“We take on people’s emotions”: a qualitative study of physiotherapists’ experiences with patients experiencing psychological distress

ABSTRACT Background Previous research suggests that physiotherapists frequently engage with patients who experience psychological distress (e.g. feelings of depression and anxiety) and that physiotherapists find supporting these patients challenging. Objective The aim of this study was to explore the experiences of Australian physiotherapists with patients they perceived were experiencing psychological distress. Methods A ‘Big Q’ qualitative research approach was used. Twenty-three interviews with physiotherapists were conducted. The data were then analyzed using iterative thematic inquiry. Results The analysis produced four interrelated themes: 1) encounters with patients in distress are common and varied; 2) becoming emotionally attuned with their patients meant that distress could invoke empathetic distress; 3) physiotherapists use emotional shields to protect themselves; and 4) physiotherapists found frequent encounters with patient distress to be emotionally exhausting. Viewed together, the themes highlight how patient distress can invoke transient empathetic distress in a physiotherapist; repeated experiences of empathetic distress may lead to empathetic distress fatigue. Conclusion While physiotherapists are sometimes viewed as ‘physical’ health professionals, the experiences of these physiotherapists suggest that patient psychological distress is highly relevant to physiotherapy practice. We recommend future research explores the relationships between patient distress, physiotherapists’ empathy, and physiotherapists’ wellbeing.


Introduction
Psychological distress is a nonspecific mental health issue that is typically characterized by the symptoms of depression and anxiety; however, it can also involve other negative affective states, including anger, guilt, grief, and loneliness (Drapeau, Marchand, and Beaulieu-Prévost, 2012;Mirowsky and Ross, 2003).While psychological distress may resolve without professional support, there are times when people experiencing psychological distress may benefit from professional support delivered by formally trained mental health professionals (Sareen et al., 2013).Psychological distress can lead to significant consequences, including reduced quality of life, long-disability, and premature mortality (Atkins, Naismith, Luscombe, and Hickie, 2013;Rai et al., 2012;Russ et al., 2012).
In Australia, the term mental health professional generally refers to practitioners practising in one of the following professions: psychiatry, general medical practice, psychology, mental health nursing, social work, and occupational therapy (Cleary, Thomas, and Boyle, 2020;Mental Health Workforce Advisory Committee, 2011).In addition to mental health professionals, Egan and Reese (2014) argued there is a second group of professionals who are also expected to help people experiencing psychological distress.This second group of professionals includes but is not limited to: dentists, non-mental health nurses, teachers, police officers, and lawyers (Egan and Reese, 2014).What separates the second group of professionals from identified mental health professionals is that, while they are experts in their respective fields, they are not considered to be experts in mental health (Egan and Reese, 2014).
While there is no definitive list of professions that belong to this second group, the professions referred to as 'physical health professions' seem to fit the description provided by Egan and Reese (2014).The Australian Psychological Society (2021) referred to the following professions as physical health professionals: physiotherapy, podiatry, speech pathology, chiropractic, dental, audiology, Chinese medicine, and exercise physiology.According to the Australian Psychological Society (2021) these physical health professions largely focus on providing physical health care.In the case of physiotherapy, physiotherapists have been described as "physical rehabilitation experts" (Webb et al., 2009) and as "movement experts" (Sahrmann, 2022).While the physiotherapy profession has historically embraced the biomedical model of health, the more recent paradigm shift to a biopsychosocial model has brought with it greater recognition of the inseparability of the body and mind (Gard and Skjaerven, 2018;Nicholls, 2017Nicholls, , 2022)).The adoption of the biopsychosocial model requires physiotherapists to have a greater understanding of the psychosocial aspects of patients' conditions (Mescouto, Olson, Hodges, and Setchell, 2022).However, the extent to which the paradigm shift has influenced clinical practice is unclear leading some researchers to call for physiotherapy, as a profession, to embrace an enactive, relational, phenomenological, and humanistic approach to care (Barlow, 2021;Cormack, Stilwell, Coninx, and Gibson, 2022;Mescouto, Olson, Hodges, and Setchell, 2022).
While physical and mental health are intrinsically linked (Stubbs et al., 2017) the findings of previous studies have brought into question the preparedness of physiotherapists to provide support for people experiencing mental health issues.Several studies have reported that physiotherapists feel ill-equipped to support patients experiencing poor mental health due to a lack of training in mental health (Andrew et al., 2019;Connaughton and Gibson, 2016a;Lennon et al., 2020;Lundin and Bergenheim, 2020;McGrath et al., 2021McGrath et al., , 2020)).In addition, studies have reported that physiotherapists are hesitant to ask about mental health issues, such as suicide, as they were fearful of opening "Pandora's box" and not being able to manage it (Holopainen et al., 2020;Lundin and Bergenheim, 2020).These results are not unexpected, given that Connaughton and Gibson (2016b) found that none of the seventeen Australian universities offering entry-level physiotherapy programs had a specific unit of study dedicated to mental health at the time of their survey.
To date only one study has been published that specifically investigated encounters between physiotherapists and patients experiencing psychological distress.Lennon et al. (2020) examined the practices and opinions of 320 Irish physiotherapists using a mixed-method survey study design.They found that physiotherapists frequently encountered patients experiencing psychological distress (i.e.40% reported contact daily, 81% reported contact weekly).Lennon et al. (2020) also reported that physiotherapists wanted better access to support services including debriefing services and greater recognition of burnout in physiotherapists caring for patients experiencing psychological distress.Physiotherapists' desire for greater recognition of burnout raises concerns about the potential effect of patient distress on physiotherapists' wellbeing.The aim of this study was to extend upon the research conducted by Lennon et al. (2020) by exploring the experiences of Australian physiotherapists with patients they perceived were experiencing psychological distress.Understanding physiotherapists' experiences will provide insight into this specific clinical interaction, which can then be used to inform continuing professional development courses, and entry-level and post-graduate curricula.Understanding physiotherapists' experiences will also inform policy, which is particularly relevant as the Australian Physiotherapy Association (2021) has called for the role of physiotherapists in mental health to be formally recognized.

Theoretical orientation and methodological framework
The study was approached from a postmodern pragmatist ontological and epistemological orientation.
Postmodern pragmatists are open to different ways of thinking and doing as they hold that no one method has access to objective reality, if such a thing exists (Hickman, 2019).Therefore, the researchers were free to choose their research methods based on their suitability to answer the research question.Postmodern pragmatists are also skeptical of grand narratives as they believe knowledge about everything and anything is always limited; thus, all knowledge claims are fallible and subject to change (Fishman, 1999;Hickman, 2019;Kaushik, Walsh, and Lai, 2019).Therefore, the researchers acknowledge that a plurality of views on the topic will exist and that the reported findings of this study are just one of the many possible ways the data could have been interpreted.
Given the lack of in-depth, contextual descriptions of the experiences of physiotherapists with patients experiencing psychological distress, the 'Big Q' qualitative approach was chosen for this study.The Big Q qualitative approach is an unstructured and inductive approach where researchers analyze data for meaning (Kidder and Fine, 1987).Researchers using the Big Q qualitative approach start with a "hunch" and let the data lead them to new questions and new knowledge (Kidder and Fine, 1987).The final products of Big Q research are not individual themes but a collection of themes that tell an analytical story (Braun and Clarke, 2021).The Big Q qualitative approach was considered to be congruent with the researchers' ontological and epistemological orientation.For example, the researchers noted particular similarities between Big Q qualitative research beginning with a hunch, which then leads to new questions and new knowledge (Kidder and Fine, 1987), and the postmodern pragmatists' position that research is initiated by the researchers' preconceptions (i.e.prior beliefs) of the topic, which are revised as new data is encountered (Morgan and Nica, 2020).

Participants, recruitment and sampling
Ethical approval for the study was granted by the Human Research Ethics Committee of Charles Sturt University (Protocol reference H21279).All participants provided written informed consent, and consent was verified again verbally before participation.Potentially identifying participant and patient information contained within the interview transcripts were not included in the manuscript, to protect privacy.
The sampling method chosen for the study was purposeful maximum variation sampling.Purposeful maximum variation sampling involves recruiting participants in such a way that it will maximize the variation in specific participant characteristics (Sandelowski, 1995).In this study, the goal was to sample physiotherapists who had experiences with patients experiencing psychological distress from across the range of physiotherapy practice areas.To participate, physiotherapists had to be currently registered with the Australian Health Practitioner Regulation Agency and report having encountered a patient or patients who they perceived were experiencing psychological distress in the context of a physiotherapy consultation within the past year.The sampling strategy was operationalized by recruiting participants through the social media networks of the Australian Physiotherapy Association (APA) National Groups, which each had a clinical focus.By recruiting from the APA National Groups, the researchers could invite participation from physiotherapists working in various areas of clinical physiotherapy.Recruitment continued until pragmatic considerations brought it to a close, with these considerations including resource (time) considerations, participant interest, and achievement of sufficient levels of information power (a variation of data saturation as described by Malterud, Siersma, and Guassora, 2015).
Twenty-three physiotherapists participated in the study.The ages of the participants ranged from 26 to 62 years (mean = 39.17 years), and their years of clinical experience ranged from 4 to 41 years (mean = 16.57years).Five participants were recognized as 'titled physiotherapists' by the Australian Physiotherapy Association (2018) in a specific area of physiotherapy practice, and the levels of education ranged from Australian Qualifications Framework Level 5 (Diploma) to Level 10 (Doctoral qualification) with the mode being Level 7 (Bachelor Degree).Primary areas of practice and primary work settings are reported in Table 1.The participants were ethnically homogenous (predominantly Caucasian) and predominantly female (21 females, 2 males).

Data collection and processing
Twenty-three in-depth interviews (21 via videoconference and 2 via telephone) were conducted and audio-recorded.
Recording the interviews allowed for accurate transcription and enabled the researchers to re-immerse themselves in the participant responses after the interviews were completed.On average, the semi-structured interviews ran for 2.00 hours (range 1.25 to 3.93 hours) (Appendix 1).Interviews were transcribed using the speech to text feature of Adobe Premiere Pro CC 2021 (version 15.4.1) as it enabled the researchers to listen to each interview and correct the transcription produced by the software.Each participant was assigned a pseudonym in the transcripts to protect their privacy.

Data analysis
The analysis method was informed by iterative thematic inquiry (ITI) (Morgan and Nica, 2020).ITI is a pragmatist-oriented analysis method (Morgan and Nica, 2020) and was chosen due to its congruence with the research paradigm in which the study was situated and its suitability to address the research aim.Unlike other approaches to thematic analysis, such as reflexive thematic analysis, where the formal analytic writing starts after coding (Braun and Clarke, 2021), in ITI, formal analytic writing begins as soon as the researcher first encounters data that reinforce, challenge, or expand their preconceptions about the topic (Morgan and Nica, 2020).Formal analytic writing involved developing an initial list of themes and a description of these themes in a form similar to what would be presented in a results section (Morgan and Nica, 2020).The initial list of themes is then revised each time the researcher encounters new data until the point at which the list of themes remains largely stable and the themes combine to tell an analytical story that captures the complexity and nuances of the data (Morgan and Nica, 2020).At this point, the list of themes is converted into a codebook and the transcripts are deductively coded, looking for new insights that may require the themes to be revised (Morgan and Nica, 2020).Note that the purpose of the codebook in this study was not to ensure reliability or reduce bias in the analysis but rather to provide an opportunity for the researchers to interrogate their interpretation of the data.NVivo (version 10) was used to assist the coding process.The final phase of the analysis involved converting the analytical story into a form that speaks to the intended audience (Morgan and Nica, 2020).The analysis performed in this study was conducted at the interpretive end of the descriptiveinterpretive spectrum (Shaw and Connelly, 2012).
Figure 1 provides an overview of the analysis process.

Trustworthiness
The measure of quality and trustworthiness in Big Q research is related to: 1) the transparency of description of the researcher's epistemological orientations and methodological choices; 2) the researcher's depth of engagement with the data; 3) the strength of the analysis; 4) the credibility of the research; and 5) the sincerity of the researchers (Braun and Clarke, 2021;Clarke and Braun, 2018;Tracy, 2010;Varpio et al., 2017).To ensure that all important aspects of the study (e.g.epistemological orientation and methodological choice) were adequately reported the manuscript was developed using the Uniform Requirements for Manuscripts Submitted to Biomedical Journals and the Standards for Reporting Qualitative Research (O'Brien et al., 2014) (Appendix 2).Furthermore, a detailed methodological description indicating how the study was conducted was provided to further promote transparency.To increase the lead researcher's depth of engagement with the data set, the first author conducted all 23 interviews and was responsible for transcribing the interviews, drafting the initial themes, and developing the codebook.To enhance the strength of the analysis the primary role of the second, third, and fourth authors in the data analysis phase was to prevent analytic foreclosure and to stimulate richer and more nuanced insights.This was achieved by the researchers engaging in group discussions about the data and the construction of potential themes.To enhance the credibility of the research, the researchers aimed to "show rather than tell" (Tracy, 2010) by including participants' voices wherever possible.
Positioning the participants' voices prominently allows the reader to judge the researchers' interpretation.To promote reflexivity, the first author kept a research journal that allowed him to reflect on his preconceptions of the topic and how his interpretation of the data changed over time.In addition, the data analysis method (ITI) explicitly required that the first author document their preconceptions of the topic so that they could reflect on whether new data reinforced, challenged, or expanded their preconceptions about the topic.For example, based on the findings of Lennon et al. (2020) the researchers held the preconception that participants would likely report feeling ill-equipped to assess and manage patients' experiencing psychological distress; however, this was not a prominent theme that emerged in this study.

Researcher statement
In Big Q research, the researcher plays an active role in the analysis as their lens allows the data to be transformed into an analytical story (Braun & Clarke, 2021).
The first author became interested in the research topic based on his experiences as a volunteer telephone crisis supporter and his experiences as a physiotherapist supporting patients experiencing psychological distress.
The second author is an occupational therapist with extensive clinical experience, an advocate of holistic, person-centered care, and an interest in researching lived and living experiences.The third author is a speech-language pathologist with a focus on holistic, culturally responsive care that moves beyond traditional physical health domains to consider all aspects of the professional-patient relationship.The fourth author is an experienced physiotherapist and researcher who has worked for many years across wide-ranging areas of physiotherapy practice and recognized the frequent exposure of physiotherapists to people experiencing psychological distress.All researchers identify themselves as ethnically Caucasian.

Results
The analysis identified four interrelated themes describing the experiences of physiotherapists with patients experiencing psychological distress: 1) encounters with patients in distress are common and varied; 2) becoming emotionally attuned with their patients meant that distress could invoke empathetic distress; 3) physiotherapists use emotional shields to protect themselves; and 4) physiotherapists found frequent encounters with patient distress to be emotionally exhausting.Viewed together, the themes highlight that the physiotherapists' experiences are embedded in the context of a complex professional and social relationship and that patient psychological distress has the potential to invoke empathetic distress in the physiotherapists.To protect the participants' privacy, participants have been assigned a pseudonym, and these pseudonyms have been used throughout the results section.

Theme 1: encounters with patients in distress are common and varied
Participants spoke about how encounters with patients experiencing psychological distress were a regular occurrence.Many participants used the words 'common, 'often,' and 'frequent' to highlight that these encounters were not an unusual occurrence.
It's so common in my role [as a neurological physiotherapist].You have some patients who are really low in mood, [and] really hard to engage . . .We often see stress and psychological issues with both the patient themselves and the family member who's supporting them.(Peter) When speaking about his experiences, Chris said he had seen so many patients he believed were experiencing psychological distress that he could not remember them all.
In terms of instances, literally hundreds .Participants spoke about psychological distress as a continuum, ranging from no distress to high levels of distress.Consequently, participants perceived that many of their patients were experiencing at least some level of psychological distress during the consultation.
[Psychological distress] can present in multiple different ways . . .Obviously, there's a continuum, and you go up and down in that continuum.(Hazel) I think it's a really big spectrum.Some people [experience] quite mild psychological distress, whereas at the opposite end of the spectrum, people could, you know, [experience] kind of a crisis type thing.(Karla) Maddison spoke about her contact with patients experiencing distress using a ten-point scale to estimate the level of distress.In a day, Maddison said most of her patients "hummed . . .between [a] four to six" out of ten.However, about once a week, Maddison would encounter a patient highly "distraught" and crying at the level of "eight plus."Like Chris, Maddison said that "distress is something we [physiotherapists] see all the time."While encounters with patients experiencing psychological distress were reported as common, the nature of the perceived distress was variable.Examples of the forms and manifestations of distress included sadness, hopelessness, restlessness, worry, panic, tension, fear, anger, frustration, grief, burdensomeness, helplessness, loneliness, and suicidal distress.
In my experiences, how patients have exhibited psychological distress [is] quite varied.Sometimes . . .those experiencing psychological distress were often withdrawn from care, very difficult to engage . .., very unmotivated . . .Some I noticed when [receiving] difficult news would shake or have difficulty just keeping eye contact . . .Others I knew would turn to booze or smoking or drugs, not often [would they tell] us this, but the signs were there.(Caroline) Some participants used the word 'suffering' to describe patients experiencing more intense forms of psychological distress.The participants who used the term 'suffering' appeared to use it to communicate the gravity of their patient's psychological distress.Participants also spoke about somatic and behavioral indicators of distress, such as substance abuse, crying, insomnia, hyper-ventilation, lethargy, violent outbursts, diminished concentration, shaking, fatigue, unexplained or disproportionate pain, and disclosure of suicidal behavior (e.g.disclosure of a non-fatal suicide attempt).
Participants spoke about how they believed people who sought their services were particularly vulnerable to distress as many had experienced one or more negative life events.Participants spoke about how the symptoms of the physical health issue (e.g.low back pain or shortness of breath) and the limitations associated with the physical health issue could be a source of psychological distress.While participants were mainly referred patients with physical health issues (e.g.chronic obstructive pulmonary disease) which they viewed as a potential source of patient distress, participants noted that the source of their patients' distress could be multifactorial.For example, participants shared experiences they recalled having with patients who had disclosed distress related to various types of traumas, including sexual assault, family violence, elder abuse, medical trauma, and combat trauma.Participants also spoke in detail about patients who shared feelings of hopelessness with them.
In those patients in the community or the wards [I] often [hear] things like "[I] feel hopeless," "I couldn't be bothered anymore," "I'm tired of life," "This just keeps going and going and going and I've had enough," or them just asking., "What's it like to die?" "What's death like?" "Have you seen it before?""Is it painful?"(Caroline) Several participants spoke about patients who had disclosed personal problems such as relationship issues, health-related anxiety, feelings of depression, general anxiety, and hopelessness.In some cases, these thoughts were associated with suicidal ideation, including death wishes.Participants reported encounters with patients who welcomed death, as their deteriorating health (physical and/or mental) had made living miserable.Several participants spoke about patients who had died by suicide during, or shortly after, their involvement in physiotherapy.While not all of these patients had disclosed their thoughts of suicide to the participants, many participants noted that the patients had expressed feelings of isolation, loneliness, burdensomeness, helplessness, and pain.

Theme 2: becoming emotionally attuned with their patients meant that distress could invoke empathetic distress
Participants spoke about how they often experienced psychological distress due to empathizing with patients experiencing psychological distress.To distinguish the distress experienced by patients from that of the participants, the form of distress experienced by the participants will hereafter be referred to as 'empathetic distress.'Participants said that the empathetic distress they had experienced generally mirrored the form of distress they perceived their patient was experiencing.For example Lynn spoke about an occasion where she found herself sharing her patient's feelings of anxiety and panic.While participants emphasized that their relationships with patients were professional, becoming emotionally attuned with their patients meant that distress could invoke empathetic distress.Participants spoke about experiencing the emotional highs and lows alongside their patients.For example, Jemima spoke about how she would find herself going on the journey "with" them.Several participants spoke about how they had to imagine themselves as if they were in their patient's situation (also referred to as perspective-taking), to understand their patient's situation more fully.Participants spoke about becoming attuned to their patients' emotional experiences through perspective-taking and that this emotional attunement was an essential part of the patient-physiotherapist relationship.
I haven't gone through all the experiences and all the spectrum of experiences that my patients have gone through [but] I can empathize at least on a human level . ... I need to be able to put myself in [their] shoes in order for me to understand what [they] need . . .[and] to be able to enter into that therapeutic alliance.(Lucy) During perspective-taking, participants spoke about times when they had lost their sense of self or lost the distinction between self and other.Beth and Jessica spoke about having to remind themselves that it was the patient experiencing psychological distress, not them.
You start to think, God, that could be me . . .and that's, that's really scary.(Jessica).
We take on people's emotions . . .So sometimes . . .I can just feel myself choking up, you know, and I think, oh, God, this is just awful . . .I kind of try and kind of quickly check myself and be like, but actually, this is not about me.(Beth) When reflecting on times they had struggled emotionally during an encounter with a patient, several participants were observed to fight back tears.Jessica became particularly emotional when talking about a patient named Anne.Jessica said that Anne had a "really nasty form of cancer" and did not have long to live.As a mother herself, Jessica found it difficult when Anne disclosed distress related to the prospect of her child not remembering her after she died.Jessica said she found it challenging to hear Anne's distress because she could easily imagine herself in Anne's position.Jessica was not the only participant to speak about how working with distressed patients who they perceived to be similar to them in some way was difficult, as they were likely to develop an intense empathetic connection with them.Beverley spoke about an experience where she had to leave the consultation room to recompose herself after hearing that her patient had lost a child the same age as her own child in a motor vehicle accident.Peter spoke about a specific patient named James.James stood out to Peter because they were of similar age, had partners of similar age, and each had two children.James had become a wheelchair user with minimal upper limb function after a spinal cord injury.
Although Peter said that James appeared positive during physiotherapy sessions, based on his assumptions about the patient's circumstances, conversations with James' family, and previous experiences with patients experiencing psychological distress secondary to a spinal cord injury, Peter said that he believed James was hiding his distress.Peter found it an emotionally demanding situation, as their similarities made it possible for him to imagine what it would be like to live James's life.

Theme 3: physiotherapists use emotional shields to protect themselves
Participants spoke about how empathy was a doubleedged sword.Empathy allowed participants to develop a therapeutic alliance that was seen as essential to achieve optimal physiotherapy outcomes.However, participants reported that empathy could at times result in empathetic distress and impair their ability to provide good care.
It is really important to have a lot of empathy and a lot of care for people when you are talking to them.But it is not going to do me any good, or them any good, if . . .I'm too emotionally [invested].I can't get into my smart brain.(Beverley) A strategy several participants used to reduce the probability of experiencing empathetic distress was emotional distancing.Participants used the words 'guard,' 'armor,' 'wall,' 'shield,' and 'boundary' to symbolize the process of protecting themselves from empathetic distress.These emotional barriers were like the emotional equivalent of personal protective equipment for emotional contagion.
[Sometimes I have] to step back and let my guard up a little bit more Ȃ6 I can be quite stoic and . . .cut them off and not let them in my head and sometimes you have to be [like that].I wouldn't be able to function if I did let them in too much . . .I guess that's where the guard moves.(Jessica) Several participants spoke about how, at times, they restricted or redirected the conversation to the physical aspects of their patient's care to reduce exposure to their patient's distress.Another strategy participants reported using was to refer the conversation to other health professionals.Statements such as "that would be a good topic to discuss with your oncologist" were used to limit emotional disclosure from patients.Other participants spoke about how, rather than shutting down the conversation, they emotionally distanced themselves from patients who were suffering.Participants who utilized this strategy did not completely detach themselves emotionally from their patients.Instead, they reduced the level of empathetic concern they had for their patient to protect themselves.Caroline used the hypothetical example of a physiotherapist treating their own mother in an intensive care unit to illustrate that having too much empathetic concern could: 1) cause a physiotherapist significant distress; and 2) impair their ability to provide good care.
It's a very fine balance . . .In some ways, being slightly numb can help . . . .I guess that numbness for me is almost like a personal-professional boundary . . .We can go in there and develop this rapport but at the same time . . . .The balancing act between emotionally connecting and emotionally distancing themselves was not easy for most participants.Lynn spoke of how she had "chinks in [her] armor" from working with patients experiencing psychological distress.Lucy said that physiotherapists, including herself, are not proficient at maintaining and creating boundaries, due to a lack of training.
When I have like young girls with horrible histories of abuse, it is hard not to put ourselves in their shoes . . .Although we love to say that we are very good at creating boundaries, I actually don't think that we physios were trained to create those boundaries . . . .It is hard not to put myself in their shoes . . .(Lucy) Ultimately, the optimal balance between emotionally connecting and emotionally distancing with patients appeared to be specific to each participant-patientrelationship.Several participants said that they could engage more empathetically with patients who were very different from themselves or patients whose stories did not emotionally resonate with them.In contrast, participants had to distance themselves more when they recognized aspects of themselves in their patients.
I think it's a fine balance between the two, you do have to develop rapport with patients . . .You know, the majority of the time there has to be some boundary or some armor there to protect the therapist . . .[ Theme 4: physiotherapists found frequent encounters with patient distress to be emotionally exhausting Empathetic distress described in the second theme was generally transitory; however, several participants spoke about experiencing a persistent form of distress.These participants spoke of experiencing emotional fatigue due to repeatedly seeing patients experiencing psychological distress and experiencing an empathetic distress response themselves.
If you're not careful.I actually do think there can be an accumulative effect of listening to lots of people's difficult stories.(Beverley) It's one of those things where spending energy on empathizing with somebody is exhausting . . .You try not to take on too much of their concerns and their stress and most of the things but inevitably, it will happen when you will have a day of particularly heavy or particularly crushing, sad stories that you've heard.(Lynn) Participants reported that they had experienced feelings of sadness, anxiety, irritability, frustration, increased cynicism, powerlessness, negativity, cognitive and emotional detachment, and a general sense of dread which they said was associated with repetitive exposure to patients experiencing psychological distress.
While all participants in the study were actively practising in a clinical role, several expressed concern that they may not last much longer in their specific area of practice, or even in the profession.Megan spoke about potentially leaving the physiotherapy profession as a result of feeling emotionally drained.Megan had previously taken extended leave of absence multiple times as a result of what she described as the cumulative effect of being too empathetic.However, Megan said she was considering leaving the profession to go into disability advocacy.For Megan, the empathetic distress she was experiencing appeared to have both an origin in the patient distress she encountered and a moral distress element.Leanne, currently working in emergency physiotherapy, said that part of her reason for leaving pediatric physiotherapy was that she "could not sustain a career where [she] was taking responsibility for children" who were not hers.Due to the transient nature of working with patients admitted to the emergency department, Leanne reported that in that department she was able to be a "health clinician without connecting and forging a personal bond with individuals that makes it difficult for me to disconnect from work."It was apparent from the participants' accounts that many had developed a professional yet emotional relationship with some of their patients.
Participants who repetitively prioritized the wellbeing of their patients above their own spoke about feeling exhausted, drained, burnt out, and tired.Lynn used the cup analogy to illustrate how supporting multiple patients experiencing psychological distress had, at times, left her feeling emotionally drained.
At the end of some days, you're exhausted, because you've spent a lot of time giving yourself [and] giving your energy to other people who are in crisis and really need it . . .[However] you can't pour from an empty cup.(Lynn) Lucy said that she had begun to "suffer" with her patients, suggesting that her experience with emotional fatigue had become severe enough to warrant that descriptor.Lucy spoke about taking her patients' distress home with her.However, Lucy later said that while her work was difficult at times, rather than suffering, she is just living "day by day."Lucy appeared to be grappling with the term suffering as she realized it came with heavy connotations.Lucy admitted that she prioritized her patients above her own mental health, later stating that: While not all participants were as explicit as Lucy, some appeared to prioritize their patients' wellbeing above their own.For example, Megan said that she provides the parents of her pediatric patients with her e-mail address because she knows how difficult and distressing it can be to care for a child with a disability.As a consequence, she assumes case management duties that she does not have time for and are more often the responsibility of a social worker.
My boss told me that I shouldn't give all of my clients my email address, but how do they, [get help when they need it]? . . .We had social work on tap for everyone; but people don't choose to have social workers.These families aren't getting the support that they need . . .so that is where I step in.I get a lot of emails from parents . . .[However, each time I receive an email I think] oh, shit, I've got to do another thing that I don't have time for.(Megan) Several participants said that working part-time or changing clinical settings helped reduce their exposure to patients experiencing distress and gave them time to engage in self-care.Furthermore, the participants who transitioned from working full time to working parttime said that the reduction in exposure and the ability to engage in self-care helped them stay in the profession.While encounters with patients experiencing psychological distress were a stressor, participants reported they were also experiencing other work and personal stressors.Participants said that if they had other stressors in their lives, their exposure to patients experiencing psychological distress could serve as a breaking point.Therefore, participants said that being able to look after themselves was essential to preventing emotional exhaustion.Participants mentioned a range of strategies they used to cope with the stress of working with people in distress and suffering.These strategies included: maintaining a healthy lifestyle outside of work (e.g.exercising, eating well, and getting adequate sleep); accessing informal personal support (e.g.family and friends); debriefing with others; engaging in alcohol consumption; engaging in retail therapy; reducing exposure to other potential stressors (e.g.avoiding news broadcasts, working part-time, and changing roles); and accessing professional support (e.g.seeing a psychologist).Alice said that if she did not engage in mindfulness and reflection that she would feel "responsible for [her] patient's feelings" or at least "responsible for . . .manag[ing] their feelings."In the latter part of their interview, a few participants reflected that "it is okay . . . to be emotionally affected by people's stories" (Simone).

Discussion
This study explored the experiences of 23 Australian physiotherapists working with patients with psychological distress.The study found that patient distress was frequently encountered and could invoke empathetic distress in the physiotherapist, that repeated empathetic distress could result in empathetic distress fatigue, and that, at times, physiotherapists emotionally distanced  (Ludick and Figley, 2017).Only the relevant components of the CFRM are shown above.
themselves to limit the intensity of their empathetic response.The four identified themes: 1) encounters with patients in distress are common and varied; 2) becoming emotionally attuned with their patients meant that distress could invoke empathetic distress; 3) physiotherapists use emotional shields to protect themselves; and 4) physiotherapists found frequent encounters with patient distress to be emotionally exhausting, echo themes from research conducted in the field of traumatology, which has similarly found that caring for people experiencing distress can come with an emotional cost (McNeillie and Rose, 2021).Once data analysis was completed and when considered together, the themes identified in the current study were noted to align with several components of a model of compassion fatigue developed by Ludick and Figley (2017) (Figure 2).
While Ludick and Figley's (2017) compassion fatigue resilience model (CFRM) was developed in the context of mental health therapists' exposure to survivors of trauma; it is the therapist's exposure to client suffering (i.e.high or very-high psychological distress) that is central to the model.The CFRM posits that the emotional duress that is experienced when working with people who are suffering is complex and often unavoidable (Ludick and Figley, 2017).Variables such as exposure to the suffering of another, empathetic concern, and empathetic ability influence the empathetic response (Ludick and Figley, 2017).Consistent exposure to the suffering of another and repetitive empathetic engagement may be harmful, leading the person to experience emotional duress (Ludick and Figley, 2017).Other variables, such as difficult life demands, self-social satisfaction, and social support may also influence the relationship between the empathetic response and emotional duress (Ludick and Figley, 2017).Because emotional duress experienced when working with people who are suffering is not confined to those working in the area of trauma, any professional whose work involves contact, directly or indirectly, with suffering are at risk (Coetzee and Klopper, 2010;Cross, 2019;Ludick and Figley, 2017).

Theme 1: encounters with patients in distress are common and varied
The first theme identified in the current study, encounters with patients in distress are common and varied, maps to the element 'exposure to suffering' in the CFRM.Ludick and Figley (2017) described exposure to suffering as the "degree to which the worker interacts with suffering clients who seek their services."Physiotherapists in the current study reported regularly encountering patients they perceived were experiencing psychological distress.Physiotherapists also reported encountering patients experiencing many different forms of distress.It is not unexpected that the participating physiotherapists would report their exposure to patients experiencing psychological distress as a 'common' occurrence, given that Lennon et al. (2020) found that 80% of physiotherapists in their study reported contact with patients experiencing psychological distress on a weekly basis.However, what was not evident in the findings reported by Lennon et al. (2020) was that patient distress encountered by physiotherapists could come in many forms and be related to a variety of sources.A theme was reported in a study of rheumatology clinicians (Silverthorne et al., 2021) called "no one shoe fits all -the many manifestations of distress in patients," which similarly reported that patient distress could come in many different forms (e.g.frustration or anger) and be expressed in many different ways (e.g.teariness).
In addition to the frequency of a person's exposure to suffering, Ludick and Figley (2017) argued the severity of the suffering to which a person is exposed is also a risk factor for secondary traumatic stress.Several physiotherapists used the term 'suffering' to describe patients they perceived were experiencing high or very high levels of psychological distress.According to Cassell (1999) suffering is "a specific state of distress that occurs when the intactness or integrity of the person is threatened or disrupted."The term suffering captures the notion that the experience of psychological distress has perforated every part of a person's existence (Best et al., 2015).While 'suffering' may not be an example of strength-based language, the word captured the seriousness and intensity of the psychological distress that participants perceived some of their patients to be experiencing.While many strategies may potentially relieve unbearable suffering, suicide including assisted suicide is one of those means (Hooley, Franklin, and Nock, 2014;Tatz and Tatz, 2019) and several physiotherapists in the current study discussed patients who had taken this route.Encounters between physiotherapists and patients experiencing suicidal ideation have been reported in other studies (Lundin and Bergenheim, 2020;McGrath et al., 2020).While it is not known for certain why the patients of the physiotherapists in the current study took their life, several physiotherapists perceived that their patient ended their life as they could no longer bear the suffering they were experiencing.Unlike some other outcomes of psychological distress such as unemployment and reduced quality of life, the finality of death by suicide deserves particular consideration (Clayborne, Varin, and Colman, 2019;Tucker, Tackett, Glickman, and Reger, 2019).Deaths by suicide also affect more than just the individual who died.Research by Cerel et al. (2019) found that for every suicide, 135 people who knew the person may be affected, with some of them potentially bereaved.Physiotherapists themselves may be affected and potentially bereaved by a patient dying by suicide.The findings of the current study suggest that physiotherapists may have opportunity to engage in suicide prevention if adequately trained and that there should be support networks readily available for physiotherapists who experience patient suicide.

Theme 2: becoming emotionally attuned with their patients meant that distress could invoke empathetic distress
The second theme identified in the current study, becoming emotionally attuned with their patients meant that distress could invoke empathetic distress, predominantly maps to the 'empathic response' component of the CFRM.Participating physiotherapists reported having experienced a transient form of empathy-related distress (i.e.empathetic distress) in response to engaging with patients experiencing psychological distress.While definitions of empathy vary, an empathetic response is generally considered a multifaceted psychological phenomenon that includes affective, cognitive, behavioral, and moral dimensions (Jeffrey, 2016).According to Rogers (2013) empathy involves a person "entering the private perceptual world of the other . . .[in order] to adopt [their] frame of reference."By adopting the other person's frame of reference, the empathizer feels distress with and for the other (Maibom, 2017).Physiotherapists reported that empathizing with patients could result in them feeling emotions similar to those of their patients.
Physiotherapists in the current study did not frame the empathetic distress response as something entirely problematic.Like Figley and Ludick (2017) who posited that empathy is an essential part of helping others who are distressed, the physiotherapists also viewed the empathetic response as a necessary part of the therapeutic relationship.Physiotherapists spoke about how experiencing their patients' emotions (i.e.affective empathy) allowed them to attune themselves to their patients' emotional states, while perspective-taking (i.e.cognitive empathy) allowed them to see, or at least try to see, the world from the viewpoint of their patient.This finding, of a positive view of empathy held by some of the physiotherapists, echoed the findings of qualitative, interview-based research conducted by Miciak et al. (2019) and Barlow (2021).The qualitative study of physiotherapists' experiences of the therapeutic relationship conducted by Miciak et al. (2019) reported a theme called 'giving-of-self.'As part of the giving-of-self theme Miciak et al. (2019) reported that physiotherapists said that they would invest a considerable amount of emotional energy deeply empathizing with their patients.For her doctoral thesis Barlow (2021) conducted a phenomenological investigation of the lived experiences of physiotherapists working with people experiencing persistent pain.Barlow (2021) reported that physiotherapists would find themselves becoming attuned to the relational aspects of the interaction and in turn experience empathetic distress with patients experiencing psychological distress.When considering the findings of the current study and the results of Miciak et al. (2019) and Barlow (2021), it appears that physiotherapists intentionally engage in emotional attunement.

Theme 3: physiotherapists use emotional shields to protect themselves
The third theme from the current study, physiotherapists use emotional shields to protect themselves, appears to map to the empathetic concern element of the CFRM.According to Ludick and Figley (2017) without empathy, there is no, or at least very little, potential for the therapist to experience an empathetic response such as empathetic distress.Additionally, without empathy, the emotional connection that underpins the therapeutic alliance is missing (Ludick and Figley, 2017).Because empathy "is both the keystone to helping others as well as a pathway to the high costs of caring" (Ludick and Figley, 2017) physiotherapists need to balance the need for emotional distancing with the need to develop an empathetic connection.Physiotherapists in the current study were concerned that empathizing too much could impair their ability to perform their job and lead to emotional exhaustion.The potential harm of empathizing too much has been documented elsewhere, with self-focused empathetic distress (i.e.personal distress) shown to be associated with negative effects such as compassion fatigue and burnout (Thomas, 2013).
The participating physiotherapists reported emotionally distancing themselves from patients by redirecting the conversation to physical health-relatedissues, deflecting disclosures of patient distress to other health professionals, and decreasing their levels of empathetic concern for their patients.Pollak et al. (2007) referred to these strategies as empathetic terminators.Sisk, Friedrich, DuBois, and Mack (2020) similarly reported that pediatric cancer care clinicians used empathetic terminators, such as shutting down conversations and deflecting patients' concerns to other health professionals.While the participating physiotherapists used metaphors such as 'shields' to describe the process of emotionally distancing themselves from their distressed patients, it could also be interpreted that these physiotherapists were shifting between two types of concern: 1) empathetic concern; and 2) detached concern described by Guidi and Traversa (2021).Guidi and Traversa (2021) described empathetic concern as the genuine interest in understanding a person's experience of suffering in its full complexity.In contrast, detached concern is an emotionally uninvolved type of concern generally directed at treating a disease (e.g.chronic obstructive pulmonary disease) (Guidi and Traversa, 2021).When the participating physiotherapists in the current study spoke about distancing themselves emotionally from their patient, they did not cease to care about the patient completely but instead may have been shifting to the more emotionally detached form of concern.While the patient may be still experiencing psychological distress, by engaging in detached concern the physiotherapist may never identify it or become aware of its nature.

Theme 4: physiotherapists found frequent encounters with patient distress to be emotionally exhausting
The fourth theme identified in the current study, physiotherapists found frequent encounters with patient distress to be emotionally exhausting, appears to partially map to the secondary traumatic stress and compassion fatigue resilience elements of the CFRM.This theme described the physiotherapists' experiences of emotional exhaustion, which they stated was associated with repeated exposure to patients experiencing psychological distress.While Ludick and Figley (2017) called the "emotional duress" that results from being: 1) repeatedly exposed to the suffering of others; and 2) required to empathize with them, 'secondary traumatic stress,' other terms such as 'compassion fatigue' and 'empathetic distress fatigue' have been used to describe the phenomenon (Cross, 2019;Klimecki and Singer, 2011).Hofmeyer, Kennedy, and Taylor (2020) argued that compassion fatigue should be referred to as empathetic distress fatigue, as it stems from a person's empathetic capacity becoming depleted due to repeated experiences of empathetic distress.While few studies have been conducted on empathetic distress fatigue in physiotherapists, a study of burnout (i.e. a potential sequela of empathetic distress fatigue) among a multidisciplinary sample of 176 health professionals working in persistent pain, which included 23 physiotherapists, found that 39% of respondents reported that patient psychosocial complexity was a source of stress (Ashton-James et al., 2021).Similarly, Barlow's (2021) phenomenological study of physiotherapists working in persistent pain management found that they experienced emotional exhaustion due to working with highly distressed patients.
Looking beyond the physiotherapy research, there is a large body of literature on a related phenomenon referred to as vicarious trauma.'Vicarious trauma' is a term that specifically describes negative changes that occur when people engage empathetically with others who disclose experiences of trauma (Branson, 2019).By engaging empathetically with another person, the empathizer may experience the other's trauma vicariously (Iqbal, 2015).Vicarious trauma in the context of mental health professionals who work with people who have experienced trauma has been well documented (Sutton, Rowe, Hammerton, and Billings, 2022) However, a review of vicarious trauma also found that the phenomenon is pervasive in nursing and has significant negative effects, including persistent psychological distress, decreased professional performance, and increased use of sick leave (Isobel and Thomas, 2022).While the focus of the current study was not the experiences of physiotherapists with patients who had experienced trauma, physiotherapists spoke about encounters with patients who had experienced psychological distress which they perceived to be related at least in part to previous trauma.Therefore, theme four may have also captured findings related to vicarious trauma reactions in physiotherapists.

Recommendations and implications for physiotherapy practice
The current study highlights that physiotherapist encounters with patients experiencing psychological distress are perceived as 'common' and because of this contact, the researchers posit that this professional group may be vulnerable to experiencing empathetic distress and empathetic distress fatigue.The findings further support this, with all participating physiotherapists noting that exposure had resulted in, or could potentially lead to, empathetic distress and empathetic distress fatigue.Several recommendations can be made on this basis.
Recommendation 1: society must recognize that physiotherapists are vulnerable Buetow (2021) posits that society has a moral obligation to "work together to find and show compassion for clinicians to prevent and manage clinician burnout."If society wants to create a health care system that is fit for service, then it needs to care about and actively support the wellbeing of clinicians (Buetow, 2016).While it is in the best interests of society to care about its health professionals, health professionals are not in a position to expect care and empathy from their patients, who may be vulnerable (Buetow, 2014).It is also not appropriate for a health professional to share with patients "a full and frank account of their current highs and lows" (Salisbury, 2021).However, health professionals, including physiotherapists, can expose their soft human underbelly to society in settings beyond the health care setting by sharing their personal stories of suffering through mediums such as books, magazines, blogs and television programs (Buetow, 2014;Hinshaw, 2008).Recognition of the problem is the first step in transforming the culture of healthcare from a patient-centered to a relational approach that cares for both patients and their clinicians (Buetow, 2016;Delgado, 2021).Only after the issue is recognized can society (e.g. government, health organizations, and professional organizations such as the APA) implement strategies such as clinical supervision aimed at supporting physiotherapists emotionally process their experiences with patients experiencing psychological distress.

Recommendation 2: physiotherapists may benefit from training on how to process and work through their experiences with patients experiencing psychological distress
A meta-analytic study of interventions designed to reduce burnout among medical practitioners found that individual-focused interventions including selfcare, stress management and communication skills training can produce clinically meaningful reductions in burnout (West, Dyrbye, Erwin, and Shanafelt, 2016).Given that responding to patient distress may be a contributor to burnout (Ashton-James et al., 2021) individual-focused training programs may be beneficial to physiotherapists who experience empathetic distress fatigue.Individual-focused training may also help physiotherapists manage the personal stressors that increase their vulnerability to empathetic distress fatigue (Adams, 2020;Durtschi and McClellan, 2016).However, Taylor (2019) argued that if individualfocused training is going to be successful it needs to teach health professionals to critically reflect on their practice and the practices of the healthcare system within which they operate.Training in self-monitoring may be beneficial to physiotherapists as it could improve their ability to recognize the early warning signs of empathetic distress fatigue and prompt them to seek help early (Lall et al., 2019;Norrman Harling, Högman, and Schad, 2020).Physiotherapists should be educated how to advocate for themselves at an organizational level so they can proactively reduce their risk of experiencing empathetic distress fatigue.Individualfocused interventions should be implemented at both university level for physiotherapy students and as professional development modules for qualified physiotherapists.

Recommendation 3: self-care is not the panacea
While some physiotherapists in the current study mentioned that self-care helped them cope with the emotional burden of working with patients experiencing psychological distress, their view may have been potentially shaped by society's assumptions regarding self-care.For example, Stiles and Fox (2019) argued that even though it is widely acknowledged that psychological practice is challenging emotionally, "psychologist self-care, despite having such social consequences, is predominantly constructed as an individual responsibility."Kaplan (2019) similarly posited that the overemphasis on self-care is the result of the prominent discourse of individual responsibility.However, even the most resilient health professional will struggle to avoid emotional exhaustion in organizational, systemic and cultural climates that do not support their wellbeing (Forrest, Abdurrahman, and Ritsma, 2020).
Suggesting that health professionals experiencing empathetic distress fatigue and its antecedents can solve the issue by increasing their resilience to stress is essentially asking the vulnerable to put in "extra effort" to be less vulnerable (Delgado, 2021).Individual strategies designed to combat empathetic distress fatigue ignore the responsibility that healthcare institutions and broader society have to look after their help givers (Delgado, 2021;Green and Cummings-Lilly, 2019;Taylor, 2019).For this reason, Kaplan (2019) argued that an overemphasis on self-care as the solution to empathetic distress fatigue is a form of victim-blaming.In order to reduce the likelihood of a health professional experiencing empathetic distress fatigue, self-care needs to move beyond the individual and instead be positioned within a framework of collective action at the level of social policy (Kaplan, 2019).For example, institutions must promote and apply flexible work arrangements, set realistic patient care and workloads, and adopt compensation models that are not tied to productivity in order to increase health professionals' ability to cope with occupational hazards such as empathetic distress fatigue (Babineau, Thomas, and Wu, 2019;Green and Cummings-Lilly, 2019).
Organizations may also consider implementing support groups such as: empathy huddles (Turner, Locke, Jones, and Carpenter, 2019); Schwartz Rounds (Adamson et al., 2018); and Balint groups (Van Roy, Vanheule, and Inslegers, 2015).Wittenberg-Lyles, Goldsmith, and Reno (2014) conducted a qualitative study of a group of oncology nurses who had selforganized a peer-support group.Wittenberg-Lyles, Goldsmith, and Reno (2014) reported that the peersupport group provided nurses with an outlet to disclose their thoughts and feelings associated with regularly experiencing patient loss.However, the peersupport group did not have management support, which meant the nurses had to participate outside work hours and consequently were not remunerated for attending (Wittenberg-Lyles, Goldsmith, and Reno, 2014).According to Wittenberg-Lyles, Goldsmith, and Reno (2014) the lack of management support was the biggest barrier to attendance.Without overgeneralizing the findings of the study by Wittenberg-Lyles, Goldsmith, and Reno (2014) the findings illustrate the positive impact that organizations can have on mitigating empathetic distress fatigue among their health staff if they also take some responsibility for the wellbeing of their staff.

Recommendation 4: social solutions are needed to address the root causes
Edwards, Delany, Townsend, and Swisher (2011) posited that a "patient's health status and quality of life, in part, may be representative or expressive of the health of that community."For this reason, the empathetic distress fatigue being experienced by physiotherapists can be viewed as a symptom of a distressed society.Given that burnout and clinician distress are positively associated with exposure to patient distress (Ashton-James et al., 2021) high levels of psychological distress among the community would logically lead to higher prevalence of empathetic distress fatigue among physiotherapists.Thus, reducing psychological distress in society may in turn benefit the wellbeing of physiotherapists.Megan, one of the participating physiotherapists who spoke about potentially leaving the physiotherapy profession to become a disability advocate so that she could make a bigger difference in the lives of those she cared for, should not feel as if they are leaving the profession if they undertake this form of work.Advocacy and health promotion are critical to addressing the social determinants of health including patient distress, yet participation in political activism and social policy decisions is often undervalued in physiotherapy (Aguilar, Stupans, Scutter, and King, 2013;McMahon and Connolly, 2013).Unsurprisingly, physiotherapy participation in public health conversations tends to be limited (Walton, 2020).A cultural shift toward increased physiotherapist participation in social initiatives is needed to address proximal causes of their empathetic distress fatigue.

Limitations and future directions
As with all 'Big Q' qualitative research, the results of the current study are not meant to be generalizable in the positivist sense (Braun and Clarke, 2021).However, the study does provide idiographic knowledge that contributes new perspectives on the experiences of physiotherapists with patients experiencing psychological distress.Future research using a different methodology is needed to ascertain if the findings are relevant to all physiotherapists, or only to some physiotherapists.Braun et al. (2021) discussed the use of qualitative online survey studies as a research approach which draws on a wide range of perspectives.Similarly, a quantitative online survey may investigate whether variables such as frequency of exposure to patient psychological distress are associated with empathetic distress fatigue and burnout.
Due to the eligibility criteria for participation in the current study, physiotherapists who had left the profession were not able to participate.The exclusion of physiotherapists who had left the profession is particularly relevant, as several participants reported that their exposure to patients experiencing psychological distress had led them to consider leaving physiotherapy.A survey conducted by the Victorian Government Department of Health and Human Services (2016) reported that 27% of physiotherapists intend to leave within five years, and thus it is recommended that future research exploring why people leave the physiotherapy profession be conducted.
In this study, the sample was predominately Caucasian, female, and had over a decade of professional experience.While it was not a goal of the study to form a representative sample, the large proportion of female volunteers is potentially interesting.Harton and Lyons (2003) found that females tend to score higher on measures of perspectivetaking than males and that perspective-taking mediated the relationship between gender and the decision to study psychology at university.Furthermore, Ludick and Figley (2017) posited that people with greater empathetic ability are better at recognizing distress in other people.The ethnocultural homogeneity of the sample is also a notable limitation.Hook et al. (2013) posited that health professionals' knowledge and understanding of patients who identify with ethnocultural backgrounds different to their own is inevitably limited.Therefore, the paucity of data regarding ethnocultural considerations in this study may reflect the ethnocultural homogeneity of the participants and researchers.Future research exploring encounters between physiotherapists and patients experiencing psychological distress should consider gender and ethnocultural factors and involve researchers and physiotherapists that identify as part of minority ethnocultural groups.The mean years of professional experience of participants (16.6 years) was greater than the average indicated in national physiotherapist population statistics (13.4 years) (Australian Government Department of Health, 2019).Therefore, the findings may not speak to the experiences of early career physiotherapists but are based on considerable experience.

Conclusion
This study provided an in-depth analysis of the experiences of twenty-three physiotherapists with patients experiencing psychological distress.The results suggest that when patients express and exhibit distress-relatedbehavior, transient empathetic related distress may be invoked in the physiotherapist.Repeated, frequent exposure to patients experiencing psychological distress left some of the physiotherapists emotionally exhausted.The results while not surprising given findings of research conducted with mental health professionals highlights that even though physiotherapists are sometimes viewed as 'physical' health professionals, psychological distress (e.g.depression, anxiety, and suicidal distress) is a common feature of physiotherapy practice.Multilevel strategies are needed to support the wellbeing of physiotherapists with clients experiencing distress, including increased recognition of the problem at all levels of society, individual training to support them to process and work through their experiences, and society-focused initiatives aimed to address the root causes of empathetic distress fatigue (e.g. the high prevalence of distress among the general public).Future research is required to explore potential associations between patient distress, physiotherapist empathetic distress, empathetic distress fatigue and burnout. (Continued).

Topic/description Location
Data analysis: Process by which inferences, themes, etc., were identified and developed, including the researchers involved in data analysis; usually references a specific paradigm or approach; rationale* Method; Data analysis; Figure 1 Techniques to enhance trustworthiness: Funding details *The rationale should briefly discuss the justification for choosing that theory, approach, method, or technique rather than other options available, the assumptions and limitations implicit in those choices, and how those choices influence study conclusions and transferability.As appropriate, the rationale for several items might be discussed together.

Figure 1 .
Figure1.Phases of the data analysis method informed by Iterative Thematic Inquiry (ITI)(Morgan and Nica, 2020).The inward spiral represents the cyclical relationship between beliefs and actions, which ends when there is a sense of resolution.

I
do not have PTSD.I've never [experienced the situation that my patient has experienced but] I'm distressed, just by the nature of empathy in the human condition.This freaks me out.(Lynn)

[
Almost in tears, Anne said] to me one day "[my child's] never going to remember me."I said "[your child will] remember you with photos, and [your child will] remember you because your husband will keep you alive for [them] . . .."But deep inside I'm thinking . . .[her child is] never gonna remember [their mum] . . .I found it really hard to treat her.(Jessica)

[
My patient disclosed to me that her child] was in a [motor vehicle] accident, and [that her child] got killed in the accident.Her [child] was [X years old] and I [also] had a [X] year old child . . .[Hearing that I started] physically breaking down and I had to leave the room for a few minutes . . .When it really cuts close to home, the brain just goes crazy, oh my God, and you personalize it.(Beverly) [prevent]  us[ing] up all my [emotional] energy with my patient.(Caroline)

I
'm an empathetic person and I do love what I do.But I do sometimes just need to drop it and walk away.Because it does, it does get to me . . .I have difficulty managing my empathetic self . ..[and] that's probably contributing to the burnout type stuff . . .I actually thought recently, I'm almost at a point where I need to walk away at the moment, but I can't really at the moment, unfortunately . . .[The recent experience with a distressed family] brought home again that [while] I'm a relatively good physio, I am feeling more and more that my calling is to decrease the distress and . . .help [people with a disability] participate in the world and be their best selves.(Megan) when I became a physio . .., I signed[up]  for taking care of other people.I signed[up]  for being there [for them] . . .It's not about me.

I
would describe it as more of like, cumulative effects.If I'm not doing very well . .., if I'm not able to keep on top of myself, then [I am more likely to] becom[e] anxious myself.(Alice)

Figure 2 .
Figure 2. Mapping of the four themes identified in the current study to elements of the compassion fatigue resilience model (CFRM) (Ludick and Figley, 2017).Only the relevant components of the CFRM are shown above.

Table 1 .
Demographics of the participants.
was always super positive, but [while he] was positive to us, you could see what was going on behind [closed doors].[I recall at the time] just thinking you could picture what your life would be if you were in his position because it would be exactly the same.(Peter) However] the boundary may differ for each and every single patient.You learn [where that boundary lies] when you've . . .let things through the armor [that] you shouldn't have.[Letting things pass through the armor] comes to bite you . . .You realize, well, I shouldn't really have lost sleep over that but I did.You try to deal with it a better way, next time around. (Angela) Techniques to enhance trustworthiness and credibility of data analysis (e.g.member checking, audit trail, and triangulation); rationale* Main findings (e.g.interpretations, inferences, and themes); might include development of a theory or model, or integration with prior research or theory Short summary of main findings; explanation of how findings and conclusions connect to, support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of application/generalizability; identification of unique contribution(s) to scholarship in a discipline or field For integration with prior work see Discussion (all paragraphs) For implications see Discussion; Recommendations and implications for physiotherapy practice For transferability see Discussion; Limitations and future directions For contributions see Conclusion for summary.Limitations: Trustworthiness and limitations of findings Discussion; Limitations and future directions Other Conflicts of interest: Potential sources of influence or perceived influence on study conduct and conclusions; how these were managed Disclosure statement Funding: Sources of funding and other support; role of funders in data collection, interpretation, and reporting