Psychological Therapists’ Experiences of Burnout: A Qualitative Systematic Review and Meta-synthesis

Purpose: Psychological therapists are vulnerable to developing burnout due to the frequent exposure to emotive narratives of distress. Several quantitative systematic reviews have provided an overview of the risk and protective factors associated with therapist burnout. To date, however, no qualitative systematic reviews on therapist burnout have been carried out. This systematic review aimed to explore the experiences and impact of burnout in psychological therapists, and the strategies they use to adapt to it. Design: Systematic searches of three electronic databases (CINHAL EBSCO, Medline EBSCO and PsycINFO EBSCO) were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Papers were screened at title and abstract and full-text review stages. The Critical Appraisal Skills Programme (CASP) qualitative checklist was used to evaluate the methodological quality of the included studies. Results: Nine peer-reviewed papers met the eligibility criteria. The findings stressed the severe professional and personal impact that burnout can have on therapists. The quality of the study designs of the included papers was overall good. The main limitations included risk of recruitment and selection bias, transparency and credibility issues due to lack of reporting on data saturation and reflexivity, and reduced transferability due to the qualitative methodologies and small sample sizes used. Conclusions: Further research is needed to expand on these findings and develop a greater understanding of the experiences and management of burnout in psychological therapists. Future studies could use mixed-method designs and larger sample sizes to increase transferability. Theoretical implications and clinical recommendations are discussed.


Introduction
The term burnout was introduced by Freudenberger (1974), who described it as a process of physical and emotional exhaustion, fatigue, detachment and self-doubt that people who work in caring and supporting roles can experience (Freudenberger, 1974).Maslach's definition of burnout (1982) emphasises the enduring nature of this type of stress, involving depersonalisation, emotional exhaustion and a reduced sense of personal accomplishment (Maslach, 1982).Burnout has been associated with a number of conceptually similar constructs, such as compassion fatigue (Bhutani et al., 2012), occupational stress (Simionato & Simpson, 2018), vicarious trauma and secondary traumatic stress (Nolte et al., 2017).While it is easier to differentiate burnout from vicarious trauma and secondary traumatic stress, given that these two concepts both entail exposure to traumatic content (Rauvola et al., 2019), the distinction between compassion fatigue and burnout is less clearcut as they share important conceptual elements, such as emotional exhaustion, fatigue and disengagement (Nolte et al., 2017).Similarly, occupational stress and burnout have both been associated with psychological suffering and impairment due to work pressures and demands, thus maintaining a stronger conceptual link (Simionato & Simpson, 2018).
Burnout has been identified as a significant work-related challenge for psychologists and psychological therapists (McCormack et al., 2018;Simionato & Simpson, 2018) and, more generally, in mental health settings, with between 21% and 67% of services reporting high levels (Morse et al., 2012).High prevalence rates of burnout have also been found in other medical professions, such as nurses, 11.23% (Woo et al., 2020), and medical and surgical residents, ranging from 27.72% to 57.18% (Low et al., 2019).However, the frequent exposure to narratives of distress, loss and trauma makes psychological therapists particularly vulnerable to developing occupational stress and burnout (Bearse et al., 2013;Simionato et al., 2019).Studies investigating the prevalence of burnout in psychotherapists show prevalence rates that range from 2-6% (Farber, 1990) to over 50% (Simionato & Simpson, 2018).Codes of conduct and professional guidelines for psychologists and psychological therapists, such as those published by the American Psychological Association (APA) and The British Psychological Society (BPS), have highlighted the risks of burnout and its potential impact on clinical work, thus recommending to also consider it from an ethical perspective (APA, 2017;BPS, 2018).
Research has highlighted that burnt-out professionals are less likely to adequately provide empathy and emotional support due to engaging in defence mechanisms that preserve their emotional capacity, which in turn has a detrimental impact on clients' wellbeing and recovery (Bearse et al., 2013;Connor et al., 2018;Lee et al., 2011).Burnout in psychologists and psychological therapists has also been linked to reduced productivity, increased absenteeism, turnover, poorer personal efficacy and a higher risk of developing mental health difficulties, such as depression (Simionato et al., 2019;World Health Organisation, 2018).A systematic review on the prevalence and causes of burnout in applied psychologists, which included 29 papers, found that emotional exhaustion was the most commonly cited component of burnout, with work setting, workload and time pressure being the most significant job factors leading to burnout.Older psychologists were less likely to experience burnout as they had learnt how to preserve their emotional energy over time (McCormack et al., 2018).Another systematic review on antecedents and consequences of burnout in psychotherapists, comprising 17 studies, found that therapist overinvolvement was the most significant variable to correlate with emotional exhaustion, while having more control over their work was the most significant factor to negatively correlate with depersonalisation (Lee et al., 2011).Another recent systematic review (Simionato & Simpson, 2018) on the risk factors associated with burnout in psychotherapists, including 40 studies, found that younger age, less professional experience and therapist over-involvement in their clients' problems were the most common factors associated with burnout.
These systematic reviews on burnout in psychological therapists have only included quantitative studies and methodologies with little attention to how psychologists and psychological therapists experience burnout within their professional roles.To date, there have been no qualitative systematic reviews or meta-syntheses on burnout in psychological therapists.As burnout is best characterised as a process, rather than an outcome (Maslach, 1982;Maslach & Leiter, 2016), a meta-synthesis of studies on therapist burnout can unveil important learnings related to the dynamic and fluid elements of this process, which might not be captured by quantitative analyses.
The aim of this qualitative systematic review and meta-synthesis is therefore to explore therapist burnout from a broader, qualitative perspective, adopting a critical realist stance.A systematic review and synthesis of qualitative studies of how therapists experience burnout could provide further insight into the difficulties and challenges they experience, uncovering their professional and personal coping strategies, which could inform service training and policies aimed at preventing burnout and promoting resilience and wellbeing.

Research Questions
Primary research question: 'How do psychological therapists subjectively experience burnout?' Secondary research question: 'What are the professional and personal strategies that can help to prevent and reduce burnout in psychological therapists?'

Methods
The systematic review was completed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021).A protocol for the systematic review was registered on the PROSPERO (International Prospective Register of Systematic Reviews) database, outlining the inclusion and exclusion criteria, the search and screening strategies, and the methodological approach (reference: CRD42021247832).
Given the high heterogeneity of the samples, settings, contexts and methodologies of the included studies, results were synthesised using a narrative synthesis approach (Popay et al., 2006).

Data Sources and Search Strategy
The available literature was reviewed by electronically searching three databases, CINHAL EBSCO, Medline EBSCO and PsycINFO EBSCO, and hand-searching the reference lists of the included studies.Boolean operators 'and' and 'or', wildcards and truncation symbols, such as '*', were used to combine search terms effectively and maximise search results (see Table 1).
Controlled vocabulary and keyword functions were also used, where possible.In order to identify all relevant studies, no date restrictions for the searches were applied.

Eligibility Criteria
Similarly to other systematic reviews on burnout in psychotherapists (Simionato & Simpson, 2018), the term 'psychological therapist' was employed broadly to encompass both psychologists and psychotherapists.This review included studies on therapist burnout and related constructs, including occupational stress, compassion fatigue and emotional exhaustion.Studies on secondary traumatic stress and vicarious trauma were not included as they focus on conceptually different constructs.Similarly, studies on therapist resilience were also excluded from this review.
Inclusion criteria included: peer-reviewed studies (i.e., dissertations were excluded), studies published in the English language, studies focussing on the experience of burnout and related concepts (i.e., occupational stress, compassion fatigue, emotional exhaustion), studies focussing entirely on psychological therapists delivering therapy (i.e., studies including nurses, doctors, social workers, etc. were excluded).
The following exclusion criteria were applied: studies including art and music therapists as participants, studies including sport psychologists as participants, studies including counsellors as the only participants (i.e., without any other psychological therapists), studies including unqualified therapists (e.g., trainees, students, etc.), studies classed as secondary research (e.g., systematic and literature reviews), studies using quantitative and mixed-method designs, single case-studies, commentaries, personal reviews or reflections, books, or book reviews.

Screening and Selection of Studies
Final electronic searches using the three databases were conducted from their inception to 27 April 2021 and generated a total of 1,151 results, with the PsycINFO database yielding 667 results, and the CINHAL and Medline databases yielding 216 and 268 results, respectively.After removing duplicates, 885 studies were retained (see Figure 1) and screened by the first author (initials).
Studies were initially screened at title and abstract stage.Following the title and abstract screening, studies were subsequently included in the review, having met the inclusion criteria.Hand-searching the reference lists of the included studies did not generate any further results.
Random samples of 25% of papers at both title and abstract (N=214) and full-text (N=9) review stages were screened by an independent reviewer, who was not part of the research team.
The percentage agreements with the first author (initials) were high, 99% (N=212) at title and abstract screening stage and 89% (N=8) at full-article review stage.Disagreements between the first author (initials) and the independent reviewer were resolved by consensus, consulting and referencing the eligibility criteria.In addition, the three authors of the review met regularly to discuss the screening process and any related decisions to ensure consistency and transparency.

Data Analysis
Due to the methodological heterogeneity of the qualitative studies included in this review, particularly in relation to the methodological and analytical frameworks employed, results were synthesised using a narrative synthesis approach (Popay et al., 2006).Narrative synthesis is a commonly used synthesis approach for systematic reviews.This approach involved developing an interpretation of the review's findings that can contribute to assessing their applicability and relevance in the context of psychological therapists' experiences of burnout.In order to organise the findings from the included studies, a preliminary analysis was carried out.This involved reading and immersing in the results and discussion sections of the included papers to familiarise with the data and develop an initial description of the findings.Subsequently, the characteristics of the findings from the included studies were explored through the use of grouping, clustering and tabulation.Findings were clustered based on their research questions and the relevance of their data for the current review.Finally, a critical evaluation of the strength of the synthesis was provided (Popay et al., 2006).

Assessment of Methodological Quality
The Critical Appraisal Skills Programme (CASP) qualitative research checklist was used by the first author (initials) to assess the methodological quality of the papers included in this systematic review (CASP, 2017).The checklist has 10 questions that consider research aims, methodology, research design, recruitment strategies, data collection methods, reflexivity of researchers, ethical issues, data analysis, presentation of findings and their contribution to the existing literature (CASP, 2017).As recommended by the Cochrane Group, the CASP checklist was used as a guiding framework to inform the synthesis and the findings (Long et al., 2020;Noyes et al., 2018), and was not used to exclude studies.The findings of the methodological appraisal were discussed with the second (initials) and third author (initials).Disagreements in interpretation were resolved through consultation.

Data Extraction Outcome
Nine papers met the inclusion criteria and were therefore included in the review.Three main themes were identified: the experience of burnout and strategies that help to prevent and reduce burnout.
Key information from the included studies was extracted using a data extraction form, comprising study aims and research questions, sample size and characteristics, study setting and context, recruitment and data collection techniques, and analytical methodology (see Table 2).A summary of the key findings was also provided (Table 3).-Experience of working in palliative care a privilege, rewarding, making a difference.Knowing that fixing (people) is not needed, just sitting with people's difficulties.Threat of patient death leads to uncertainty in the therapeutic relationship.Pressure of organisational changes, 'trying to do more for less', managerial tasks most stressful ones -Therapists affected by work, being unable to separate themselves from their patients ('You're just like me'); awaiting sadness (patient death); more awareness of their own mortality; compassion fatigue (dealing with deaths and grief) experienced as inability to listen to patients, rumination and insomnia ('I just didn't want to hear it, any more bad stuff'), avoidance of emotionally challenging sessions -Clinical psychologists' expectations to be infallible experts on emotions and distress, and able to contain other people's emotions; awareness of emotional impact on self even when able to manage distress experienced by other people; difficulty containing own emotions and need to share this with their team and managers ('I'm a human being too') -Therapeutic work as main source of satisfaction; seeing improvements in patients' quality of life, feeling appreciated and seeing work as a learning experience; negative emotions arising from working with patients, particularly complex mental health problems and suicidal ideation; impact on therapists' personal lives and and experiences; lack of training to work with complex presentations; therapists turning negativity into an enriching experience through reflection -Professional issues and negative emotions related to clinical approach in the MDT; perceiving mental health system as dominated by the medical model, rather than based on a collaborative approach; implied acceptance that the psychiatrist is the most important professional in the team; dominant values in the service clashing with therapists' beliefs; service not empowering patients choice and focus on symptoms; psychology perceived as an adjunct to the medical treatment and power dynamics leading to therapists' helplessness and powerlessness; therapists not feeling trusted and valued, feeling demotivated -Enthusiasm, motivation and positive feelings replaced by demotivation; leaving public services due to lack of trust, not feeling valued, lack of involvement in decision-making, divergence with the medical ideology; focussing exclusively on client-work to keep motivated and recover from burnout; self-awareness to manage negative environments, personal therapy, further education and outside supervision; support from colleagues; need to be accepted and share similar values at work -The experience of burnout -Attributions of burnout -Recovery -Sudden and long-term impact of burnout leading to being unable to work.Emotional exhaustion, depersonalisation and reduced professional efficacy.Burnout gradually building over time -Burnout explained as a combination of workplace, systemic and organisational factors, personal difficulties and the culture of psychology (stigma about own mental health difficulties) and training (lacking self-care and focus on therapist's values); difficulty establishing boundaries between work and professional life -Implementing personal and workplace self-care; finding meaning in everyday work; establishing boundaries and letting go of responsibility for clients' well-being outside of therapy; good quality supervision; seeking own therapy; recovery and self-care strategies leading to pre-burnout functioning; burnout as a process of personal change

Quality Assessment and Presentation of Findings
The results of the critical appraisal process are summarised in Table 4. Based on the information provided in the published papers, Cramond et al. (2020) and Hammond et al. (2018) met all the criteria of the CASP checklist, while Papadomarkaki & Lewis (2008) and Sim et al.
All included studies used an established qualitative methodology that was in line with the aims of the research.In terms of recruitment, most studies used either purposive recruitment techniques or snowball recruitment techniques.All the studies assessed included at least some information about the inclusion and exclusion criteria, with the exception of one study (Papadomarkaki & Lewis, 2008).All studies provided a rationale for using semi-structured interviews to collect data and included at least some detail about the content of the interview (e.g., interview schedule and questions).
Only three studies specifically referenced the concept of saturation when explaining their data collection process (Clarke et al., 2020;Cramond et al., 2020;Hammond et al., 2018).While data saturation can be operationalised in different ways (Saunders et al., 2018), it is important for researchers to consider it in order to increase credibility and transparency (Fusch & Ness, 2015).
Reflexive diaries, memos, regular reflection and involving additional researchers to review themes and interpretations were some of the most commonly used tools used to counter researcher bias and promote reflexivity.

PSYCHOLOGICAL THERAPISTS' EXPERIENCES OF BURNOUT 20
All paper except two (Papadomarkaki & Lewis, 2008;Sim et al., 2016) explained how and where ethical approval for their research was granted.All but three studies (Clarke et al., 2020;Papadomarkaki & Lewis, 2008;Turnbull & Rhodes, 2019) described how the research was explained to participants, included information about the process of obtaining participants' consent, and how confidentiality was maintained.All studies used an established qualitative method and described their analytical process, although their level of detail varied.All the studies presented their findings including at least some of their data.Two studies (Clarke et al., 2020;Sciberras & Pilkington, 2018) did not include some of their findings due to lack of sufficient evidence or relevance to the research question.The findings in Sim et al. (2016) appeared to reflect the structure of the interview questions rather than providing an analytic narrative based on the data.All included studies employed at least one credibility check, including team debriefing and consultation amongst the authors and research supervisors (Clarke et al., 2020;Hammond et al., 2018;Papadomarkaki & Lewis, 2008;Sim et al., 2016), involving additional analysts (Norrman Harling et al., 2020), using memos and reflexive diaries (Cramond et al., 2020;Turnbull & Rhodes, 2019), carrying out multiple reviews of theme and code identification processes (Reitano, 2021), and participant validation procedures (Clarke et al., 2020;Sciberras & Pilkington, 2018).All the studies presented their findings in relation to their research questions.All except one of the studies (Papadomarkaki & Lewis, 2008) discussed the generalisability and/or transferability of their findings as one of the limitations of the research.All included studies discussed their findings in relation to the existing literature and made at least some recommendations for future research and practice.The lack of reporting on dropouts and exclusions in seven of the nine included studies implied that the risk of recruitment and selection bias was not addressed.Limitations around generalisability and transferability have been acknowledged in eight of the nine studies.The qualitative methodologies and the small sample sizes of these studies hinder generalisations to wider populations of psychological therapists and practitioners.Overall, all the studies included in the review provided useful data to address the research questions.

The Experience and Impact of Burnout
Therapists' experiences of burnout (and related concepts) and its impact were described in all the included studies.Therapists reported a number of physical, emotional and psychological difficulties associated with burnout, which significantly affected their lives.
Therapists talked about feeling fatigued and struggling to focus at work, describing a sense of 'being there but not being there' (Clarke et al., 2020).The emotional impact of these difficulties was evidenced by the participants' experiences of feeling numb and demotivated.
Similarly, their professional efficacy and emotional availability were also affected.As a result, therapists reported experiencing decreased personal accomplishment, which led to being unable to work (Turnbull & Rhodes, 2019).
One of the participants described the intense experience of feeling exhausted and fatigued due to stress and burnout: 'I've had these setbacks with burnout … I was sitting in my car after an intense week, where I've done lots of travel and done things in other places, in my job.And afterwards, I had to stop the car and sort of let it spin for a while, and get out.And I got so scared, I thought 'Dammit!My brain is whacked now'' (Norrman Harling et al., 2020, p. 9).
Another participant talked about the lack of motivation and sense of dread experienced when feeling burnt-out: '. . .One of the main things I remember is driving to work. . .just wishing I felt sick that day or, you know, that I get a flat tyre or something just so I didn't have to go' (Hammond et al., 2018, p. 7).
Four of the included studies (Clarke et al., 2020;Papadomarkaki & Lewis, 2008;Sim et al., 2016) highlighted the extent to which burnout affected therapists' personal lives and relationships.This lack of emotional availability experienced by therapists when feeling depleted and burnt-out seemed to permeate their personal relationships with family and friends, leading to reduced social contact, isolation and loneliness.As one of the participants described: '...I'm just like a zombie at the end of the day...And then kind of having that blunt, you know, when other people tell you stuff, you're just kind of like 'I wanna have that emotion, and I wanna show you that, but I've literally got nothing left in the tank', '...And so it feels like the, the, the more, um... infinite some of those levels [of empathy] are in the room, in therapy, then the more finite they become out there in personal relationships' (Clarke et al., 2020, p. 7).
Participants stressed how the experience and impact of burnout were entangled with their personal circumstances.One of the therapists shared the sense of failure that pervaded professional and personal aspects of their life: 'It was like a perfect storm, I was feeling like a failure in the three big aspects of my life, as a mum, as a wife, and as a psychologist' (Turnbull & Rhodes, 2019, p. 55).

Factors Contributing to Burnout
Eight studies identified factors that contributed to the development and experience of therapist burnout.These factors ranged from organisational and systemic issues to personal difficulties experienced by therapists.However, systemic and organisational pressures were described as the most significant factors contributing to therapist stress and burnout: 'I find myself today hanging on to my client-work to keep me motivated because it's the system that sometimes feels like an obstacle to my work...' (Sciberras & Pilkington, 2018, p. 154).
The lack of adequate resources, time pressures, working overtime, the impact of nonclinical work, such as administration and managerial tasks, high caseloads, poor quality supervision, and the clinical complexity of their work were the most commonly faced challenges.Therapists identified the lack of training to support their clients adequately, a poor understanding of their role in the teams, the subsequent ambiguity and uncertainty about the nature of their work, and the ethical challenges caused by the disparity between increasing demands and poor resources as significant factors contributing to burnout.These factors fuelled their sense of powerlessness and hopelessness, as one of the participants stated: 'It's straining when we don't have the resources, when we know that we could have done something, but the resources aren't enough.(…) So we don't feel like we can stand behind what we deliver' (Norrman Harling et al., 2020, p. 8).
Three studies (Papadomarkaki & Lewis, 2008;Reitano, 2021;Sciberras & Pilkington, 2018) linked the ethical issues experienced by the therapists to the difficulties of working within a medical model.Therapists reported facing ethical dilemmas such as being asked to persuade their clients to engage in therapy, following the recommendations of the medical team (Reitano, 2021), and doubting the value of their input, particularly when being requested to provide short-term interventions, perceived as inflexible and unhelpful (Papadomarkaki & Lewis;Reitano, 2021).The experience of these challenges conveyed a sense of powerlessness that left therapists frustrated at not feeling 'trusted' and 'valued' (Sciberras & Pilkington, 2018).As one participant highlighted: 'I felt that I was not valued as a professional.My work was not being seen and valued for what it was . . .so when I started to experience this, I said: 'This is not why I became a psychologist, this is not exactly how I wanted to work! . . .I was not trusted and that was my major issue with this' (Sciberras & Pilkington, 2018, p. 154).
These studies emphasised the tensions that burnt-out therapists experienced within the medical model, both within the public and private sector.Their experience of burnout was associated with the challenges faced within a medical system that was perceived as rigid and hierarchical, where doctors and psychiatrists would take the most important decisions, including those related to the provision of psychological interventions.Therapists reported conflicting feelings stemming from ethical dilemmas and disagreeing with the dominant values of the medical model, which did not focus on developing a collaborative and empowering approach to supporting clients.As one of the participants described: 'My role in the mental health system is something that often does make me feel anxious because I feel that (…) I don't sort of fit in with the medical model, which is the prevalent view in the service that I work in, and (…) I have a lot of doubts about what I am doing sometimes, whether we really help people that much in the long run or not' (Papadomarkaki & Lewis, 2008, p. 44).

Strategies that help to Prevent and Reduce Burnout
All the included studies highlighted strategies that can help to prevent and reduce burnout.All bar two of the included studies (Clarke et al., 2020;Papadomarkaki & Lewis, 2008) identified implementing self-care strategies as a way of reducing and preventing burnout.Participants described self-care as a set of tools to embed in their routine, including looking after themselves physically (e.g.eating and sleeping well), seeing family and friends, and nurturting hobbies and interests in their spare time.Participants saw self-care as an essential component in 'building resilience' (Norrman Harling et al., 2020;Reitano, 2021) and developing a true and 'authentic self' (Turnbull & Rhodes, 2019).One participant described how the implementation of self-care strategies helps to prevent stress and fatigue: (Norrman Harling et al., 2020, p. 10).
Seven studies discussed the impact of supervision on therapist burnout.Participants described good quality supervision as a fundamental space to process difficult feelings and emotions related to their work, while maintaining adequate standards of good practice.This 'great source of support' (Reitano, 2021) allowed them to share their challenges without feeling judged: 'Supervision has taken the pressure off me; it's allowed me to share what's going on for me (…).Sometimes the supervisor can help me to see something in a different way, to look something in a different way and I'll think: 'oh, yeah!' and I'll go on from that way' (Papadomarkaki & Lewis, 2008, p. 45).
Five studies (Norrman Harling et al., 2020;Papadomarkaki & Lewis, 2008;Reitano, 2021;Sciberras & Pilkington, 2018;Sim et al., 2016) explored the role of peer support in reducing burnout.Participants described the support they receive from other colleagues as 'vital' and 'invaluable' for managing work-related stress.One participant, for example, talked about the restorative nature of peer support: '[At lunchtime I] go into the staff lounge because there's a good mix of people in there … we jokingly refer to it as the no empathy zone … we laugh at ourselves … it's restorative' (Sim et al., 2016, p. 392).
Five studies (Cramond et al., 2020;Norrman Harling et al., 2020;Sciberras & Pilkington, 2018;Sim et al., 2016;Turnbull & Rhodes, 2019) highlighted the importance for therapists to find meaning in their professional role.Job satisfaction achieved through finding meaning and purpose in their day-to-day work was seen as a helpful strategy to alleviate burnout.Therapists described working with people in distress as 'a privilege' and 'an absolute humbling honour' (Cramond et al., 2020).Seeing improvements in clients' quality of life was highly valued by therapists and seen as 'the biggest reward you can get' (Sciberras & Pilkington, 2018).

Discussion
The present review aimed to explore therapist burnout from a qualitative perspective, synthesising studies to develop a richer understanding of the difficulties and challenges experienced by psychological therapists, as well as their professional and personal coping strategies.The findings appear to validate the dynamic and fluid nature of burnout (Maslach & Leiter, 2016), highlighting that the experience of burnout in therapists is complex, affecting a number of areas, including their physical and emotional wellbeing, and the boundaries between personal and professional lives.Participants talked about feeling depleted and emotionally disconnected from their role, and being unable to support their clients effectively.This is consistent with existing research on therapist burnout and its impact on their wellbeing and professional effectiveness (Morse et al., 2012;Simionato et al., 2019).
The impact of burnout on therapists' personal lives was also evidenced, leading to reduced social engagement and lessened ability to connect and empathise with others.It appears that therapists' reduced effectiveness and motivation impaired their ability to engage in therapeutic work meaningfully, thus reinforcing their dissatisfaction.These findings contribute to existing research on therapist burnout, stressing the link between the manifestations of burnout, therapist effectiveness, absenteeism and turnover (Connor et al., 2018;Maslach, 1982;McCormack et al., 2018;Simionato & Simpson, 2018;Simpson et al., 2019).
The review also highlighted some important contributing factors to developing burnout.Participants identified the systemic and organisational challenges they faced as the most significant contributing factors.It appears that therapists perceive systemic and organisational challenges as something they have little or no control over, which fuels their sense of powerlessness and hopelessness.Some of these organisational difficulties seemed to foster the awareness of clashing values, with related ethical implications.Therapists experience ethical dilemmas stemming from dealing with systemic issues they do not feel in control of, which can increase the sense of responsibility they carry (McCormack et al., 2018;Simionato et al., 2019).Similarly, participants found working within services that adopted a medical model as their organisational framework difficult.The clash of perspectives and beliefs, particularly in relation to offering collaborative, patient-centred and psychologically informed care to clients, appeared to raise ethical concerns that made participants feel devalued and unappreciated, which contributed to the development of burnout.As others have suggested (Simionato et al., 2019), exploring the ethical and values-based implications of burnout can help to gain a deeper and more comprehensive understanding of the issues faced by psychological therapists.
The findings of this review have emphasised the importance of individual and systemic coping strategies to reduce therapist burnout.Implementing self-care strategies was perceived as one of the most effective strategies to prevent and alleviate burnout.It seems that participants found the prompt use of self-care and wellbeing tools essential to prevent burnout and foster wellbeing.The wide range of tools mentioned by the participants suggests that self-care strategies can be personalised and customised to meet their individual needs.It has been theorised that self-care acts as a buffer, enhancing professional satisfaction and thus protecting against the effects of burnout and preserving wellbeing (Rupert & Dorociak, 2019).This review also validated the role of systemic and organisational strategies in preventing and managing burnout, such as effective supervision and peer support.
Participants found good quality supervision very valuable in preventing burnout and maintain wellbeing, particularly when processing their own feelings and emotions.Adding to existing literature in the area (Connor et al., 2018;Simionato et al., 2019), the review found that this focus on self-reflection, rather than case-management, plays a key role in preventing burnout and promoting therapist wellbeing, and can provide opportunities to consider and address organisational and systemic factors contributing to burnout.The findings of the present review highlighted that key role of peer support when facing work-related adversity and burnout.Participants talked about peer support and supervision as a restorative space where difficulties are normalised both formally and informally.It seems that this flexible nature of peer networks allows therapists to maximise opportunities to give and receive support, thus addressing a wide range of therapist needs (Rothwell et al., 2019).Finally, finding meaning in day-to-day work was also seen as an effective coping strategy to mitigate therapist burnout.Participants valued being able to help others and being part of their recovery journey.Seeing improvements in clients' wellbeing and quality of life enables therapists to feel valued and experience a sense of purpose.Being able to conceptualise work-related stress in relation to meaning and purpose has been shown to be a healthy coping mechanism that increases stress tolerance and, more generally, work-related ambiguity and uncertainty (Iannello et al., 2017).

Clinical Implications and Recommendations
The findings of this review demonstrate the impact that therapist burnout can have on their ability to work effectively, which has important implications in terms of staff absenteeism, turnover and retention.This appears in line with previous findings suggesting that lower therapist wellbeing is associated with increased likelihood to leave their roles (Summers et al., 2021).Services should consider promoting a culture in which staff wellbeing is safeguarded.National guidelines and policies are increasingly recognising that preserving and maintaining staff wellbeing also has longer-term economic benefits, as a recent report by the National Health Service (NHS) in England underscored (Health Education England, 2019).Managers and supervisors should be trained to discuss and review burnout factors and related difficulties regularly with their supervisees, offering access to additional support and training when needed (Simionato et al., 2019).
Supervision remains a cost-effective preventative measure for therapist burnout.The findings of this review provide evidence that therapists utilise supervision to manage and reflect on their own feelings and emotions.As evidenced in the present review, in addition to offering case-management, effective supervision should provide a space for therapists to reflect on systemic and organisational challenges, and the impact this has on their clinical work.Given its focus on the therapist's emotional challenges, self-reflection in supervision may be a more effective measure to prevent therapist burnout (Jones & Thompson, 2017;Rothwell et al., 2019;Simionato et al., 2019).Relying on peer support was also validated as an invaluable coping strategy.Whilst peer support commonly features as an important aspect of practice in the professional work of many psychological therapists, services should proactively facilitate relational and peer-based activities, such as mindfulness and selfcompassion classes, offering therapists opportunities to engage meaningfully with their colleagues (Lomas et al., 2019;Simionato et al., 2019).Evidence shows that relational networks increase awareness of wellbeing-related difficulties, promote compassion within the workplace (Simpson et al., 2020), and address needs that formal supervision tends to neglect (Rothwell et al., 2019).Finally, this review highlighted that finding meaning in their work and appraising stress in relation to values and beliefs systems helped therapists to manage burnout-related challenges.Services should consider psychoeducational training and practices that enhance self-reflection, such as mindfulness and reflective practice, to encourage therapists to get in touch with their values and embrace work-related stress as a natural part of their work (Lomas et al., 2019;Simionato et al., 2019).

Strengths, Limitations and Future Research
To our knowledge, this is the first systematic review synthesising qualitative studies on burnout in psychological therapists.The methodological appraisal of the included papers was discussed and consensus reached with the second (initials) and third authors (initials).
One of the limitations of this review was related to the definition of psychological therapist.This encompassed a number of professionals, including different kinds of psychologists and psychotherapists, but excluded other professionals, such as sport psychologists, counsellors, trainees, and students.Studies including these professionals could provide further insight into the experiences of burnout in psychological therapists.This review included studies on psychological therapists practising in both public and private sectors.Future research could differentiate these sectors to explore differences and similarities, and whether the experiences and process of burnout differs depending on the context in which therapists operate.Taking into account the experiences of burnout in education and training settings through the recruitment of trainees and students could help to gain a more comprehensive understanding of this phenomenon in psychological therapists early in their professional development, thus uncovering further learnings.All the studies included in this review used qualitative methodologies with small sample sizes, and therefore the transferability of the findings need to be considered with caution.Including studies using mixed-method designs and larger sample sizes could increase the transferability of findings in this area.The reference lists of similar and relevant systematic reviews were not handsearched, which represents another limitation of this review.Finally, future systematic reviews could include studies that utilise measures of burnout to further evaluate the process of experiencing and overcoming burnout.

Conclusions
The findings of this review have highlighted that experiencing burnout has a significant impact on psychological therapists' personal and professional lives.Systemic and organisational difficulties were identified as the most significant contributing factors to burnout.Implementing self-care and wellbeing strategies, relying on supervision and peer support, and finding meaning in their work were the most helpful strategies to prevent and reduce burnout reported by the participants.Clinical recommendations and implications for services and training programmes include the promotion of workplace cultures in which staff wellbeing is protected.Further research on therapist burnout using different methodological approaches and larger samples is needed to increase transferability.Adopting distinct conceptualisations of burnout and including other kinds of psychological therapists could provide further insight into the experiences of therapist burnout.

Figure 1 PRISMA
Figure 1 PRISMA Flow Diagram showing the Screening and Selection Process

'
I'm much better at noticing my compassion fatigue now.I can see what's happening (…) and I can try and change things.(…) Like 'oh, now this happened, I have to change tracks here'

Table 3
Summary of Results of Included Studies -Emotion management at work leading to personal growth through emotional expansion and awareness;being on a journey of self-discovery, self-learning and self-reflection; therapists reporting an increased understanding of their emotional experiences and interpersonal interactions, and more able to empathise with clients -Managing emotions linked to burnout, feeling depleted, exhausted and fatigued; 'being there but not being there', experiencing compassion fatigue as inability to feel the emotion for the patient; feeling depleted of emotional resources, unable to engage well interpersonally; reduced emotional availability; reduced capacity to provide emotional support due to emotion management with clients; becoming more intolerant and frustrated a with family and friends; dissatisfaction and frustration with personal interactions perceived as trivial and lacking depth -Need for space from other relationships, reduced stimulation, tendency to avoid work-related emotions; not seeking social contact and wanting to spend time alone in less stimulating environments; less engagement in emotionally taxing relationships and leisure activities; avoiding content that is likely to re-evoke Jesus complex', being always expected to show compassion; forcing compassion; ethical stress and lack of resources -Annoyance, categorical thinking, numbness and isolation as signs of compassion fatigue -Support from colleagues; amplification of each other's complaints through talking; role of leadership; friends and family as a source of support and distraction; personal relationships exacerbating difficulties Lack of understanding of therapist's role.Challenges faced in the medical model, lakc of collaborative approach.Organisational pressures and unrealistic expectations as the greatest source of occupational stress.Expectation to contain not only patients' distress but also other professionals' stress.Need to challenge other professionals to work ethically.Pressures from increased workload, lack of resources, operational rules, long waiting lists, little time to prepare in between sessions and miscommunication with other professionals.Occupational stress from focus on targets and diagnoses, rather than clients' needs -Team support as the most valuable resource to prevent and reduce occupational stress.Building a positive team culture to help therapists feel less isolated and exposed.Importance of being able to talk freely about own vulnerabilities.Identifying common values at work.Balancing power dynamics in the team and build collaborative practice.Being committed to doing their best for patients; fostering a flexible and caring approach to practice; offering and receiving support when needed, staying connected with peers -Wide range of different tasks (e.g., excessive admin, coordination), clinical complexity and high caseloads;dissatisfaction with framework and policies -'-Building resilience key to reducing occupational stress and preventing burnout; importance of selfawareness, self-care, reflection and self-compassion; keeping boundaries in place and being mindful of own limits (e.g., 'not having to fix people').Accepting one's own vulnerability, developing ability to recognise and accept own difficulties.Clinical supervision and promoting therapists' wellbeing outside of work to prevent stress (e.g., mindfulness and relaxation) Recognition for achievement, clients improving and appreciating therapists' support, receiving praises from colleagues, support from colleagues and managers or directors, a sense that staff work well together, therapist autonomy, respect for limits at work and social activities with colleagues at work; supervising, training and mentoring new colleagues perceived as very satisfying; client improvement, opportunities to progress and develop further -Challenges related to therapists' work, such as non-clinical and crisis/clinical work, lead to burnout (e.g. 'not doing things as well as they like, feeling drained and exhausted, defeated, low satisfaction, staying afloat'); lack of time for clinical and crisis work contributing to burnout; imbalance between perceived demands and resources available; challenges related to professional relationships, including colleagues and peers; difficult relationships with supervisors and directors (e.g.'not sleeping and functioning well, 'sense of anger and insecurity'), lack of mentors; personal difficulties, loneliness, sadness, isolation; health concerns, feeling depressed and worried about the future -Interpersonal and social support; self-care, engaging in wellbeing and leisure activities (e.g., exercise, mediation, yoga, healthy eating and hobbies); increasing self-awareness, adopting new perspectives and thinking about change; behavioural strategies such as setting boundaries and adjusting work schedule;

Table 4
Summary of Critical Appraisal using the Qualitative CASP Checklist(CASP, 2017) : fully met; : partially met; : not met; Can't tell: unable to assess.