Resilience, Psychological Distress, and Mental Health Attitude among Clinical Psychologists during COVID-19 Pandemic: Moderating Role of Coping Strategies

Faryal Zafar* and Asad Javed

Riphah Institute of Clinical & Professional Psychology, Riphah International University, Lahore, Pakistan

*Corresponding Author: [email protected]

Abstract

Clinical psychologists deal with a variety of job-related stressors. One significant stressor involves the exposure to a critical or stressful situation. To manage the untoward effects of exposure to such situations, these professionals use a variety of coping strategies. Therefore, the current study examined the effectiveness of resilience skills, as to how resilience tends to improve the distress and well-being of a person. Moreover, it also identified the moderating role of coping strategies in seeking mental health services among clinical psychologists who were exposed to COVID-19 patients in a stressful environment. A purposive sampling technique was used to conduct the current study. A sample of 200 female clinical psychologists, working in different government hospitals across eight districts of KPK, Pakistan including districts Abbottabad, Bannu, Charsadda, Dera Ismail Khan, Kohat, Mardan, Nowshera, and Peshawar. A demographic information sheet, Depression, Anxiety, and Stress Scale (DASS-21), The Brief Coping Oriented Problems Experienced Inventory (Brief COPE), Brief Resilience Scale (BRS), and Attitude towards Seeking Professional Psychological Help (ATSPPH-SF) were used to collect data. Pearson product moment correlation, linear regression, and moderation analyses were executed to test the hypotheses. Findings revealed that the moderating role of coping strategies plays a vital role to deal with psychological distress. Effective coping strategies can improve resilience and decrease psychological distress. The study concluded that resilience and psychological distress are negatively correlated, and a high level of resilience can decrease psychological distress which is beneficial for the psychological well-being of a person. The study also determined a positive linkage between coping strategies and psychological distress.

Keywords: clinical psychologists, coping strategies, COVID -19, mental health attitude, psychological distress, resilience

Introduction

Pakistan is a developing country, where people confront various challenges in multiple fields with limited resources.  For the last few decades, the developing threat of terrorist attacks and natural disasters including earthquakes, floods, and communicable and non-communicable diseases such as HIV, cancer, dengue, and COVID-19, which require active emergency response has increased. The outbreak of coronavirus named as COVID-19 pandemic was initiated and declared on 11th February 2020. In order to better compete with this virus, stringent rules of physical distancing, quarantine, and lockdown were practiced. These rules were implemented for the assistance of the community such as physical distancing, loneliness, fear of infection, marital conflicts, and loss of income which led to huge suffering and mental health issues among people (Joshi & Sharma, 2020). After the pandemic began, clinical psychologists were also exposed to COVID-19 isolation wards, and a few of them provided online services through helplines. Telephonic counselling and therapeutic services proved to be effective for people who were experiencing undesirable feelings. However, the nature of the workload on practitioners during the pandemic was emotionally challenging which was left unsolved and proved to be hazardous for emerging complications among them (Joshi & Sharma, 2020).

Resilience can be explained as "the method of well-adjusting to adversities, tragedies, trauma, and threats. A resilient individual is one who effectively manages his/her stress and views stressful situations positively, that is, easily adopts according to the changes, and effectively deals with adverse situations in life (Fung, 2020). Higher levels of psychological distress cause impaired mental health and may reproduce communal mental syndromes, such as depressive and anxiety disorders (Viertio et al., 2021). There is one predominant indication of distress among psychologists" depression. A survey has revealed that most of the mental health workers have experienced at least one episode of clinical depression. However, not every health professional who is vulnerable to life-threatening incidents experiences psychological distress since certain protective factors act as a shield from the adverse effects of serious incidents (Ashikyan, 2005).

Mental health is an indicator of the social life of a population. The increasing level of morbidity and mortality is a sign of social as well as individual malaise. In most parts of the world, mental health and mental illness are largely ignored or neglected, resulting in an increasing burden of mental disorders in the community and a widening of the "treatment gap.” The community showed a kind, and non-stigmatizing, however, pessimistic attitude towards the future of people suffering from mental illness. At the same time, participants also felt that maintaining social relationships with these people should be restricted (Sayers, 2001).

Lazarus and Folkman (1984), defined coping as actions performed by individuals to recognize and connect with situational or different environmental stresses in their lives. According to a study (Schoenmakers et al., 2015), people experience loneliness when there are discrepancies between the relationships that they want and the relationships they have. Such discrepancies can be resolved by lowering expectations and improving the relationships. Relationships can be improved by developing innovative friendships or redeveloping the interaction through old ones, which is basically a problem-focused mode of coping. Lowering expectations occurs through the caparisoning of one's self with somebody who is inferior, which is called emotion-focused coping. These two coping methods also enhance resilience among individuals

Literature Review

Life is an exciting game of provocation and comeback cycle that continuously drives on. Psychologists, just like the general public, also deal with stressful situations probably due to their hectic duties placed on them. Their professional worries prone them to suffer owing to which they may face mental health problems in their lives. A study was conducted on the psychological well-being of healthcare experts during the COVID-19 outbreak in 2020. This study identified mental health concerns and emotional resilience of healthcare specialists who were in close connection with effecters. It was discovered that psychological resilience is linked with mental well-being. The study identified that enhanced resilience leads to decreased psychological distress among healthcare professionals (Bahar et al., 2020). On the other hand, Del Olmo-Romero et al. (2019) carried out a survey concerning psychological complaints using a sample of specialists employed concisely to psychological health areas in Spain, Portugal, and Italy. They concluded that psychologists and social analysts had the utmost encouraging approaches toward mental illness, while nursing assistants showed more negative attitudes. However, worldwide, mental health specialists have an encouraging attitude towards mental sickness. Another study conducted on Indian psychiatrists in 2020, envisioned to determine the stressors faced by mental health professionals during COVID-19 which put them at burnout risk. The study revealed that an ongoing pandemic, with the increased ratio of people seeking online counselling, leads to the greatest upsurge in informed mental health problems among Indian professionals. Emotional contagion, apparent stress, fatigue, traumatic stress, poor healing efficacy, and longer duration of treatment were among the contributing factors that increased burnout risk among mental health practitioners (Joshi & Sharma, 2020). Another study (Bukhari & Ejaz, 2020) carried out in Pakistan identified the level of distress among students. The study selected fresh graduates from various universities in Islamabad and Rawalpindi. It was also concluded that there is a negative association between total adjustment and psychological distress among freshly joined students in higher education institutions. A positive relationship was found between overall adjustment and coping strategies. This study also concluded that many psychologists receive therapy services which were found to be helpful.

Likewise, while working in a mental health setting, Chang et al. (2019), conducted a cross-sectional study in Singapore on 470 psychological health experts. Their research aimed to determine the association between resilience and associative stigma among a group of experts. The findings exhibited that age remained suggestively accompanied by resilience, wherever older age individuals forecasted greater bounciness scores. Individuals whose household members or colleagues were spotted with a mental sickness had suggestively greater resilience outcomes as compared to those who did not. While considering the barriers faced by professionals to seek assistance, Bearse et al. (2013), conducted a study on blockades to psychologists in looking for mental health care, this study revealed that there are a number of barriers to seeking specialized assistance comprising social disgrace, treatment reservations, emotional distress, predictable risks, and self-revelation. Societal customs and self-image may also influence the decision to pursue therapy. This study suggested that many psychologists receive therapeutic services which were found to be rather helpful. However, some factors obstruct their service-seeking behavior from pursuing therapy at the times when they desire it.

To better understand self-consideration and psychological distress in association with the therapeutic process and mindfulness, Bourgault and Dionne (2018) conducted a cross-sectional study on French Canadian psychologists. The results of this study concluded that mindfulness was significantly related to self-consideration among psychotherapists. The outcomes also showed specifically that the greater the extent of mindfulness among psychotherapists', the less they would undergo mental discomfort. Awad et al.  (2022) investigated the relationship between coping strategies and resilience, taking into consideration the moderating role of emotional regulation. Their cross-sectional study concluded that lower expressive suppression was significantly associated with more resilience in individuals with high problem-focused engagement and emotion-focused engagement. Individuals with high problem-focused disengagement and high expressive suppression were significantly associated with less resilience. Similarly, another cross-sectional study was conducted in Greece by (Galanis et al., 2023). Their study investigated the impacts of resilience and social support on anxiety, depression, and quality of life among patients with post-COVID-19 syndrome. Multivariable analysis identified that resilience and social support reduced anxiety and depression among patients. Additionally, a significant positive relationship was determined between resilience, social support, and quality of life.

Rationale

There is a dearth of analytical studies about the pervasiveness of psychological distress among mental health professionals in Pakistan. Moreover, existing studies mostly communicate about the strain of life-threatening incidents, on their survivors/sufferers, however, there is less consideration given to psychologists, their work-related stress, and how they manage it. Therefore, the study at hand attempts to determine the connection between resilience and psychological distress. Additionally, it also aims to identify the moderating role of coping strategies that were used by clinical psychologists who had been consistently dealing with patients during COVID-19 in various healthcare units. Moreover, the study also identified the moderating role of coping strategies used by clinical psychologists in perceiving mental health care. The findings of the study would play an important role in handling mental discomfort. Moreover, these findings may also help to recognize stress-coping approaches and resilience skills in a better way to benefit mental health specialists.

Objectives

The current study attempted to meet the following objectives:

• To analyze the relationship concerning psychological distress, and the role of resilience skills
• To investigate coping strategies that help clinical psychologists who were dealing with COVID-19 patients during a pandemic era in a stressful environment.
• To identify the moderating role of coping strategies used by clinical psychologists in seeking mental healthcare during COVID-19 pandemic

Hypotheses

H1: There would be a significant negative relationship between resilience and psychological distress.

H2: There would be a negative relationship between problem-focused coping strategies and psychological distress among clinical psychologists.

H3: There would be a positive relationship between emotional-focused coping strategies and psychological distress among clinical psychologists.

H4: Psychological distress would show a positive association with avoidant-coping strategies among clinical psychologists.

H5: There would be a positive relationship between resilience and mental health attitudes among clinical psychologists.

H6: Mental health attitudes would be positively associated with coping strategies among clinical psychologists.

H7: Resilience and coping strategies would predict psychological distress among clinical psychologists.

H8: Resilience and coping strategies would predict mental health attitudes among Clinical Psychologists.

H9: Coping strategies would moderate resilience, psychological distress, and mental health attitudes among Clinical Psychologists.

Method

Research Design

The current study followed a correlational research design.

Participants

The study enrolled a sample of 200 designated female clinical psychologists using a purposive sampling strategy from public hospitals located in the different districts of Khyber Pakhtunkhwa (KPK), Pakistan including Abbottabad, Bannu, Charsadda, Dera Ismail Khan, Kohat, Mardan, Nowshera, and Peshawar. The sample age ranged between 25-35 years (M = 28.76; SD = 3.19). All the study participants had dealt with COVID-19 patients and worked in COVID-19 wards and isolation centres in hospitals/healthcare units during the pandemic. They had a minimum of two years of experience and were Muslim. The given below Table 1 shows the participants' information.

Table 1

Descriptive Analysis of the Demographic Variable of the Study (N=200)

Assessment Measures

Participant Information Sheet

A participant information sheet was designed for the present study that was used to obtain personal and family-related information about the study participants.

Brief Resilience Scale (BRS)

The BRS was developed by Smith et al. in 2008, to study the apparent ability of an individual to bounce back or get well from strain. This scale inspects the individuals to decide how much they reach agreement or disagreement with the statements. Each answer is assigned a number. It is a 5-point Likert-type scale that ranges from Strongly Disagree (1) to Strongly Agree (5). As item 2 (I have a tough time making it over stressful events), item 4 (It is tough for me to snap back when something bad happens), and item 6 (I tend to take a long time to get over set-backs in my life) are reverse-scored. The Cronbach's α value for resilience is .60 which indicates low internal consistency (Taber, 2018).

The Brief Coping Oriented Problems Experienced Inventory (Brief-COPE)

The Brief-COPE was developed by Carver in 1989. It consists of 28 items; it is self-report inquiry form which measures healthy and unhealthy behaviors to deal with a stressful life occurrence. It can help to identify adaptive or maladaptive styles of coping. The inventory determines somebody's prime coping styles through scores on subsequent three subscales: problem, emotion, and avoidant focused coping. The Brief-COPE items are rated on a four-point scale which is marked as:1 = I usually don't do this at all; 2 = I usually do this a little bit; 3 = I usually do this a medium amount, and 4 = I usually do this a lot. The Cronbach's α value for the coping strategy scale is .86 which indicates high internal consistency (Taber, 2018).

Depression, Anxiety and Stress, Scale -21 (DASS-21)

This scale was industrialized by Lovibond and Lovibond (1995).  It is a self-report inventory specifically proposed to evaluate the adversative emotive states of depression, anxiety, and stress. There are 21 items in this scale with four response options: 0 = Did not apply to me at all–Never; 1 = Applied to me to some degree, or some of the time–Sometimes; 2 = Applied to me to a considerable degree, or a good part of time–Often, and 3 = Applied to me very much, or most of the time–Almost always. Items 3, 5, 10, 13, 16, 17, and 21 measure feelings of dejection, despair, worthlessness, self-criticism, lack of interest in activities, low ability to seek pleasure, and inactivity. Items 2, 4, 7, 9, 15, 19, and 20 measure palpitation, hyperventilation, nausea, anxiety, and subjective experience of anxious affect, Items 1, 6, 11, 12, 14, 19, and 20 measure the levels of long-lasting nonspecific arousal, difficulty in getting relaxed, being easily distracted/restless, short-tempered/over-reactive, and intolerant. The Cronbach's α value for this scale is .90 which indicates high internal consistency (Taber, 2018).

Attitude towards Seeking Professional Psychological Help (ATSPPH-SF)

The 10-item ATSPPH-SF was used to evaluate wide-ranging attitudes toward psychological help-seeking. Statements are valued on a 4-point Likert-type scale ranging from (3 = Agree, 0 = Disagree). Among 21 scale items, items 2, 4, 8, 9, and 10 are reverse counted and are linked with lower levels of stigma contrary to psychological illness (Fischer & Farina, 1995). The Cronbach's α value for the ATSPPH-SF is .60 which indicates low consistency (Taber, 2018).

Ethical Considerations

The study was approved by the institutional review board of the university. In addition, permission was sought from the concerned hospitals before data collection. Furthermore, study participants were briefed about the study purpose and their role as participants. They were assured of the confidentiality of their information. Participants also provided informed consent before their participation.

Procedure

The set of assessment measures was distributed among all the clinical psychologists. The selected participants were briefed regarding the aim of the study and their rights as research participants. Moreover, they were also asked to fill out consent forms before their inclusion in the study to ensure their voluntary participation. The research proceeded while keeping all principal considerations into account.

Statistical Analysis

The study used Statistical Package for Social Sciences (SPSS) version 20 to test the hypotheses.

• Correlation was used to identify the relationship between variables
• Regression was used to see the predictors
• Moderation analysis was conducted to determine the moderating role of coping strategies in psychological distress and mental health attitudes among clinical psychologists

Results

The analysis was performed in three steps. Firstly, demographic variables were analyzed by calculating frequency, percentage, mean, and standard deviation for the demographic data. Secondly, the relationship between the study variables was assessed by using correlation analysis. Finally, the regression analysis and moderation were performed to determine the predictive and moderating associations.

Table 2 shows the correlation between variables. Findings suggest that psychological distress in terms of depression, anxiety, and stress did not show any significant association with coping strategies. Distress also showed a negative association with resilience; however, this relationship was not significant. So, H1 was not approved. The results also indicated that H2 was not accepted because no significant association was observed between problem-focused coping strategies and psychological distress. H3 and H4 were approved because psychological distress showed a significant positive relationship with avoidant and emotional-focused coping strategies among clinical psychologists. Results also showed a weak positive correlation of mental health attitudes with resilience and coping strategies such as problem and emotion-focused coping. Given that, H5 and H6 were approved showing a meaningful association between resilience, coping strategies used by clinical psychologists and their mental health attitudes.

Table 2

Correlation between Psychological Distress, Resilience, Coping Strategies, and Mental Health Attitudes (N=200)

Note. DASS_T= Depression, Anxiety and Stress Scale, BRS_T= Brief Resilience Scale, BCS_T= Brief Cope Scale, PFC= Problem-focused Coping, EFC= Emotional Coping Scale, AC= Avoidant Coping, ATSPPH_T= Attitude towards Seeking Professional Psychological Help the result for sample of women (N=200) are **p<.01, *p<.05

Table 3

Predictors of Psychological Distress among Clinical Psychologists (N=200)

Table shows regression analysis where the dependent variable is psychological distress, while the independent variables include resilience and coping strategies. Value of R^2, .28 displayed that predictor variables explained 28% variance in outcome variable with F(2,197) =39.02, ***p<0.001). Findings revealed that resilience negatively foreseen psychological distress (β= -.31, p<0.001), whereas coping strategies have significant consequences on psychological distress (β= .42, p<0.001). Given these findings, H7 was approved.

Table 4

Predictors of Mental Health Attitude among Clinical Psychologists (N=200)

Table 4 illustrates regression analysis where dependent variable is mental health attitude, while the independent variables are resilience and coping strategies. The R² value of .79 shows that the predictor variables enlightened 79% variance in the outcome variable with F(2,197) =8.49, p<0.001). Findings revealed that resilience has non-significant consequences on mental health attitude (β= .16, p> 0.001), whereas coping strategies have significant consequences on mental health attitude (β= .24, p<0.001). According to the findings, H8 was approved.

Table 5 indicated that the interaction effect is not significant suggesting no moderating impact of coping strategies on the association between resilience and psychological distress. Following on these results, H9 was not approved.

Table 5

Moderate effect of Resilience, Coping Strategies and Psychological Distress among Clinical Psychologists (N=200)

Discussion

The current study aimed to discover the connection between resilience and psychological distress and coping strategies that benefited clinical psychologists who had been exposed to COVID-19 wards/healthcare units. Additionally, it also explores the moderating role of coping strategies of clinical psychologists in seeing mental health care.

According to Bacchi and Licinio (2017), gender affects distress or resilience considerably. This is because psychological distress is higher in women as compared to men. Specifically targeting the female respondents as a sample population was justified as psychological distress is higher among women as reported in literature. There is a possibility that these women were already vulnerable and their profession might have enhanced their vulnerability towards distress during the global pandemic. The current study also examined resilience and psychological distress in association with mental health attitudes and among the health professionals. Findings showed a significant negative correlation of resilience with psychological distress in terms of depression, anxiety, and stress among clinical psychologists. It means that if a person is highly resilient, they would likely to experience less psychological distress. Findings from Bacchi and Licinio (2017) are consistent with the results of the current study and have also reported that healthcare professionals are likely to experience lower psychological distress when they are more resilient. Present study has not observed any significant association between mental health attitudes and psychological distress. However, contrary to this, evidence suggests potential impact of distress and attitudes towards mental health in defining mental well-being (Martins et al., 2022).  One possible explanation for this contradictory finding can be individual differences or other factors involved such as coping strategies, for instance avoidance coping, employed by these professionals to deal with psychological distress.

Extending on this, present study also explored coping strategies including problem, avoidant, and emotional coping strategies, used by clinical psychologists. Findings suggested a significant positive relationship of distress with coping strategies except for problem-focused coping. Chudzicka-Czupała et al. (2023) in their study identified that engagement in less adaptive or maladaptive style of coping such as emotion-focused and avoidance coping was associated with increased distress among individuals who experienced war emergency circumstances. These study findings support our present findings. Similarly, Fluharty and Fancourt (2021) in their study during COVID-19 identified that people were more likely to use problem-focused strategies, emotion-focused strategies, and avoidant coping strategies to deal with psychological distress due to the COVID-19 pandemic. In the present case, no association between problem-focused coping and distress could be due to several factors. It is possible that the problem-focused approach to deal distress couldn't work out due to unique challenges posed by coronavirus pandemic or external stressors (Joshi & Sharma, 2020 ; Singh et al., 2021).

Mental health attitudes showed a weak correlation with resilience and coping strategies. However, this relationship was significant for problem and emotion-focused strategies. This suggests an effective use of coping strategies in response to challenging life circumstances by individuals who are more resilient and have a positive mental health attitude. It also suggests that adopting an avoidance approach nullifies the usefulness of coping strategies used to approach challenges. In line with the present study, research also suggests potential role of resilience in managing distress and fostering mental health (Bacchi & Licinio, 2017; Jeamjitvibool et al., 2022; Weitzel et al., 2022) that becomes more obvious when individuals opt for health coping styles (Cheng et al., 2022) and show a positive attitude towards their mental health (Hiebel et al., 2021; Srivastava, 2011).

It has been observed that resilience negatively predicted psychological distress but positively the mental health attitudes among clinical psychologists. This has been supported by existing evidence suggesting a negative association between distress and resilience among healthcare providers during the pandemic (Jeamjitvibool et al., 2022). Another community-based study highlighted a strong association between psychological health and resilience (Weitzel et al., 2022). Individuals who are resilient usually hold an optimistic approach and are more confident and flexible which helps them to effectively deal with challenges (Hiebel et al., 2021; Srivastava, 2011). So, resilience and a positive mental health attitude are protective factors against mental health outcomes.

Finstad et al. (2021) in their study during COVID-19 pandemic identified that a higher level of resilience and the use of appropriate coping strategies helped people improve their personal growth in workplace during the COVID-19 pandemic. Similar evidence (Cheng et al., 2022) suggested that coping strategies such as problem-solving and accommodation play a moderating role in the association between distress and psychological well-being. This shows that adaptive coping strategies play a significant role in managing distress.  However, presently, contradictory findings were observed as coping strategies did not show any moderating impact between resilience and distress. There could be several factors behind this association such as burnout due to continuous distress, uncertainty surrounding the pandemic situation, heavy workload and limited or no access to mental health facilities to the healthcare workers that might have influenced the effectiveness of coping strategies even among the resilient individuals. In this context, Bannon et al. (2022) reported that burnout, depression, and anxiety were among the prevalent factors to cause poor health outcomes among healthcare workers during the COVID-19 pandemic. Research (Singh et al., 2021) has also shown that individuals experiencing severe depression and anxiety often use maladaptive coping strategies that may worsen their functioning and increase distress. So, the present findings can be justified based on complex the interplay of several factors influencing the use of coping strategies.

Conclusion

The study concluded a significant role of resilience in predicting mental health outcomes among clinical psychologists. The findings of the study suggest that adopting a positive mental health attitude would decrease distress in challenging circumstances such as the pandemic and promote effective use of coping strategies in response to threats. Additionally resilience trait of personality being a strong predictor of mental health outcomes would support distress management. However, in extreme distress situations, effective use of coping strategies may not be compromised. Study findings suggest resilience, coping strategies, and mental health attitude as significant factors influencing the mental well-being of individuals.

Limitations and Recommendations

The current study observed certain limitations that can be addressed in future studies carried out during such potentially threatening circumstances as the pandemic and involving healthcare workers. The findings of the present study are based on a smaller sample from eight the districts of KPK only and cannot be generalized to other provinces of Pakistan that witnessed varied numbers of COVID-19 cases. Additionally, a possibility of varied observations exists for male clinical psychologists. Therefore, in the future, equal presentation of genders as well as various geographical regions can be ensured. Moreover, factors influencing effective use of coping strategies and distress management can also be focused.

Implications of Study

The implications of the current research are wide for health professionals such as doctors, paramedics, psychologists, and pharmacists working in the healthcare sector in challenging circumstances. It welcomes research in the healthcare sector in the context of mental health and encourages policymakers and organizations to promote mental health among healthcare workers.

Acknowledgment

This manuscript is an extract of my thesis work and I would like to acknowledge the assistance and guidance of my supervisor Mr. Asad Javed in the completion of my thesis.

References

Ashikyan Z. (2005). Post-traumatic stress symptoms and coping styles of emergenc department Physicians [Unpublished doctoral dissertation]. Alliant International University.

Awad, E., Fawaz, M., Hallit, S., & Obeid, S. (2022).The moderating effect of emotion regulation in the association between coping strategies and resilience in Lebanese adults. BMC Psychology, 10, Article e296. https://doi.org/10.1186/s40359-022-01019-9

Bacchi, S., & Licinio, J. (2017). Resilience and psychological distress in psychology and medical students.Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry,41(2), 185–188. https://doi.org/10.1007/s40596-016-0488-0

Bahar, A.,·Koçak, H. S.,Baglama, S. S., &Çuhadar, D. (2020). Can psychological resilience protect the mental health of healthcare professionals during the COVID-19 pandemic period? Dubai Medical Journal, 3(4), 133–139 https://doi.org/10.1159/000510264

Bannon, J., Evans, C. T., Freedman, M., Lee, C., Vu, T. H., Wallia, A., Wilkins, J. T., Moskowitz, J. T., & Hirschhorn, L. R. (2022). Psychological wellbeing and the association with burnout in a cohort of healthcare workers during the COVID-19 pandemic. Frontiers in Health Services, 2, Article e994474. https://doi.org/10.3389/frhs.2022.994474

Bearse, J. L., McMinn, M. R., Seegobin, W., & Free, K. (2013). Barriers to psychologists seeking mental health care [Doctoral dissertation, George Fox University]. Digital Commons @ George Fox University, http://digitalcommons.georgefox.edu/gscp_fac/114

Bourgault, M., &, Dionne, F. (2018). Therapeutic presence and mindfulness: Mediating role of self-compassion and psychological distress among psychologists. Mindfulness, 10(4), 650–656. https://doi.org/10.1007/s12671-018-1015-z

Bukhari, S. R., & Ejaz, T. (2020). Relationship between psychological distress, coping strategies and adjustment to university life among university freshmen. Pakistan Journal of Medical Research, 59(2), 66–69.

Carver C. S. (1997). You want to measure coping but your protocol's too long: Consider the brief COPE. International Journal of Behavioral Medicine, 4(1), 92–100. https://doi.org/10.1207/s15327558ijbm0401_6

Chang, S., Picco, L., Abdin, E., Yuan, Q., Chong, S. A., & Subramaniam, M. (2019). Resilience and associative stigma among mental health professionals in a tertiary psychiatric hospital: A cross-sectional study in Singapore. BMJ Open, 9(12), Article e033762. https://doi.org/10.1136/bmjopen-2019-033762

Cheng, W. L. S., Young, P. M. C., & Luk, K. K. H. (2022). Moderating role of coping style on the relationship between stress and psychological well-being in Hong Kong nursing students. International Journal of Environmental Research and Public Health, 19(18), Article e11822. https://doi.org/10.3390/ijerph191811822

Chudzicka-Czupała, A., Hapon, N., Man, R. H. C., Li, D. J., Żywiołek-Szeja, M., Karamushka, L., Grabowski, D., Paliga, M., McIntyre, R. S., Chiang, S. K., Pudełek, B., Chen, Y. L., & Yen, C. F. (2023). Associations between coping strategies and psychological distress among people living in Ukraine, Poland, and Taiwan during the initial stage of the 2022 War in Ukraine. European Journal of Psychotraumatology, 14(1), Article e 2163129. https://doi.org/10.1080/20008066.2022.2163129

Del Olmo-Romero, F., González-Blanco, M., Sarró, S., Grácio, J., Martín-Carrasco, M., Martinez-Cabezón, A. C., Perna, G., Pomarol-Clotet, E., Varandas, P., Ballesteros-Rodríguez, J., Rebolleda-Gil, C., Vanni, G., González-Fraile, E., & INTER NOS group (2019). Mental health professionals' attitudes towards mental illness: Professional and cultural factors in the INTER NOS study. European Archives of Psychiatry and Clinical Neuroscience, 269(3), 325–339. https://doi.org/10.1007/s00406-018-0867-5

Finstad, G. L., Giorgi, G., Lulli, L. G., Pandolfi, C., Foti, G., León-Perez, J. M., Cantero-Sánchez, F. J., & Mucci, N. (2021). Resilience, coping strategies and posttraumatic growth in the workplace following COVID-19: A narrative review on the positive aspects of trauma. International Journal of Environmental Research and Public Health, 18(18), Article e9453. https://doi.org/10.3390/ijerph18189453

Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychologial help: A shortened form and considerations for research. Journal of College Student Development, 36(4), 368–373.

Fluharty, M., & Fancourt, D. (2021). How have people been coping during the COVID-19 pandemic? Patterns and predictors of coping strategies amongst 26,016 UK adults. BMC Psychology, 9(1), Article e107. https://doi.org/10.1186/s40359-021-00603-9

Fung, S. F. (2020). Validity of the Brief Resilience Scale and Brief Resilient Coping Scale in a Chinese sample. International Journal of Environmental Research and Public Health, 17(4), Article e1265. https://doi.org/10.3390/ijerph17041265

Galanis, P., Katsiroumpa, A., Vraka, I., Siskou, O., Konstantakopoulou, O., & Kaitelidou, D. (2023). COVID-19-related burnout reduces COVID-19 vaccination intention in cardiac patients: A cross-sectional study in Greece. medRxiv. Advance online publication.. http://dx.doi.org/10.1101/2023.01.27.23285082

Hiebel, N., Rabe, M., Maus, K., Peusquens, F., Radbruch, L., & Geiser, F. (2021). Resilience in adult health science revisited-a narrative review synthesis of process-oriented approaches. Frontiers in Psychology, 12, Article e659395. https://doi.org/10.3389/fpsyg.2021.659395

Jeamjitvibool, T., Duangchan, C., Mousa, A., & Mahikul, W. (2022). The association between resilience and psychological distress during the COVID-19 pandemic: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 19(22), Article e14854. https://doi.org/10.3390/ijerph192214854

Joshi, G., & Sharma, G. (2020). Burnout: A risk factor amongst mental health professionals during COVID-19. Asian Journal of Psychiatry, 54, Article e102300. https://doi.org/10.1016/j.ajp.2020.102300

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer.

Lovibond, S. H., & Lovibond, P. F. (1995). Depression anxiety stress scales (DASS--21, DASS--42) [Database record]. APA PsycTests.https://doi.org/10.1037/t01004-000

Martins, E. L. M., Salamene, L. C., Lucchetti, A. L. G., & Lucchetti, G. (2022). The association of mental health with positive behaviours, attitudes and virtues in community-dwelling older adults: Results of a population-based study. The International Journal of Social Psychiatry, 68(2), 392–402. https://doi.org/10.1177/0020764021999690

Sayers, J. (2001). The world health report 2001 — Mental health: New understanding, new hope. Bulletin of the World Health Organization, 79(11), Article e1085.

Schoenmakers, E. C., van Tilburg, T. G., & Fokkema, T. (2015). Problem-focused and emotion-focused coping options and loneliness: How are they related? European Journal of Ageing, 12(2), 153–161. https://doi.org/10.1007/s10433-015-0336-1

Singh, J., Sood, M., Chadda, R. K., Singh, V., & Kattula, D. (2021). Mental health issues and coping among health care workers during COVID19 pandemic: Indian perspective. Asian Journal of Psychiatry, 61, Article e102685. https://doi.org/10.1016/j.ajp.2021.102685

Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The Brief Resilience Scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(3), 194–200. https://doi.org/10.1080/10705500802222972

Srivastava, K. (2011). Positive mental health and its relationship with resilience. Industrial Psychiatry Journal, 20(2), 75–76. https://doi.org/10.4103/0972-6748.102469

Taber, K. S. (2018). The use of Cronbach's alpha when developing and reporting research instruments in science education. Research in Science Education, 48, 1273–1296. https://doi.org/10.1007/s11165-016-9602-2

Viertiö, S., Kiviruusu, O., Piirtola, M., Kaprio, J., Korhonen, T., Marttunen, M., & Suvisaari, J. (2021). Factors contributing to psychological distress in the working population, with a special reference to gender difference. BMC Public Health, 21(1), Article e611. https://doi.org/10.1186/s12889-021-10560-y

Weitzel, E. C., Löbner, M., Glaesmer, H., Hinz, A., Zeynalova, S., Henger, S., Engel, C., Reyes, N., Wirkner, K., Löffler, M., & Riedel-Heller, S. G. (2022). The association of resilience with mental health in a large population-based sample (LIFE-Adult-Study). International Journal of Environmental Research and Public Health, 19(23), Article e15944. https://doi.org/10.3390/ijerph192315944