect the therapeutic relationship. At the same time, it is crucial to note that what is a significant risk factor for secondary traumatic stress, will also have negative consequences for patients. This interdependence seems to be very binding, as every man reflects oneself in the daily work.

Conclusions
The COVID 19 pandemic has had a negative impact on both patients and those who help them [30]. Nearly 9.80% of psychotherapists in this study obtained high and very high results in the intensity of secondary stress. Predictors of STS included: task-induced stress during the pandemic, fear of COVID-19 and emotional coping style. The model explained 32% of the variation in the secondary traumatic stress variable.
Practical application of this research: 1) Determining whether and to what extent the COVID 19 pandemic affected the mental health of psychotherapists.
2) The reported increase in the severity of STSD may also draw the attention of psychotherapists to the role of self-care programs.
3) Additionally, the appendices (1-4) to this manuscript turned out to be a significant help. They presented percentage data identifying specific risk factors reported by the respondents. Publishing them will allow the development of support tools for psychotherapists in the future. 4) This research also draws attention to the essence of the working conditions in which psychotherapists found themselves and whether they are sufficiently prepared to perform their work. Stress related to the performance of tasks at work during a pandemic turned out to be an important risk factor.