Exploring the Experiences of Integrative Psychotherapists Regarding Resilience during the COVID-19 Pandemic in Greece: An Interpretative Phenomenological Analysis

Abstract

The coronavirus pandemic invaded every aspect of everyday life; shook individuals’ personal, social, economic, and value systems; and led to a loss of the fundamental sense of safety and predictability, marking a global health emergency. Being exposed to the adverse life events of their clients and working under higher levels of risk, psychotherapists are experiencing increased anxiety and work-related stress. The objective of the study is to acquire a better comprehension of the processes and factors that supported integrative psychotherapists in Greece to promote resilience during the pandemic, to explore possible effective interventions, and to contribute to the limited literature on psychotherapists’ ability to foster positive outcomes for themselves and ultimately for their clients. The study utilised a qualitative perspective, analysed by an Interpretative Phenomenological Analysis. The participants experienced increased distress associated with the pandemic; however, they could develop adaptive strategies to safeguard against these adverse effects and balance personal and professional needs, maintaining resilience. In the professional field, they flexibly used the advantages of the Integrative Approach to adapt to the social conditions and the needs of the clients.

1. Introduction

In March 2020, the World Health Organization [1], declared COVID-19 infection as a pandemic that brought the planet into an emergency [2]. Although humanity has confronted infectious epidemics before (AIDS, SARS, Ebola), they did not create such prolonged disruptions on psychological, social, and economic levels on a worldwide scale [3], evading all protective barriers of the medical system and overwhelming societies. The pandemic brought to the forefront the existential issues of insecurity, the vulnerability of human life, mortality [4,5], loneliness, and fear of dying alone [6,7], which resulted in profoundly increased rates of psychological distress and depression [8,9], trauma-related symptomatology [10,11], and sleep disorders [12,13], in the general population, leading to a “parallel pandemic” [14]. Additionally, a potential economic crisis has amplified financial insecurity, unemployment, and socioeconomic adversities [3,8]. In Greece, a country in Southeast Europe, the current health crisis followed a 10-year-long financial and socioeconomic downturn [15], which tested the resilience of the Greek health, social and economic system, leading to an incremental impact of complex distress [16,17,18,19]. In particular, in March 2020, the Greek government enforced a large number of rigorous protocols to protect public health, such as mandatory hygiene measures, social distancing, and lockdowns [19], which reduced people’s essential social, emotional, and physical activities [20].

During the COVID-19 pandemic, psychotherapists have found themselves at the centre of the mental health hurricane, being confronted with increased distress and exposure to traumatic events and struggling to balance personal concerns with professional conscientiousness [21]. A plethora of studies investigating the psychological impact of the Coronavirus and the quarantine on healthcare providers support that in comparison with the general population, show higher rates of severe anxiety, depression, PTSD [22], exhaustion and burnout [23], sleep disturbances, and psychosomatic problems [24].

On the other hand, the therapeutic and research practice is recently shifting the focus from the world of deficits and dysfunctional behaviours towards discussions and dialogues about possibilities and demonstrating the significance of adaptive psychological responses and resilience [24,25,26]. Psychological resilience is part of the human capacity to moderate the adverse effects of significant crises [27], promote adaptation [28], and contribute to personal functioning and psychological growth [29]. Despite the abundance of research on resilience in healthcare professionals (mainly medical practitioners) during the COVID-19 outbreak [21,30] and a corpus of quantitative studies focused on mental health professionals in Greece [17,18], a lack of qualitative research was observed [21,31]. The study aims to explore how integrative psychotherapists in Greece perceive the imprint of the COVID-19 pandemic on their personal and professional lives from April 2020, when the World Health Organization [1] called a global alarm for public health and declared COVID-19 a pandemic till May 2022, when the Greek Government decided to lift of restrictive measures and return to social and economic normality [32]; what factors contribute to increasing their psychological assets; and which processes and key skills foster adaptive coping responses and enhance resilience.

1.1. What Is Psychological Resilience?

Resilience is broadly referred to as the ability to recover from frustrations, traumas, and adverse situations quickly and effectively [27,33]; to adapt successfully to the constant demands of life; and to rebound from distress and misfortune [34]. The literature refers to four forms of psychological resilience: resistance to stressors, recovery from a stressful or traumatic experience, normalisation and reconstruction, and personal development, both in terms of functionality and mental health (post-traumatic growth) [29]. Psychological resilience seems to be a complex construct [35] that has been studied in various ways, such as a trait [36], a process [37], or an outcome [38]. Recent research highlights the dynamic nature of resilience [34], which may change across a lifespan. Further research has indicated that psychological resilience can be influenced by characteristics of personality [39], internal control [40], neurobiological profiles [41], and a supportive social and cultural environment [42], factors that interact with each other. Research findings over the past 50 years have led to three theoretical models of psychological resilience that attempt to describe the way personal and social parameters interweave to equalise the negative consequences of risk factors: the compensatory model [43], the challenge model [44], and the protective factor model [45]. The present study, based on the protective factor model developed by Fergus and Zimmerman (2005), aims to explore how protective factors operate, and interact with risk (the COVID-19 pandemic), influencing its effects.

1.2. The Moderating Role of Resilience for Healthcare Professionals during Epidemics

Multiple studies examining the long-term psychological consequences for healthcare professionals following previous epidemics, such as MERS, Ebola, SARS, and Influenza A (H1N1), reported increased sensitivity to psychological disorders [46]. Data during the pandemic indicate that healthcare workers experience moderate to high levels of anxiety, depression, burnout, and PTSD [47], facing similar exhausting challenges, as in previous epidemics [48]. The COVID-19 outbreak brought considerable challenges for psychotherapists, whose role is crucial in ensuring mental health and optimising sustainment. According to numerous studies, psychotherapists, like all health professionals, shouldered a heavy charge during the current global adversity and are among the most vulnerable groups [18,49,50]. The psychological well-functioning of healthcare professionals is directly linked with the quality of services they provide accordingly; there is a shift in the scientific world on prevention and resilience [26,27].

2. Materials and Methods

2.1. Design and Setting

Interpretive phenomenological analysis (IPA) [51] was chosen as an inductive thematic analysis, generating theory from data and identifying patterns during research, informed by a social constructionist epistemology [52]. The research questions were grounded in a phenomenological and hermeneutic research approach, a preferable method in health psychology [53]. The study relied on idiography, the third orientation of IPA, a detailed examination of every case before producing any general statement [54].

The current study was approved by the Ethics Committee of the University of Derby. The researcher followed the ethical guidelines for research practice of the British Association for Counselling and Psychotherapy [55], the British Psychological Society [56], the General Data Protection Regulation [57], and the Standards for Reporting Qualitative Research [51].

2.2. Participants

Purposive sampling of eight qualified integrative psychotherapists was preferred, a smaller sample, which is common in IPA [54], to explore in-depth the experiences of the participants without acquiring repetitive data [53]. Of the nine psychotherapists invited to participate, eight qualified integrative psychotherapists who provide private services within Greece replied voluntarily, six women and two men. Their age range was 32–56 years, and the average professional experience was 14 years (

Table 1. Participants demographics.

Pseudonym	Age	Gender	Theoretical Orientation	Professional Experience	City
Claire	56	Female	Integrative	25 years	Athens
Nikos	32	Male	Integrative	9 years	Thessaloniki
Rosa	37	Female	Integrative	9 years	Athens & Thessaloniki
Vera	33	Female	Integrative	9 years	Thessaloniki
Fotis	33	Male	Integrative	11 years	Thessaloniki
Lisa	52	Female	Integrative	4 years	Thessaloniki
Rea	50	Female	Integrative	20 years	Thessaloniki
Maria	48	Female	Integrative	25 years	Thessaloniki

). According to different surveys, women are increasingly outnumbering men in practising psychotherapy [58,59,60].

2.3. Procedure

Once the participants had responded to the invitation, the researcher carried out a pilot interview to identify any problems related to the research [61] and then conducted and audio-recorded the semi-structured interviews. Informed consent was obtained from all therapists involved in the study. All interviews were carried out online through the ZOOM platform. The interviews followed three essential parts, namely opening, intermediate, and ending questions [62]. If it was necessary, follow-up questions were asked to clarify concrete aspects. Later, the Jeffersonian notation [63] for transcribing verbatim the interviews was applied, each transcript was analysed, and themes were identified. The chosen method to analyse the research material was IPA [51], a thematic analysis considered a flexible method for accessing participants’ experiences relating to the research question [64,65]. The present study followed the steps proposed for data analysis by Smith et al. [51], (Figure 1).

3. Analysis

Four interrelated themes were identified: Theme 1: The impact of the pandemic on personal and social life, Theme 2: The impact of the pandemic on professional life, Theme 3: Promoting positive adaptation, and Theme 4: Cultivating Resilience (Figure 2) (Table S1–S4).

3.1. The Impact of the Pandemic on Personal and Social Life

During the first period of the pandemic, the feelings of surprise, fear, and anxiety about the unknown as well as a sense of personal and social responsibility were dominant. The majority of the participants named their condition as a crisis that had the characteristics of an emergency and sudden change in daily life and reported existential anxiety, vulnerability, and a crash test, which escalated from the level of health to the economy and social life: The coronavirus pandemic was a threat. A huge threat to health and life… which escalated to other levels, such as finances: “What will happen to the economy?” of each house but also in general, and ours… personally, in our own house… Social… people who were alone, helpless… and couldn’t accept help, precisely because of the threat of the pandemic… The children inside the houses closed… The schools were closed… It was a threat at all levels… (Maria, 9). They spoke about mixed emotions, anger along with anxiety and worry, depressive symptoms along with resignation, and emotional and physical dysregulation: I lost my sleep… I had a hard time… I couldn’t sleep…. It was the first time I had to take a hypnagogic in my life. (Maria, 16).

Reflecting on the middle stage of the pandemic, Rosa names it the pandemic of loneliness: And then, there was absolute isolation… So, this particular pandemic was not just… how to say it, a health epidemic but also an epidemic of loneliness. Not only did it make us feel vulnerable about ourselves, but it isolated us socially and ultimately changed the way we relate and the way we will possibly relate from now on (Rosa, 10). The marital relationships were seriously affected, and intra-family tensions arose: For the first time, we raised a hand to our children. Both me and him… I mean, there were times… when we had to hit him… And it’s something I’m ashamed and sad about, right? And then, we had to manage all this sadness between us… (Maria, 56).

In the late stage of the pandemic, reframing was the result of comprehension and repositioning. The participants focused on their perception of the new reality: As if I had to find myself again, what I am good with and how much I stand, with fear, with protection, with care (Rea, 25). They reported stepping back, and gradually balancing the family relationships: It took us a lot to reflect… as a family, each one alone, how I stand, what I need to do, to talk, to explain to the children some things… So, the challenge was to find our position… (Rea, 13), and mourning the lost relationships: My relations with some of these people have not yet been restored… with most of them, I would say…. So, that was a loss too (Maria, 53).

3.2. The Impact of the Pandemic on Professional Life

In the early stage of the COVID-19 pandemic, the therapists reported a low in requests due to the physical distancing restrictions and the shift to online therapy: Initially, a new way of communication and meetings had to be found, since there could not be a face-to-face meeting… At first, there was an interruption and fragmentary communication, and along the way, we had to find ways, through the internet platforms, like Skype, ZOOM or some others… At first, this brought awkward feelings, resistance, and a lot of resistance from the clients… And: “No, it’s not the same, and I can’t do online therapy… and I don’t want to, and when we open… and so on”, until the permanence of the situation, bent this resistance, because the need was bigger, and somehow the profession was established through the internet… (Rea, 17).

Additionally, sitting in the same boat with clients intensified the therapists’ delicate position: At first, it was very difficult to manage my inner difficulty to function therapeutically… I think, for quite a long period of some months… I worked on the one hand because I felt an ethical obligation to support people, who were in need and were asking me for it… and at the same time, there was also an economic need to work… At the same time, I had to manage my difficulty… In the first period, I lost it and very often expressed my anxiety… (Maria, 16). Furthermore, Rea reflects: “I am here to face your fear and your anxiety, for something, which at the same time concerns me too, and I have my anxiety and my fear”, creating such a… special therapeutic condition… We are in the same boat! So, once upon a time, there was a… how to say it, an agreement, a sympathy, in that “Yes, things are difficult”…, as if we were sitting on the same side of the couch and we talk about it… Other times, I needed to stand VERY well in my position, opposite, to Hold someone, who, probably… had sunk a little more than me… Which was both difficult and helpful at the same time… Μany times I felt to get support from my clients in hard times (Rea, 19).

Moving to the middle phase of the pandemic, all therapists interviewed described feeling fatigued and exhausted due to the increased workload and the continuous change in requests: During the second epidemic wave, I felt a mental collapse… And while cognitively, I could now understand and help with the irrational thoughts, with the obsessions, with all of that, I had the tools, and now I believed that we would survive all this, psychologically… I was also exhausted (Rosa, 26).

Working as integrative psychotherapists amid the pandemic, they referred to the opportunity to use the full quiver of tools they were trained in: Even things that I didn’t use to apply, now, I somehow rediscovered them, remembered them, used them, they found their place… (Rea, 73). All participants mentioned assessing elements of existential psychotherapy, CBT, and Systemic interventions: I can say that during the pandemic, I went back to basics… because there were very structural, let’s say… problems, that had to do with anxiety and obsessions and obsessive thoughts. (Rosa, 75). The systemic context was as follows: “Where are you?”, “Who are you with?” Some people may have been forced to return home due to the pandemic. This is a change in context, moving back home, especially in a hard environment… (Nikos, 85). Rea described her journey as an integrative psychotherapist: I will say…. the phenomenology from Gestalt psychotherapy and the here and now… Because there was no future perspective at all… That nothing is certain… the whole existential part… What it means for everyone, what they experience, how everyone stands against it… The meaning… and beyond that. There was also a part of the Behavioral Cognitive Approach about how I will manage, let’s say, my fear, how I will manage my partner’s resistance to follow me… on a walk, on a ride… how to reassure the child…. Artistic approaches also helped me a lot…. Role-playing… “Me and the disease”, “Me and death”… my phobias… the open accounts, many times, with people who left and didn’t have time… didn’t have time to see them again and say goodbye… There, many times this role-playing technique and the empty chair, somehow, helped to soften this, to be able to somehow… close it… (Rea, 69, 71).

3.3. Promoting Positive Adaptation

Apart from the survival instinct, the primal urge to survive (Fotis, 73), what supported the participants was the activation of personal assets: No matter how much you prepare, a crisis is a crisis… And that’s where abilities come out… what is deep inside you… Regardless of how much you’ve been prepared… At that time, you are working with your reserves, you are not working with what is on your surface. It’s… deep inside. (Maria, 90).

The psychotherapists underlined the importance of self-efficacy: What I think has helped me is, how good I felt with the knowledge and the skills I had as a therapist… It wasn’t something that I was questioning, how much I knew or not. I was very sure of what I could do with people, and that’s why I did it, despite my difficulty… (Maria, 90). The motivation to protect her family was a strong driving force for one of them: I remember having great anxiety, which was very clear though, that it was my love, that gave me strength… Now, I need to protect my family… as a mother, wife, and person… I had a role… (Maria, 18). Two psychotherapists mentioned their family history: And let me tell you that it was also an element of… my family. My parents left Cyprus in 1974 when the Turks invaded Cyprus, but they started again from scratch… It was in their nature… (Lisa, 47). Another part that always gives me strength is my family history. I mean, I know from my parents, how much they have fought… Immigration, refugee, it is an intergenerational one… Which I think is probably also for all Greeks, but I have experienced this in my skin… This is the model, especially of my father, whom I loved very much, that “OK, we are fighting in Life”… So, this inspires me. These are the messages I stand by in life, and they give me strength too. (Maria, 42).

Despite all the difficulty, they also noted the moments of gratitude: At the same time, it was a huge blessing to feel that I am at home, in security, with people I love, to be able to protect my children, to have a livelihood, to have our health… (Maria, 40).

Cognitive assessment and cognitive restructuring proved supportive tools as well as having realistic expectations, neither to try to beautify it nor to be in denial that something bad could happen to me too… (Vera, 49), and positive emotions, such as staying in flow and nurturing self-care: The correct assessment of my capabilities (Fotis, 63), willpower and courage that We will make it, as well as love, hope, and faith in God: A deep belief that: “All this is done for good”… and a belief in God… And let’s show trust, let’s do what we can, not passively and fatalistically, not at all… (Maria, 42).

Humans are social beings, and although the social restriction during the coronavirus pandemic created a rift in social relations, all participants found alternative ways of connecting with their social resources: There wasn’t the degree and the frequency that was before, however… to a large extent, contact was maintained with 2–3 families, this bubble that we have created… more as a need of the children, with friends, or classmates and neighbours and there was a stability to it. In other words, there was no complete isolation. (Rea, 39). Even in the professional field, creative ways of meeting together were found: Sometimes, I held meetings in open spaces. Like a park bench… walking on the beach… We found alternative ways to meet and conduct therapy. (Rea, 17). In addition, in peer groups, the psychotherapists had the opportunity to exchange information, support, and empowerment for each other: Daily communication with colleagues… We shared things, supported each other, and enacted the weekly… online drinks… (Fotis, 49).

They all emphasised the significance of ongoing personal therapy and supervision: I think supervision helped me… I got fewer clients than I would have under normal circumstances, and I got easier incidents… Personal psychotherapy… because no matter, how much you worked with yourself when you’re faced with something like this, I think that all the things you think you’ve worked on (laughter) are mobilised and resurface, as if you’ve never worked on them… (Rosa, 28).

All participants enhanced self-care by focusing on healthy food choices, good sleep, contact with nature and animals, physical exercise, and avoiding alcohol or toxic substances. For half of them, the psychosomatic symptoms played the role of alarm and awakening: Psychosomatics help me a lot… It was a body alert. To learn to listen to my body better and not to criticise it… (Fotis, 75). Rosa described the following: To be flexible, to listen to me on what I need… and to allow myself to lower the rhythms. When I see myself reaching its limits, I try to understand what hurts me, bothers me, stresses me, and tries to remove this stimulus. If my work is something I can’t stand, reduce it, at least some hours, if it’s not possible to reduce it, to take easier cases… (Rosa, 73).

3.4. Cultivating Resilience

The majority of the therapists illustrated a process of self-regulation due to the ability to adapt and stay open to the experience. The current major personal, professional, and social crisis ultimately ended up strengthening autonomy, empowering growth, and enhancing self-esteem: Now, I’m… a little more realistic that things might not work out, but it’s a joy to be able to follow the process, what they say, the road… That’s what joy is. I am sure. And for the fact, how much I supported my family, and I’m happy for myself… and for all of us, because we all did it together. I didn’t do it alone. (Maria, 65).

Self-compassion, mindfulness practice, and emotional processing of the experience was another critical point of positive adjustment: To be able to know what I feel, all that I feel…. because things happen and I am in contact with the environment…. the pandemic, let’s say and the anxiety it causes me, but… to be able to bear all this within me (shows balance with hands)… both emotionally and physically and mentally… To be able to hold me in a balance… To be able to manage the stress, all these emotions that I feel, because things happen in my life… And not to overpower one and eventually… I fall apart… as a person, but to keep me in one piece… OK, yes, I have anxiety, but I also have this, I have that, I have fear, I have anger and love and I am ALL. And to find the source of strength. (Maria, 35).

Mastering their environment, they could use the pause as an opportunity for personal changes and rediscovering nature: The pandemic was a pause that gave me the opportunity for introspection, readjustment, changes and realisations (Claire, 21). Furthermore, the participants noted a sense of responsibility towards themselves and others, finding a common place to meet: So, that was something… finding WHERE I can meet you, IF I want to meet you AND IF you want to meet me as far as it is OK for you and as far as it is OK for me, sort of. I think it was all so new and so experimental that we discovered our creativity… and our flexibility. (Rea, 49). They emphasised the importance of interconnectedness: The COVID pandemic… this invisible disease was just that: How can another person’s actions have an impact on me, how can my actions have an impact on another human being… That could maybe also be considered a positive part… Through the pandemic, we have seen that this mentality of “I should be fine” or “My house should be fine” ultimately does not work… (Vera, 13, 17), and they supported the realisation that this particular crisis can only be overcome as a common goal.

In addition, technology opened new roads: One, let’s say in professional life, one of the positive outcomes was that, before I was working online, it was something that, as I said before, brought resistance, clients didn’t choose it, and now it’s something that’s taken for granted. It has been approved. So, I can work… I live in Thessaloniki with people from all over the world… And this is considered normal, and it happens… Another positive outcome is that many seminars were held on campus, and I had to travel to foreign countries to participate in them, now, they are done online. So, I can watch them from my home… (Rea, 59).

Furthermore, they reflected on a new balance through reframing: All our experiences are tools for our work. And a crisis like that, it’s very different when it’s a lived experience and when it’s just something I heard, or something I read, or something we were trained in… The truth is that we heard about crises and we were trained in how to manage crises… but I think now, the experience after all of these crises came and established it for good. (Vera, 177). Moreover, self-acceptance enhanced self-confidence and the internal locus of evaluation of the experience and oneself: My sense of security does not lie in what comes from the outside and what they impose on me from the outside… My sense of security also lies in what I consider capable, suitable, and safe for me… Both at the level of health, the level of work, and at the social level. And political even, if you want… So, it was very important to me not only to be obedient… but also responsible at the same time for my principles, judgment… my knowledge too… (Rea, 27)

Additionally, by finding deep resources in herself, Maria illustrated her sense of coherence: To be whole. I am not just my fear… I am afraid of something, there is a crisis or a challenge, so I have to endure something. So, there, I need to have with me all the parts that have nothing to do with this particular part, which are other parts of me. To be here whole (Maria, 37).

4. Discussion

4.1. The Impact of the Pandemic on Personal and Social Life

During the early phase of the outbreak, the main topic named by the participants was “crisis” (

Table 2. The impact of the pandemic on personal and social life.

	Sub-Themes	Codes
Early stage of the pandemic	Crisis Crash test	Emergency Sudden change of everyday life Escalating threat Vicarious trauma Existential anxiety Vulnerability Uncertainty Fear of the unknown Fear of infection Emotional dysregulation: Anger, anxiety and worries, depressive symptoms Resignation and Catastrophising Somatization (Sleep and Sexual disturbances)
Middle stage of the pandemic	The pandemic of loneliness Dispute	Introversion Social isolation Fear of physical proximity Changing the way of relating Dilemmas and sense of responsibility Intra-family conflicts Guilt Polarization Shaking part of the political, scientific, social and ethical beliefs Lack of trust Anger because of the contradictory information
Late stage of the pandemic	Reframing	Comprehension and repositioning Focus on personal perception of the new reality Gradually balancing the social and family relationships Grieving the losses in relationships

).

The term crisis signifies an emergency and a reversal to a steady state that includes unforeseen and quick changes while individuals have limited control and are called to adjust themselves to the circumstances in a short time [66]. Aligned with evidence, which indicates that the psychological effects during the COVID-19 emergency may be alleviated by individual traits and social determinants [8], all participants reported a sense of urgency and escalating threat, sudden change in everyday life, and uncertainty about tomorrow, a situation that has reactivated unresolved conflicts from previous experiences, leading to reactions of excessive disorganisation.

Moving into the peak of the pandemic, they expressed existential anxiety, vulnerability, uncertainty, fear of the unknown, and psychosomatic symptoms, such as sleep, hormonal, and sexual disturbances, findings that agree with systematic reviews during the pandemic [9,12]. The COVID-19 pandemic was mass destruction, an extraordinary condition that caused large-scale losses and social damages and concerned the global community [4]. Such stressful events are particularly traumatic because they shatter human adaptation to life, have multiple consequences, and are crucial for people’s physical and mental health [9]. All interviewees agreed that fear of infecting themselves or transmitting the virus to other people led them to avoid physical proximity to reduce risk, findings in line with the foregoing studies, which underline that the quarantine interrupted personal and professional routines, limited social interactions, and decreased the possibilities for social support, leading to pandemic fatigue [8,30,67]. Recent evidence underlines the essential role of social connection and companionship during crises, especially when physical proximity is not recommended [8,16,30,68]. Furthermore, the participants reflected on intra-family conflicts, findings that align with a growing corpus of research that highlights the enormous challenges faced by families during the disease outbreak and the sharp rise in domestic violence [69,70].

In the late stage of the pandemic, there was a reframing through cognitive processing and focusing on personal perception of the new reality. By embracing impermanence, the idea that everything is forever in flux and ever-changing [71], and grieving their losses in relationships, they gradually balanced their social and family relationships.

4.2. The Impact of the Pandemic on Professional Life

All integrative psychotherapists referred to the particular condition of being in the same position as clients, which intensified the difficulty of balancing their insecurity and vulnerability with professional responsibility (

Table 3. The impact of the pandemic on professional life.

	Sub-Themes	Codes
Early stage of the pandemic	Pause We are at the same boat Working as Integrative Psychotherapist	Pause turning into online therapy sessions Feeling left alone Lack of guidance, support and information Change of requests Countertransference: Difficulty in balancing the personal difficulty with the professional responsibility Dynamic process Practicality Flexibility and Creativity Working parallel in many levels Trying new techniques and rediscovering the old ones
Middle stage of the pandemic	Fatigue Broad use of technology Integration of methods	Increased workload & Change of requests Psychological breakdown Sense of responsibility Sessions held online or in combination with in vivo Online trainings, Online supportive groups Utilizing the entire quiver of tools Integration on Mind-body-emotions Systemic interventions CBT—PCA—Focus on Here and Now—Existential Psychotherapy Psychodynamic Approaches—Psychoeducation—Gestalt Therapy Role playing—Counselling Artistic interventions Visualisations
Late stage of the pandemic	Self-regulation	The meaning of psychotherapy in the era of the pandemic Stepping back Self-care

), findings that agree with recent research [18,21].

During the second phase of the disease outbreak, they reported experiencing stress and fatigue due to increased workload, the constantly changing demands, and difficulty in countertransference management, along with a sense of responsibility towards their clients despite mental exhaustion, findings that align with a rich body of earlier studies, which proved an expanded risk of symptoms of anxiety, depression, burnout, compassion fatigue, and PTSD and vicarious traumatisation on mental health professionals [10,21,23].

On the other side, working as integrative psychotherapists, they were able to enlarge the limitations of a single approach and incorporate a multidimensional and synergetic theoretical background of therapeutic methods, taking into account different aspects of human functionality to respond to the uniqueness and the individualised needs of each client in a dynamic perspective [72,73]. They applied the existential approach [71], systemic interventions [74], the person-centred approach [75], cognitive behavioral therapy [76] interventions, eye movement desensitization and reprocessing (EMDR) [77], counselling techniques and psychoeducation [78], gestalt therapy [79], and mindfulness practices [80,81] to reduce physiological arousal and optimise stress responses, facilitate progressive relaxation, and maintain social functioning, findings that confirm previous research [82]. Psychoeducational interventions and psychological support seem to reduce fear of the coronavirus and potentiate resilience [18], and CBT, EMDR, and trauma-focused psychotherapies proved beneficial in the first epidemic waves. At the same time, holistic psychotherapeutic approaches were efficient in reducing anxiety and distress in emergency periods [78].

4.3. Promoting Positive Adaptation

A crisis can become a catalyst and cause new responses to the adaptive mechanisms of the organism, leading to new actions; therefore, people in a crisis may need to integrate appropriate social resources and individual adaptive responses to regain the lost equilibrium [67]. The participants have associated positive adaptation with personal assets, such as individual strengths, cognitive assessment and positive emotions, nurturing social networks, and enhancing self-care (

Table 4. Promoting positive adaptation.

	Sub-Themes	Codes
Personal assets	Activating personal strengths Cognitive assessment The family history Positive Emotions	Self-awareness and Self-compassion Motivation to protect the loved ones Self-efficacy Acceptance, Flexibility, and Humour Cognitive restructuring and emotional processing of experience Realistic expectations Signification The family history Gratitude, Flow, Love, Hope, Faith in God, Courage Motivation to protect the family
Social resources	Supportive networks Supervision and Personal Therapy Technology Information	Supporting a common aim Supportive networks—Peer groups Exchanging info and experiences Ongoing Supervision and Personal Therapy Appreciating relationships Discovering adaptive ways of socialization Finding a common place to meet and new roads of communication Online sessions Online trainings Selected update Limited exposure to the media
Enhancing self-care	Emphasis on well-being Contact with nature and animals	Physical activity Healthy dietary choices and Good sleep Taking time for the self Listening to the alarm of the body Creating a healthy routine Mindfulness practice and Meditation

).

Personal assets are character strengths that promote flourishing and buffer against adversities fostering positivity and coping with challenging obstacles [24]. The psychotherapists have reported that positive emotions, such as gratitude, kindness, flow, hope, and mindfulness, have supported them to mitigate the consequences of anxiety and negative emotions during the pandemic. A rich body of research during the COVID-19 outbreak indicates a positive relationship between gratitude [83], well-being [84], hope and adaptability [85], tolerance of uncertainty [6], flexibility [86], optimism [87], and faith [37] with resilience. According to research, spirituality and religious practice allow individuals to connect with larger values and a more benevolent meaning and direction in life [24,88]. Furthermore, the participants reflected on their experiences of compassion and love as master forces for overcoming adversity. Compassion includes the recognition of the imperfection and pain of others as well as one’s own, along with the ability of kindness and the willingness to take action [73]. Love and compassion are powerful motivational resources that enhance understanding, acceptance, and an expanded sense of meaning and purpose [24]. Moreover, family history seems to enhance connectedness, providing mutual support and commitment to one another and nurturing the individuals [34].

4.3.1. Social Resources

The lack of social connectedness intensified stress, pandemic-specific worries, mental fatigue, and psychosomatic symptoms. On the other hand, the psychotherapists expressed their appreciation of the value of human touch and closeness, and later, they reshaped the current dilemma as discovering adaptive ways to nurture and support each other rather than social distancing, physical distancing, and social connectedness. Numerous recent studies indicate that social capital alleviates the effects of psychological distress [14,68,88] and protects therapists against professional worries, the risk of burnout, and vicarious trauma [8]. As the usual support networks were not as available as before the pandemic and maintaining friendships became critical, peer groups offered a sense of belonging, empowering the practitioners to discover creative ways to overcome adversity [89] as well as being a form of supervision and personal therapy [90].

Among all the transformation processes that occurred during the disease outbreak, the turn in technology and digitalisation changed how psychotherapists work, interact, cooperate, teach, and learn [91,92]. As online psychotherapy has been proven to be similarly effective as in-person, and the earlier obstacles, such as the lack of technological expertise, could be overcome; teletherapy offered professional and social integration without geographical limitations and became a preferable tool among psychotherapists and peer groups [93].

4.3.2. Enhancing Self-Care

Self-care refers to a wide range of habits and activities that ensure that both physical and emotional needs are being met and involves conscious participation in activities that promote healthy functioning, enhancing well-being and quality of life in the mental, emotional, physical (healthy diet, physical exercise), environmental (contact with nature), spiritual (meditation), and social domains (social networks, work–life balance) [90]. All interviewed therapists mentioned the crucial role of physical activity [94], healthy nutrition, contact with nature and animals [78], and the quality of sleep [12,13,47].

4.4. Cultivating Resilience

Reflecting on the experiences of the last three years, the participants realised that any life is a life of change. Being able to tolerate uncertainty and face the experiences of transition in work and relationships in parallel with the changes in the world, minimising the risk of psychological distress and depression, they could self-regulate and maintain balance. Therefore, they were able to cultivate wholesome qualities and use the crisis as an opportunity for personal changes. According to their narratives, crucial factors for positive adaptation were the ability to accept the flow of life, remain optimistic and creative, and discover unexpected paths for overcoming adversity, findings that align with data from recent research [85,86,87].

By mastering their environment, the therapists could overcome the shrinking of their world and maintain a sense of responsibility (the ability to respond) towards themselves and others, through altruistic behaviour and generosity, interconnectedness, and radical compassion.

As the individuals were called upon to discover new ways of being through reframing, the conditions for change were created. The ability to create meaning, re-evaluate the changing situations, and modify coping mechanisms instead of remaining fixed on the old strategies, enhanced coherence, a crucial quality for resilience, highlighted by earlier research [27].

Finding a new balance, the psychotherapists experienced personal growth, empowering their self-esteem (

Table 5. Cultivating Resilience.

Sub-Themes	Codes
Self-regulation	Adaptability—Openness in the experience
	Accepting the Flow of life
	Personal growth
	Self-acceptance
	Enhancing of self-esteem
	Courage
Environmental mastery	Rediscovering nature
	Opportunity for personal changes
	Interconnectedness
	Sense of responsibility towards oneself and the others
	Generosity
	Polite way of contact
	Radical compassion
Reframing	Finding a new balance
	Softening behaviours
	Enhancing self-confidence
	Internal locus of evaluation of the experience and oneself
	Autonomy
	Coherence

). This process describes the building effect of resilience [95], which occurs when individuals can transform a crisis or a traumatic experience into post-traumatic growth [16].

5. Strengths, Limitations, and Future Directions

Despite the corpus of quantitative research focused on resilience in mental health professionals in Greece [17,18,85], the present qualitative study presents detailed documentation of the way eight qualified integrative psychotherapists reflect on their experiences during the COVID-19 outbreak and their adaptation strategies on both a personal and professional level. Choosing qualitative methodology invites comments about the validity and reliability of the analysis since the findings are not statistically tested, the implication to the general population is limited [65], and the authenticity of the findings relies on the narrations of the participants and on the researcher’s capability to be innovative while immersing herself in the data [61]. Another limitation is that, despite the researcher’s purpose to ensure the homogeneity of the sample, the female participants are three times greater in number than the males. Even though the percentage ratio corresponds to the average of psychotherapists in Europe and the USA [59,60], the researcher acknowledges that the lack of homogeneity can affect the results of the study since evidence during COVID-19 showed that women are more exposed to the negative consequences of the pandemic than men [96]. The researcher understands that there is no neutral, uninvolved approach while conducting a qualitative study [64]. During this time, the story changes and grows, and multiple factors influence the ongoing process, including new information surrounding the perception of adversity and the cultural context in which the individuals live.

6. Conclusions

Providing psychological rehabilitation, psychotherapists are exposed to the clients’ fear, loss, guilt, shame, frustration, and anger, and still, they accompany them to weave together the strands of life, find meaning and strength in themselves, and help them reconnect and integrate their new identity as having withstood daunting times. As the focus of recent research is currently shifting from the diminished psychological functioning and the harmful after-effects of the coronavirus outbreak on mental health towards the concept of resilience for reducing the risk of occupational hazards and therapist impairment and promoting successful adaptation, the present study explores how integrative psychotherapists have experienced the COVID-19 pandemic and how taking a broad perspective on the problem could facilitate coping mechanisms and generate creative solutions for overcoming adversity. In times when the possibility of existential disasters, including climate change, wars, refuge dislocations, disease outbreaks, or terrorism, is increasing, the incorporation of research and education programs on the psychological capital of resilience for healthcare professionals to effectively manage and respond to the psychological and behavioural challenges of future crises is not a luxury but essential to human survival.