Artículos

Why do Italian psychology graduates dream of becoming psychotherapists? A study on decision-making in undertaking psychotherapy

¿Por qué los licenciados en psicología italianos sueñan con convertirse en psicoterapeutas? Un estudio sobre la toma de decisiones para emprender la formación psicoterapéutica

Introduction

Many pieces of research have explored the potential motives that influence the decision to take up a psychotherapeutic profession, by focusing on the background of psychotherapists’ career choices among students, psychotherapy trainees, and trained psychotherapists (Duggal & Sriram, 2016; Lebiger‐Vogel, 2016;McBeath, 2019; Messina et al., 2018; Nikendei et al., 2018; Plchová, Hytych, Řiháček, Roubal, & Vybíral, 2016; Rek et al., 2018; Taubner, Kächele, Visbeck, Rapp, & Sandell, 2010). In detail, literature has suggested different motives mainly focused on unconscious needs to help oneself and others, as well as on altruism, personal growth and intellectual stimulation (Farber et al., 2005; Rek et al., 2018). Besides, research on how psychotherapists of different theoretical orientations vary, in terms of motivations and skills, has been also developed (Lebiger‐Vogel, 2016; Messina et al., 2018; Safi et al., 2017), highlighting the relevance of both previous academic training, personal background, and individual characteristics. As well, some studies have tried to inspect such a career choice in terms of professional success, job-related possibilities and future career perspectives (McBeath, 2019; Safi et al., 2017).

The issue of the decision to become a psychotherapist seems to be particularly relevant in the Italian context, where the overall picture of psychotherapy training seems to be quite complex, given the highly disparate situation about the availability and modalities of psychotherapy training (Fiorillo et al., 2011). According to Law n. 56 of 18 February 1989, to practice psychotherapy in Italy a degree in medicine (six years of studies) or psychology (five years) is needed. Psychotherapy professionals must be registered as medical doctors or psychologists and undertake a four- or five-year specialized training, which may be provided by state universities (i.e. clinical psychology, neuropsychology, developmental psychology, health psychology, psychological assessment or counseling) or private institutions controlled by a Technical Committee under the Ministry of Education, University and Research (MIUR). In this regard, a recent study about the private offer of psychotherapy training in Italy has highlighted the uneven geographical distribution of the schools, the disorderly amalgamation of traditional scientific paradigms, and the low focus on practical activities, thus failing to meet international guidelines (Maffei, Del Corno, Dazzi, Cioffi, & Strepparava, 2015). In particular, a critical issue refers to the excess supply concerning demand, because Italy has the second-highest density of qualified psychotherapists across European countries and the highest number overall, with consequent problems of underemployment and financial hardship for graduated psychotherapists, especially women (Maffei et al., 2015). More widely, this critical issue seems to be intertwined with the conditions of psychology graduates, representing about 96 % of psychotherapy trainees in the Italian context (Maffei at al., 2015), who show high unemployment rates at one and five years after graduation (59 % and 13 % respectively) and the lowest income levels among several professionals (Alma Laurea, 2015). Indeed, Italy has one of the highest numbers of professional psychologists per capita in Europe (Cranney & Dunn, 2011), thus posing new challenges to psychologists in terms of competitiveness and entrepreneurship (Bosio & Lozza, 2013). Indeed, the loss of a reassuring belonging to university context after graduation seems to lead to a crisis of professional identity among psychologists (Langher & Caputo, 2016), who often report a gap between academic training, internship experiences and the labor market (Langher, Brancadoro, D’Angeli, & Caputo, 2014). From this perspective, exploring the underlying motivations to psychotherapy training and the related career perspectives among psychologists seems to be particularly important, because they generally have a modest reputation about academic training and, as a consequence, tend to undertake further postgraduate training in 80 % of cases (Bosio & Lozza, 2013), mostly in psychotherapy field, despite its being an oversaturated job sector. Besides, even if specialization in psychotherapy is a necessary condition for psychologists to go to positions in the Italian National Health Service, psychotherapeutic interventions are generally limited and there is a scarce reputation of psychological science among other professionals within the hospital context (Tomai, Esposito, & Rosa, 2017).

The general aim of the present research study is to explore psychologists’ demands for and choices of specialized training in psychotherapy within the Italian context, thus contributing to improve the educational offer of psychotherapy training from public and private schools and to provide greater information, transparency and service quality. Specifically, this study examines the entire decision-making process for undertaking psychotherapy training, including the use of information sources, the analysis of training options, key purchase factors and the potential satisfaction with the performed choices. In detail, the aim is double-faceted:

1) To explore the main themes reported by psychologists, in terms of motivations, demands, and choices affecting the decision to undertake specialized training in psychotherapy;

2) To detect different groupings of respondents based on the themes reported about the decision to undertake specialized training in psychotherapy.

Method

Participants

A convenience sample of 549 italian participants voluntarily took part in the study, by using as inclusion criteria (a) being graduated in Psychology, and (b) being interested in, undertaking or having already completed a psychotherapy training. The mean age was 36.27 (SD = 9.38) and the sample was mainly composed of female participants (86 %), consistently with general trends on psychology graduates’ characteristics within the Italian context (Alma Laurea, 2015). Participants were guaranteed anonymity and provided their informed consent.

Procedure

Due to the wide variety and geographical spread of the target population, a web-based survey was promoted according to the online survey design, development and implementation guidelines suggested by Andrews, Nonnecke, and Preece (2003). Consistently with previous research on the issue (e.g., McBeath, 2019), online survey was chosen because of its widespread use for research and its easy access to geographically diverse respondent groups across the national context (Evans & Mathur, 2005), whose validity and reliability were demonstrated to be comparable to those of the paper-based versions (Caputo, 2017).

Specifically, the survey was financed and supported by the Psychologist Certification Board of the Latium Region^[1]. With regard to the recruitment process, direct email invitations were sent to the entire eligible list of psychologists who were officially registered. Besides, the research project was promoted through newsletters to public and private psychotherapy schools and via social media (forums, blogs, social networks about professional psychology) to advertise the link to the online survey. Access to the online survey was available on the institutional website for 30 days. The survey was presented as addressed to psychologists who were interested in, were undertaking or had already completed psychotherapy training to assess demands for psychotherapy training at different stages of the decision process. Indeed, consistently with our reference model about decision-making in postgraduate higher education (Towers & Towers, 2018), it is important to include potential consumers (prospective psychotherapy trainees), current consumers (enrolled psychotherapy trainees), and past consumers (psychotherapy professionals). Given the study aim of detecting groups of respondents, albeit there is no generally accepted rule of thumb regarding minimum sample sizes for cluster analysis (Siddiqui, 2013), we considered a sample size closer to 500 as optimal for profiling segments of respondents in market-based research (McQuarrie, 2015).

Instruments

An on-line questionnaire was administered, which included socio-demographic and job-related information. Participants were also requested to indicate whether they were generally interested in, were undertaking or had already completed psychotherapy training. In order to collect a rich and meaningful base of information about the demand for psychotherapy training, open-ended questions were preferred consistently with a bottom-up approach. The model by Engel, Blackwell, and Kollat (1968) about consumer behavior in business and marketing was adopted as a research framework, from the original contribution of Dewey (1910), who proposed a systematic problem-solving approach to decision making. In the modern economy, purchase processes are more and more influenced by intangible, symbolic, psychosocial and value-based systems of the offer, rather than by tangible and technical features. In such a perspective, consumers act on the basis of their motivations and emotional states that trigger purchase and consumption behaviors (Solomon, 2004). The model by Engel et al. (1968) consists of five-steps, which occur in several models of the consumer buying decision process (Mitchell & Boustani, 1993): problem/need recognition, information search, alternative evaluation, purchase, and post-purchase outcomes. A recent review of decision-making models (Towers & Towers, 2018) has highlighted that, despite their most updated revisions, the stages identified in the original model by Engel, Blackwell, and Kollat are still relevant in current research across both linear/causal and circular/back-and-forth approaches to decision making. Besides, the relevance of such stages has been confirmed in postgraduate higher education (Towers, 2019; Towers & Towers, 2018), as they succeed in identifying the key components of course selection when intentions are driven either by emotional or rational factors.

An initial pool of nine open-ended questions was formulated accordingly, after conducting a comprehensive search of the academic literature on decision making stages regarding course selection in postgraduate higher education (for a review, see Towers & Towers, 2018). Consensus was achieved among three psychology experts regarding the choice and operationalization of the variables that should be assessed. Motivations to psychotherapy training (Q1) and preferences for psychotherapy theoretical approach (Q2) were explored to inspect the problem/need recognition stage. Information sources about psychotherapy training (Q3) and related search difficulties (Q4) were explored for the information search stage. Key factors for selecting (Q5) or excluding (Q6) a specific psychotherapy school/institution, as well as other potential available training options (Q7) were examined for the alternative evaluation stage. Ideal or desired features of a psychotherapy school (Q8) were asked concerning the purchase stage; whereas, potential satisfaction and job expectations after the completion of psychotherapy training (Q9) for assessing the post-purchase outcomes. The open-ended questions were formulated as to be suitable across respondents who were interested in, were undertaking or had already completed psychotherapy training. Specifically, a team of three psychology experts assessed the content validity of the created questionnaire. Each question was given four different ratings, respectively regarding relevance, clarity, simplicity, and ambiguity by a 4-point scale (from 1 = not relevant/clear/simple or doubtful to 4 = very relevant/clear/simple or meaning is clear). In detail, the Item Content Validity Index was computed as the percentage of experts that approved the item and gave it a score of 3 or 4. Only those questions that scored over 0.75 for each criterion were directly retained (Martuza, 1977), while the remaining questions were restated and newly rated through an iterative process so to get the final version of the questionnaire.

Strategy of Analysis

A multi-step procedure was adopted by using multiple analysis techniques, comparing different researchers’ perspectives and integrating qualitative and quantitative methods according to a principle of triangulation (Denzin, 1970). This was in order to reduce interpretation bias and ensure a better quality of data analysis. The strategy of analysis included the following steps: text analysis - consisting of computer-assisted thematic analysis and content analysis - and cluster analysis.

Text analysis

The first inspection of textual responses provided to the open-ended questions was based on computer-aided thematic analysis, as to detect a map of the main emerging themes. This allows for greater systematization and transparency in the analysis, as well as a reduction in the possible errors that the researcher may incur when having to analyze large amounts of data (Flores-Kanter & Medrano, 2019). The T-LAB text analysis tool used was the “Thematic analysis of elementary context” (Lancia, 2004), which represents a relevant method for qualitative inquiry in clinical, social and educational fields (Caputo, 2014, 2015; Caputo, Giacchetta, & Langher, 2016; Caputo & Rastelli, 2014), which may provide useful insights also in the examination of psychotherapy related issues (Caputo, 2013). In more detail, through some statistical multidimensional techniques ( i.e. cluster and correspondence analysis), for each open-ended question, T-LAB allows the automatic detection of some thematic clusters from grouping responses (used as elementary context units) characterized by the same patterns of words (lexical units). This allows getting a representation of textual corpus contents through few and significant thematic domains, derived from the distribution of the words in the textual corpus itself in terms of its semantic variability.

In the second step, consistently with the thematic clusters resulting from the computer-assisted analysis, some content categories were developed for coding textual responses for each respondent. Such content categories were pre-tested on 20 % of randomly chosen textual responses by two independent researchers, to assess the accuracy and exhaustiveness of the coding system in terms of correspondence with empirical data and inclusion of the largest number of analysis units, respectively. Therefore, when the previously detected thematic clusters were not well accurate and exhaustive, some additional content categories were developed. When the final codebook was defined, the textual responses to each open-ended question were coded by a first researcher, whereas a second researcher coded 20 % of them to assess inter-rater agreement, on both univariate (Cohen’s kappa for each content category; Cohen, 1960) and multivariate nominal level (Iota coefficient simultaneously considering all the content categories; Janson & Olsson, 2001), with values from 0.81 to 1.0 indicating almost perfect or perfect agreement (Landis & Koch, 1977).

Cluster analysis

Cluster Analysis (CA) was performed by using the two-step method, as to detect different groupings of respondents based on the main themes reported about the decision-making process in undertaking psychotherapy training. Based on modes of response, groups of participants were identified with the character of maximum uniformity among participants themselves and maximum heterogeneity with respect to other groups. Then the associations between such groups and some variables defining respondents’ characteristics (i.e. gender, age, geographical area, employment status and type of respondents) were assessed using Chi-square test (χ²) for nominal variables and one-way ANOVA with post hoc Bonferroni adjustment (pairwise t-test) for numerical ones, at p < .05 (95 % confidence level). The software used was IBM SPSS Statistics 23.

Results

Characteristics of Participants

Regarding participants’ characteristics, 50.8 % of participants came from Northern Italy, 20.1 % from Centre Italy and 21.2 % from Southern Italy. In detail, 24.3 % of participants were interested in undertaking psychotherapy training, 37.3 % were currently enrolled in psychotherapy schools/institutions, and 38.4% had already completed psychotherapy training. The distribution by type of respondents (potential, current and past consumers of psychotherapy training) can be considered as substantially satisfactory considering our study aims and reference model. About employment status, 63.4 % of them was permanently employed, 25.9 % had casual or other types of employment and 10.8 % was not currently employed.

Themes regarding the decision-making process in undertaking psychotherapy training

In Table 1 the themes emerging from the text analysis of the responses to each open-ended question are reported, along with the respective percentages and inter-rater reliability coefficients.

Groupings of respondents based on the detected themes

Cluster Analysis (CA) was performed by using the two-step method to detect different groupings of respondents, based on 57 themes previously detected and used as active variables referring to the decision-making process in undertaking psychotherapy training. About questions 4, 7 and 9, only themes relating to the presence/absence of the relative dimensions were included so to avoid an excessive number of excludes cases, due to missing values on sub-themes. The optimum number of clusters, log-likelihood distance measure and Schwarz's Bayesian Criterion were used. The analysis revealed three clusters (with a fair cluster quality) which allowed the classification of 83.6 % of overall participants. As reported in Figure 1, the three most important predictors for cluster membership were the prestige of the school/institution or teachers as key factor for selection (1.0), followed by the preference for cognitive-behavioral approaches (.85) and high costs as key factor for exclusion (.58) (p < .05, at 95 % confidence level).

Further analyses confirmed that there were some associations between clusters and some variables defining respondents’ characteristics, with specific regard to age, F(2, 455) = 11.878, p < .001, and type of respondents, χ² (4, N = 459) = 27.588, p < .001. Table 2 illustrates the main themes that characterize each cluster and thus allow cluster comparison.

Cluster 1

This cluster includes only 14.6 % of participants. Almost half of them (53.6 %) have completed psychotherapy training, against a mean value of 38.3 % among classified respondents. Participants express a strong preference for a systemic-relational theoretical approach, whereas there is a scarce propensity to choose the psychodynamic/psychoanalytic, gestalt or transactional ones. While searching for information about psychotherapy training, they use the internet to a lesser extent and mainly tend to rely on exchanges with colleagues. The prestige of the school/institution or teachers represents the key factor for the school selection; whereas, the features of the theoretical approach and logistics/proximity to house are the lowest relevant themes. Besides, high costs and distance from house seem not to affect the decision to exclude a specific school/institution. According to the participants’ perspective, the ideal psychotherapy school is characterized by the high quality of training offer; instead, organizational aspects (logistics, schedule, classes’ organization) do not have an important role. Among the satisfaction factors after the completion of psychotherapy training, respondents report a (potential or actual) job situation that is fully consistent with their expectations.

Cluster 2

This is the largest cluster, with 51.2 % of overall participants. Personal interests represent the main motivation to undertake specialized psychotherapy training, albeit this decision seems to be scarcely oriented to career development. There is a higher preference for psychodynamic/psychoanalytic, gestalt and transactional theoretical approaches and a reduced tendency to choose cognitive-behavioral and systemic-relational ones. While searching for information about psychotherapy training, participants talk with their colleagues to a reduced extent. The features of the theoretical approach are the key factor for selecting a specific school/institution; instead, costs, schedule/classes organization and the prestige of the school/institution or teachers do not seem to have a relevant role. When imagining the ideal psychotherapy school, the quality of the training offer is generally less important.

Cluster 3

This cluster included 34.2 % of participants and is mainly associated with psychologists who are interested in undertaking psychotherapy training (34.4 % against a mean value of 21.4 % among classified respondents). Participants included in this cluster are generally younger to a statistically significant extent (M = 33.34; SD = 5.64), if compared to other groups of respondents of both Cluster 1 (M = 38.64, SD = 9.77), t (266) = -5.57, p < .001, and Cluster 2 (M = 36.88, SD = 9.80), t (467) = -4.48, p < .001. Career development represents the main motivation to undertake psychotherapy training, whereas personal interests have a marginal impact. This group expresses a strong preference for cognitive-behavioral theoretical approaches and a scarce propensity to select the psychodynamic/psychoanalytic, gestalt and transactional ones. When searching for information about psychotherapy training, respondents mainly use the internet and colleagues as information sources. Low costs are the key factor for selecting a specific school/institution, even at the expense of the specific features of the chosen theoretical approach. Also schedule/classes organization and logistics/proximity to house are perceived as particularly relevant, so much to be used as discriminant criteria for excluding some schools/institutions. With regard to the ideal or desired psychotherapy school, the quality of the training offer and organizational aspects (classes’ organization, schedule, logistics) are perceived as the most important key factors.

Discussion

The present research study allows the disentanglement of several aspects affecting the decision-making process in undertaking psychotherapy training. In detail, the reported motivations to psychotherapy training seem to suggest a weak focus on the acquisition of professional competencies that are actually spendable and oriented to career development (theme reported by only 50.6 % of participants), despite their usefulness for coping with sudden changes and instability of the current labor market (Bocciardi, Caputo, Fregonese, Langher, & Sartori, 2017). This result can be better understood in the light of the need to fill gaps in previous academic psychology training, deemed as scarcely professionalizing, and for accumulating further qualifications to achieve status and recognition in the labor market (Carlsson, Norberg, Sandell, & Schubert, 2011), consistently with a crisis of professional identity after psychology graduation (Langher & Caputo, 2016). As well, the decision to undertake psychotherapy training seems to be particularly affected by personal interests, rather than by the demand for improving the quality of the professional offer to meet clients’ needs. In this regard, several studies have confirmed that personal predispositions and experiences, as well as altruistic motives, were among the most relevant factors behind the decision for psychotherapy training (Messina et al., 2018; Norcross & Farber, 2005; Safi et al., 2017). For instance, a study by Messina et al. (2018) found that negative personal experiences (e.g., family conflicts, school-related problems, or relational difficulties with a partner or a friend) were the most frequent motivations reported by almost half of psychotherapy trainees. As well, people choosing psychotherapy as a career are generally characterized by a wish for warm proximity and report harmonious interpersonal motives to a greater extent compared to general population samples (Rek et al., 2018).

Preferences for psychotherapy training theoretical orientations are mainly focused on cognitive-behavioral (29.3 %), psychodynamic/psychoanalytic (26.6 %) and systemic-relational (16.3 %) approaches, in line with what highlighted by a previous study conducted by Maffei et al. (2015) in the Italian context. It is worth noting that, in most cases (57.1 %), such preferences derive from personal interests and perceived affinities between some features of the theoretical approaches and individual characteristics or talents. This appears consistent with previous findings (Messina et al., 2018) revealing differences by preferred theoretical approach in the trainees’ interpersonal styles, with those having a psychodynamic orientation experiencing themselves as intuitive or introspective, differently from trainees with a systemic or cognitive-behavioral orientation who mostly described themselves as critical or reserved, respectively.

With regard to the search for information about psychotherapy schools/institutions, almost three respondents out of four use not more than two information sources, and tend to rely on horizontal information channels rather than to look for direct communication with schools/institutions, that are claimed to have poor transparency about costs and low clarity about training offer. Among the key factors orienting the selection or exclusion of specific schools/institutions, the features of the theoretical approach and costs are reported as the most prevalent ones, in line with previous findings about the relevance of personal preferences (Messina et al., 2018) and financial burden among psychotherapy trainees (Nikendei et al., 2018).

Whereas, the quality of the training offer and the prestige of the school/institution or teachers – despite being quite relevant in the school/institution selection – are less reported as exclusion criteria, potentially suggesting that they may be elements of attractiveness only when the theoretical approach of the selected school/institution is consistent with personal interests. About half of participants (45.9 %) report only a single criterion for selecting a psychotherapy school (on average two criteria are reported); whereas, on average only a single exclusion criterion is indicated (63.1 %). The limited selection criteria seem to suggest rigid strategies orienting the decision-making process, which are poorly articulated based on specific features of schools/institutions. In this regard, previous research has highlighted the importance of flexibly exploring the features of different schools of psychotherapy to become epistemologically developed therapists, rather than dogmatically adhere to theoretical orientations or personal assumptions (e.g., Plchová et al., 2016).

Besides, about half of participants (48.6 %) report to have examined further training options (mainly masters) that are generally perceived as more spendable in the labor market. In 70.8 % of cases, such options are deemed as valid alternatives to psychotherapy training. Taking into account the low flexibility and exploration of decision-making as discussed above, the demand for psychotherapy training appears scarcely defined and anchored to the analysis of differences among schools/institutions. This indefinite and blurred demand for postgraduate training may thus be interpreted as a form of manic reparation to face anxiety when entering into the labor market, rather than as the expression of a genuine interest in developing specialized competencies (Caputo, Fregonese, & Langher, 2020). Indeed, in the light of the uncertainty issues that young professionals are confronted with, especially in the early stages of their career (Langher, Nannini, & Caputo, 2018), becoming psychotherapists may represent an attempt to reach high status and membership in the privileged psychotherapy community, as to remedy the perceived defects in one’s professional identity (Carlsson et al., 2011; Langher & Caputo, 2016). In line with this, trainees’ demand may be potentially dealt with by a wider pool of schools/institutions and a system of training provision that is alternative to psychotherapy training.

From participants’ perspective, the ideal psychotherapy school/institution should provide trainees with more clinical practice, be cheap and characterized by a high quality of the training offer, thus suggesting the prominence of the cost-benefit logic. This is confirmed by the study by Safi et al. (2017), which has highlighted the importance of financial and time conditions concerning the training, as well as the need for better socioeconomic status and financial security, as factors influencing the decision to undertake psychotherapy training. Concerning job expectations after the completion of psychotherapy training, only 47 % of respondents report (potential or actual) satisfaction (29 %) or dissatisfaction (18 %) about psychotherapy training. This seems to suggest the difficulty to examine the quality and usefulness of psychotherapy training in the labor market, consistently with the poorly articulated demand for it and the rigidity of selection criteria previously discussed, probably also because of the disillusionment with training after being confronted with the hardships and challenges of practice (Rønnestad & Skovholt, 2003).

About the detection of different groupings of respondents, based on the themes concerning the decision to undertake specialized training in psychotherapy, the results show low variability in the demand for psychotherapy training. Indeed, only three groupings of respondents emerge, which are strongly differentiated based on the prestige of the school/institution or teachers as a key factor for selection, the preference for cognitive-behavioral approaches, and high costs as a key factor for exclusion.

In detail, the smallest cluster (14.6 % of respondents) – which mainly expresses a preference for systemic-relational approaches – shows a high investment in the quality of the training offer and the prestige of the school/institution or teachers, regardless of the high costs of training.

Whereas, the largest cluster (51.2 % of respondents) is characterized by the preference for psychodynamic/psychoanalytic, gestalt and transactional approaches, and by the low propensity to cognitive-behavioral and systemic-relational orientations. This cluster is mainly motivated by personal interests and attributes higher relevance to the features of the theoretical approach, without accurately examining the quality of training offer, the prestige of the school or teachers and further school/training related specificities. This result seems to be consistent with the study by Safi et al. (2017), who found that candidates for psychodynamic psychotherapy training emphasize the role of personal experiences, interest in self-exploration and life history background in their decision for the respective therapeutic orientation, as well as the importance of working on themselves (Messina et al., 2018).

Then, a third cluster (34.2 %) expresses a strong preference for cognitive-behavioral approaches and scarce propensity to psychodynamic/psychoanalytic, gestalt and transactional orientations. It is characterized by career development as motivation to undertake psychotherapy training, giving more emphasis on economic, logistic and organizational aspects, in line with concerns about cost and length of training found in those interested in behavior therapy training (Lebiger-Vogel, 2016). In this regard, previous studies have confirmed that socioeconomic motives may play a more crucial role among trainees favoring cognitive-behavioral approaches (Lebiger‐Vogel, 2016; Safi et al., 2017). Besides, this last cluster is better represented by those interested in undertaking psychotherapy training and, thus, seems to better grasp an emergent demand for psychotherapy training. This is in line with a study by Lebiger‐Vogel (2016) concluding that behavior therapy is perceived by students as more compatible with the prevailing scientific understanding and with current societal and cultural trends compared to other approaches.

Overall, the study results integrate previous findings (Buckman & Barker, 2010; Lebiger‐Vogel, 2016; Messina et al., 2018; Nikendei et al., 2018) about the existence of some differences on person- and training-related factors predicting orientation preference. It can be concluded that those respondents who prefer psychodynamic/psychoanalytic, gestalt and transactional orientations are mainly triggered by personal interests and features inherent to the selected theoretical approach in their decision-making process, as already found by Messina et al. (2018). Therefore, this cluster is quite different from the other two groupings, whose orientation preferences are not necessarily contrasting and respectively seem to privilege the quality (systemic-relational) or efficiency (cognitive-behavioral) of some school/training related factors.

The added-value of the present study relies on the accurate examination of different aspects potentially affecting decision-making processes in undertaking psychotherapy training, within a more complex and exhaustive frame. As well, the integration of researchers’ perspectives and the use of mixed methods according to a principle of triangulation ensure good quality of data and ecological validity of results, trying to formulate data-driven hypotheses by directly using participants’ narratives rather than testing specific or well-defined indicators, previously assumed by the researcher. Indeed, most of the past research studies draw on questionnaire-based data, with limited use of open-ended questions (Taubner et al., 2010), whereas the need for rigorous qualitative approaches in this field is increasingly advocated (Safi et al., 2017).

Some limitations need to be acknowledged regarding the present study, because of its exploratory nature. Indeed, it only provides some thematic areas regarding the decision-making processes in undertaking psychotherapy training that might be characterized by higher variability and thus need further investigation. In this regard, future research could carry out a representative nationwide survey to confirm and better explain our results. Then, the generalizability of our findings can be called into question due to the convenience nature of the study sample and to the online administration which could have generated a self-selection bias. In this regard, it should be acknowledged that our study participants included psychology graduates that were at least interested in undertaking psychotherapy training. This does not allow the deepening of the adverse factors preventing unmotivated individuals from taking up psychotherapy as a career. Also, trans-cultural validity is almost limited because our sample was entirely composed of Italian respondents; therefore, cross-cultural validation studies should be conducted in the future.

This notwithstanding, in the light of our findings, we can suggest some theoretical developments for future research as well as practical implications for the improvement of the provision of psychotherapy training. Concerning theoretical implications, the present study underlines the relevance of personal interests and motivations in decisions for postgraduate psychotherapy training, with status achievement and reassuring membership in the psychotherapy professional community as main underlying expectations (Carlsson et al., 2011; Langher & Caputo, 2016). In this regard, future studies could inspect the role of different symbolic and affective motives, such as achievement, affiliation, power and autonomy (e.g., Fregonese, Caputo, & Langher, 2018a), in undertaking psychotherapy training and taking up psychotherapy as a career. As well, the use of constructs of career adaptability and reparation could be fruitful to understand to what extent such choices are actually oriented to develop personal resources and knowledge or involve defensive patterns to remedy a defective professional identity as psychologists (Caputo et al., 2020; Langher, Caputo, Nannini, & Sturiale, 2016).

About practical implications, the demand for psychotherapy training seems to be affected by several critical issues, such as the scarce continuity with psychology academic training and the need for gaining recognition and legitimization as professionals in the labor market. From this perspective, it may be useful to take into account such complexity and promote a training offer, which more clearly provides professional skills that are spendable, also because of the high competitiveness of other training options perceived as valid alternatives to psychotherapy training. Besides, as suggested by Duggal and Sriram (2016), higher awareness of factors that contribute to entering the field should be promoted among psychotherapy trainees through self-reflective practice and supervision, as to provide professional training evaluation also in the field of psychotherapy training (Fregonese, Caputo, & Langher, 2018b).

Another critical issue refers to the scarce articulation and differentiation of the decision-making process based on specific features characterizing psychotherapy schools (except for the reference theoretical approach). This supports the concern that therapists should have more certainty about their motivations than might be the case, also considering that motivations for doing their job may change over time (McBeath, 2019). Therefore, the attractiveness of schools/institutions may be further developed to promote their reputation among potential trainees. Concerning this, the presence of almost rigid decision-making strategies, along with the scarce clarity of information about costs and training offer, may represent a factor that potentially discourages from undertaking psychotherapy training. Therefore, communication with potential trainees about information, transparency, and quality of services offered by schools/institutions should be further improved.

Then, an emergent demand seems to be characterized by a strong pragmatic tendency orienting the decision-making process, where logistic, economic and organizational aspects are primarily relevant to the selection of schools/institutions. This seems to be in line with poor investment readiness and the need to maximize the cost-benefit ratio, as suggested by the prevalence of attitudes toward saving, austerity, and rationality in higher education environments (Godoy et al., 2018). From this perspective, it seems to be necessary that schools/institutions ensure better accessibility and availability of their services to reconcile trainees’ needs and support them to engage in training options that are mostly perceived as expensive and time-consuming (e.g., psychoanalytic training) (Lebiger‐Vogel, 2016).

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