Mental Health & Prevention 33 (2024) 200253

Contents lists available at ScienceDirect

Mental Health & Prevention

journal homepage: www.elsevier.com/locate/mhp

Psychological therapists’ experiences of burnout: A qualitative systematic

review and meta-synthesis
Marco Vivolo 1, *, Joel Owen, Paul Fisher
Department of Clinical Psychology and Psychological Therapies, University of East Anglia

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Psychological therapists are vulnerable to developing burnout due to the frequent exposure to emotive
Burnout narratives of distress. Several quantitative systematic reviews have provided an overview of the risk and pro­
Stress tective factors associated with therapist burnout. To date, however, no qualitative systematic reviews on ther­
Mental health
apist burnout have been carried out. This systematic review aimed to explore the experiences and impact of
Psychological therapists
Psychologists
burnout in psychological therapists, and the strategies they use to adapt to it.
Systematic review 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 quali­
tative 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 recommenda­
tions are discussed.

1. Introduction 2019), the distinction between compassion fatigue and burnout is less
clear-cut as they share important conceptual elements, such as
The term burnout was introduced by Freudenberger (1974), who emotional exhaustion, fatigue and disengagement (Nolte et al., 2017).
described it as a process of physical and emotional exhaustion, fatigue, Similarly, occupational stress and burnout have both been associated
detachment and self-doubt that people who work in caring and sup­ with psychological suffering and impairment due to work pressures and
porting roles can experience (Freudenberger, 1974). Maslach’s defini­ demands, thus maintaining a stronger conceptual link (Simionato and
tion of burnout emphasises the enduring nature of this type of stress, Simpson, 2018).
involving depersonalisation, emotional exhaustion and a reduced sense Burnout has been identified as a significant work-related challenge
of personal accomplishment (Maslach, 1982). Burnout has been asso­ for psychologists and psychological therapists (McCormack et al., 2018;
ciated with a number of conceptually similar constructs, such as Simionato and Simpson, 2018) and, more generally, in mental health
compassion fatigue (Bhutani et al., 2012), occupational stress (Sim­ settings, with between 21% and 67% of services reporting high levels
ionato and Simpson, 2018), vicarious trauma and secondary traumatic (Morse et al., 2012). High prevalence rates of burnout have also been
stress (Nolte et al., 2017). While it is easier to differentiate burnout from found in other medical professions, such as nurses, 11.23% (Woo et al.,
vicarious trauma and secondary traumatic stress, given that these two 2020), and medical and surgical residents, ranging from 27.72% to
concepts both entail exposure to traumatic content (Rauvola et al., 57.18% (Low et al., 2019). However, the frequent exposure to narratives

* Corresponding author at: Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ.
E-mail address: vivolom87@gmail.com (M. Vivolo).
1
This research was carried out as part of the first author’s doctoral thesis for the Doctorate in Clinical Psychology at the University of East Anglia.

https://doi.org/10.1016/j.mhp.2022.200253
Received 13 June 2022; Received in revised form 11 November 2022; Accepted 16 November 2022
Available online 19 November 2022
2212-6570/© 2022 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

of distress, loss and trauma makes psychological therapists particularly 2. Methods

vulnerable to developing occupational stress and burnout (Bearse et al.,
2013; Simionato et al., 2019). Studies investigating the prevalence of The systematic review was completed in line with the Preferred
burnout in psychotherapists show prevalence rates that range from 2-6% Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
(Farber, 1990) to over 50% (Simionato and Simpson, 2018). Codes of guidelines (Page et al., 2021). A protocol for the systematic review was
conduct and professional guidelines for psychologists and psychological registered on the PROSPERO (International Prospective Register of
therapists, such as those published by the American Psychological As­ Systematic Reviews) database, outlining the inclusion and exclusion
sociation (APA) and The British Psychological Society (BPS), have criteria, the search and screening strategies, and the methodological
highlighted the risks of burnout and its potential impact on clinical approach (reference: CRD42021247832).
work, thus recommending to also consider it from an ethical perspective Given the high heterogeneity of the samples, settings, contexts and
(APA, 2017; BPS, 2018). methodologies of the included studies, results were synthesised using a
Research has highlighted that burnt-out professionals are less likely narrative synthesis approach (Popay et al., 2006).
to adequately provide empathy and emotional support due to engaging
in defence mechanisms that preserve their emotional capacity, which in 2.1. Data sources and search strategy
turn has a detrimental impact on clients’ wellbeing and recovery
(Bearse et al., 2013; Connor et al., 2018; Lee et al., 2011). Burnout in The available literature was reviewed by electronically searching
psychologists and psychological therapists has also been linked to three databases, CINHAL EBSCO, Medline EBSCO and PsycINFO EBSCO,
reduced productivity, increased absenteeism, turnover, poorer personal and hand-searching the reference lists of the included studies. Boolean
efficacy and a higher risk of developing mental health difficulties, such operators ‘and’ and ‘or’, wildcards and truncation symbols, such as ‘*’,
as depression (Simionato et al., 2019; World Health Organisation, were used to combine search terms effectively and maximise search
2018). A systematic review on the prevalence and causes of burnout in results (see Table 1). Controlled vocabulary and keyword functions were
applied psychologists, which included 29 papers, found that emotional also used, where possible. In order to identify all relevant studies, no
exhaustion was the most commonly cited component of burnout, with date restrictions for the searches were applied.
work setting, workload and time pressure being the most significant job
factors leading to burnout. Older psychologists were less likely to 2.2. Eligibility criteria
experience burnout as they had learnt how to preserve their emotional
energy over time (McCormack et al., 2018). Another systematic review Similarly to other systematic reviews on burnout in psychotherapists
on antecedents and consequences of burnout in psychotherapists, (Simionato and Simpson, 2018), the term ‘psychological therapist’ was
comprising 17 studies, found that therapist over-involvement was the employed broadly to encompass both psychologists and psychothera­
most significant variable to correlate with emotional exhaustion, while pists. This review included studies on therapist burnout and related
having more control over their work was the most significant factor to constructs, including occupational stress, compassion fatigue and
negatively correlate with depersonalisation (Lee et al., 2011). Another emotional exhaustion. Studies on secondary traumatic stress and
recent systematic review (Simionato and Simpson, 2018) on the risk vicarious trauma were not included as they focus on conceptually
factors associated with burnout in psychotherapists, including 40 different constructs. Similarly, studies on therapist resilience were also
studies, found that younger age, less professional experience and ther­ excluded from this review.
apist over-involvement in their clients’ problems were the most common Inclusion criteria included: peer-reviewed studies (i.e., dissertations
factors associated with burnout. were excluded), studies published in the English language, studies
These systematic reviews on burnout in psychological therapists focussing on the experience of burnout and related concepts (i.e.,
have only included quantitative studies and methodologies with little occupational stress, compassion fatigue, emotional exhaustion), studies
attention to how psychologists and psychological therapists experience focussing entirely on psychological therapists delivering therapy (i.e.,
burnout within their professional roles. To date, there have been no studies including nurses, doctors, social workers, etc. were excluded).
qualitative systematic reviews or meta-syntheses on burnout in psy­ The following exclusion criteria were applied: studies including art
chological therapists. As burnout is best characterised as a process, and music therapists as participants, studies including sport psycholo­
rather than an outcome (Maslach, 1982; Maslach and Leiter, 2016), a gists as participants, studies including counsellors as the only partici­
meta-synthesis of studies on therapist burnout can unveil important pants (i.e., without any other psychological therapists), studies
learnings related to the dynamic and fluid elements of this process, including unqualified therapists (e.g., trainees, students, etc.), studies
which might not be captured by quantitative analyses. classed as secondary research (e.g., systematic and literature reviews),
The aim of this qualitative systematic review and meta-synthesis is studies using quantitative and mixed-method designs, single case-
therefore to explore therapist burnout from a broader, qualitative studies, commentaries, personal reviews or reflections, books, or book
perspective, adopting a critical realist stance. A systematic review and reviews.
synthesis of qualitative studies of how therapists experience burnout
could provide further insight into the difficulties and challenges they Table 1
experience, uncovering their professional and personal coping strate­ Search terms.
gies, which could inform service training and policies aimed at pre­
Therapist, therapy Participant, Methodology terms
venting burnout and promoting resilience and wellbeing. or impact on participant
therapist terms experiences or
1.1. Research questions impact on client
terms
Primary research question: ‘How do psychological therapists sub­ therapist* OR AND burnout OR ‘burn AND ‘qualitative research’
jectively experience burnout?’ psychotherapist* out’ OR burn-out OR ‘qualitative’ OR
Secondary research question: ‘What are the professional and per­ OR OR stress OR ‘grounded theory’ OR
psychologist* ‘occupational ‘narrative’ OR
sonal strategies that can help to prevent and reduce burnout in psy­ stress’ OR ‘Interpretative
chological therapists?’ ‘compassion phenomenological
fatigue’ OR analysis’ OR ‘thematic
‘emotional analysis’ OR
exhaustion’ ‘discourse analysis’

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

2.3. Screening and selection of studies 2.4. Data analysis

Final electronic searches using the three databases were conducted Due to the methodological heterogeneity of the qualitative studies
from their inception to 27 April 2021 and generated a total of 1,151 included in this review, particularly in relation to the methodological
results, with the PsycINFO database yielding 667 results, and the and analytical frameworks employed, results were synthesised using a
CINHAL and Medline databases yielding 216 and 268 results, respec­ narrative synthesis approach (Popay et al., 2006). Narrative synthesis is
tively. After removing duplicates, 885 studies were retained (see Fig. 1) a commonly used synthesis approach for systematic reviews. This
and screened by the first author (M. V.). Studies were initially screened approach involved developing an interpretation of the review’s findings
at title and abstract stage. Following the title and abstract screening, 35 that can contribute to assessing their applicability and relevance in the
articles were retained and screened at full-text stage. This led to a further context of psychological therapists’ experiences of burnout. In order to
reduction and nine studies were subsequently included in the review, organise the findings from the included studies, a preliminary analysis
having met the inclusion criteria. Hand-searching the reference lists of was carried out. This involved reading and immersing in the results and
the included studies did not generate any further results. discussion sections of the included papers to familiarise with the data
Random samples of 25% of papers at both title and abstract (N=214) and develop an initial description of the findings. Subsequently, the
and full-text (N=9) review stages were screened by an independent characteristics of the findings from the included studies were explored
reviewer, who was not part of the research team. The percentage through the use of grouping, clustering and tabulation. Findings were
agreements with the first author (M. V.) were high, 99% (N=212) at title clustered based on their research questions and the relevance of their
and abstract screening stage and 89% (N=8) at full-article review stage. data for the current review. Finally, a critical evaluation of the strength
Disagreements between the first author (M. V.) and the independent of the synthesis was provided (Popay et al., 2006).
reviewer were resolved by consensus, consulting and referencing the
eligibility criteria. In addition, the three authors of the review met
2.5. Assessment of methodological quality
regularly to discuss the screening process and any related decisions to
ensure consistency and transparency.
The Critical Appraisal Skills Programme (CASP) qualitative research
checklist was used by the first author (M. V.) to assess the methodo­
logical quality of the papers included in this systematic review (CASP,

Fig. 1. PRISMA Flow Diagram showing the Screening and Selection Process.

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

2017). The checklist has 10 questions that consider research aims, Two studies (Clarke et al., 2020; Sciberras and Pilkington, 2018) did not
methodology, research design, recruitment strategies, data collection include some of their findings due to lack of sufficient evidence or
methods, reflexivity of researchers, ethical issues, data analysis, pre­ relevance to the research question. The findings in Sim et al. (2016)
sentation of findings and their contribution to the existing literature appeared to reflect the structure of the interview questions rather than
(CASP, 2017). As recommended by the Cochrane Group, the CASP providing an analytic narrative based on the data. All included studies
checklist was used as a guiding framework to inform the synthesis and employed at least one credibility check, including team debriefing and
the findings (Long et al., 2020; Noyes et al., 2018), and was not used to consultation amongst the authors and research supervisors (Clarke et al.,
exclude studies. The findings of the methodological appraisal were 2020; Hammond et al., 2018; Papadomarkaki and Lewis, 2008; Sim
discussed with the second (J. O.) and third author (P. F.). Disagreements et al., 2016), involving additional analysts (Norrman Harling et al.,
in interpretation were resolved through consultation. 2020), using memos and reflexive diaries (Cramond et al., 2020; Turn­
bull and Rhodes, 2019), carrying out multiple reviews of theme and
3. Results code identification processes (Reitano, 2021), and participant validation
procedures (Clarke et al., 2020; Sciberras and Pilkington, 2018). All the
3.1. Data extraction outcome studies presented their findings in relation to their research questions.
All except one of the studies (Papadomarkaki and Lewis, 2008) dis­
Nine papers met the inclusion criteria and were therefore included in cussed the generalisability and/or transferability of their findings as one
the review. Three main themes were identified: the experience and of the limitations of the research. All included studies discussed their
impact of burnout, the factors contributing to burnout, and the strategies findings in relation to the existing literature and made at least some
that help to prevent and reduce burnout. recommendations for future research and practice. The lack of reporting
Key information from the included studies was extracted using a data on dropouts and exclusions in seven of the nine included studies implied
extraction form, comprising study aims and research questions, sample that the risk of recruitment and selection bias was not addressed. Lim­
size and characteristics, study setting and context, recruitment and data itations around generalisability and transferability have been acknowl­
collection techniques, and analytical methodology (see Table 2). A edged in eight of the nine studies. The qualitative methodologies and the
summary of the key findings was also provided (Table 3). small sample sizes of these studies hinder generalisations to wider
populations of psychological therapists and practitioners. Overall, all
3.2. Quality assessment and presentation of findings the studies included in the review provided useful data to address the
research questions.
The results of the critical appraisal process are summarised in
Table 4. Based on the information provided in the published papers, 3.3. The experience and impact of burnout
Cramond et al. (2020) and Hammond et al. (2018) met all the criteria of
the CASP checklist, while Papadomarkaki and Lewis (2008) and Sim Therapists’ experiences of burnout (and related concepts) and its
et al. (2016) met the fewest criteria. impact were described in all the included studies. Therapists reported a
All included studies used an established qualitative methodology number of physical, emotional and psychological difficulties associated
that was in line with the aims of the research. In terms of recruitment, with burnout, which significantly affected their lives. Therapists talked
most studies used either purposive recruitment techniques or snowball about feeling fatigued and struggling to focus at work, describing a sense
recruitment strategies. All the studies assessed included at least some of ‘being there but not being there’ (Clarke et al., 2020). The emotional
information about the inclusion and exclusion criteria, with the excep­ impact of these difficulties was evidenced by the participants’ experi­
tion of one study (Papadomarkaki and Lewis, 2008). All studies pro­ ences of feeling numb and demotivated. Similarly, their professional
vided a rationale for using semi-structured interviews to collect data and efficacy and emotional availability were also affected. As a result,
included at least some detail about the content of the interview (e.g., therapists reported experiencing decreased personal accomplishment,
interview schedule and questions). which led to being unable to work (Turnbull and Rhodes, 2019).
Only three studies specifically referenced the concept of saturation One of the participants described the intense experience of feeling
when explaining their data collection process (Clarke et al., 2020; Cra­ exhausted and fatigued due to stress and burnout:
mond et al., 2020; Hammond et al., 2018). While data saturation can be ‘I’ve had these setbacks with burnout … I was sitting in my car after
operationalised in different ways (Saunders et al., 2018), it is important an intense week, where I’ve done lots of travel and done things in other
for researchers to consider it in order to increase credibility and trans­ places, in my job. And afterwards, I had to stop the car and sort of let it
parency (Fusch and Ness, 2015). Only 5 of the 9 studies (Clarke et al., spin for a while, and get out. And I got so scared, I thought ‘Dammit! My
2020; Cramond et al., 2020; Hammond et al., 2018; Norrman Harling brain is whacked now’’ (Norrman Harling et al., 2020, p. 9).
et al., 2020; Sciberras and Pilkington, 2018) referenced researcher Another participant talked about the lack of motivation and sense of
reflexivity and its impact on the study, which impedes wider implica­ dread experienced when feeling burnt-out:
tions on their credibility (Dodgson, 2019). Three additional studies ‘. . . One of the main things I remember is driving to work. . . just
(Reitano, 2021; Sim et al., 2016; Turnbull and Rhodes, 2019) considered wishing I felt sick that day or, you know, that I get a flat tyre or some­
the position of the researcher to counter biases and assumptions but thing just so I didn’t have to go’ (Hammond et al., 2018, p. 7).
without referencing reflexivity. Reflexive diaries, memos, regular Four of the included studies (Clarke et al., 2020; Papadomarkaki and
reflection and involving additional researchers to review themes and Lewis, 2008; Sim et al., 2016) highlighted the extent to which burnout
interpretations were some of the most commonly cited tools used to affected therapists’ personal lives and relationships. This lack of
counter researcher bias and promote reflexivity. emotional availability experienced by therapists when feeling depleted
All papers except two (Papadomarkaki and Lewis, 2008; Sim et al., and burnt-out seemed to permeate their personal relationships with
2016) explained how and where ethical approval for their research was family and friends, leading to reduced social contact, isolation and
granted. All but three studies (Clarke et al., 2020; Papadomarkaki and loneliness. As one of the participants described:
Lewis, 2008; Turnbull and Rhodes, 2019) described how the research ‘...I’m just like a zombie at the end of the day...And then kind of
was explained to participants, included information about the process of having that blunt, you know, when other people tell you stuff, you’re
obtaining participants’ consent, and how confidentiality was main­ just kind of like ‘I wanna have that emotion, and I wanna show you that,
tained. All studies used an established qualitative method and described but I’ve literally got nothing left in the tank’, ‘...And so it feels like the,
their analytical process, although their level of detail varied. All the the, the more, um... infinite some of those levels [of empathy] are in the
studies presented their findings including at least some of their data. room, in therapy, then the more finite they become out there in personal

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

Table 2
Study characteristics.
Author(s), Date and Aims Sample Size and Characteristics Setting and Context Recruitment and Data Analysis
Country Data Collection Methodology
Techniques

Clarke et al. (2020), To explore the perceived effects of 24 psychologists with varying Government and non- Semi-structured Thematic analysis and
Australia emotional labour in psychologists training backgrounds (e.g., clinical government agencies, interviews theme frequency
providing individual psychology, counselling independent practice or a (purposive and analysis
psychotherapy. To explore psychology, organisational mix of these three in snowball
whether there are differences in psychology) working primarily in outpatient and community recruitment
the perceived consequences of the provision of individual settings in Australia techniques)
emotional labour between psychotherapy
psychologists with varying levels
of experience
Cramond et al. To explore the experiences of 12 clinical psychologists working Various palliative care Semi-structured Interpretive
(2020), United clinical psychologists working in in palliative care settings in the UK interviews phenomenological
Kingdom palliative care services for adults (purposive analysis
with cancer, and to gain an recruitment
understanding of the impact of techniques)
the work on their self and how
they manage this
Hammond et al. To explore clinical psychologists’ 6 privately practising and solo- Private sector in Australia Semi-structured Thematic analysis
(2018), Australia experiences of burnout employed clinical psychologists interviews
(purposive
recruitment
techniques)
Norrman Harling To explore psychologists’ 8 psychologists working in publicly Both general and Semi-structured Thematic analysis
et al. (2020), experiences of compassion fatigue funded organisations specialised publicly funded interviews
Sweden and identify individual, care settings in Sweden (purposive
interpersonal and organisational recruitment
factors perceived as protecting or techniques)
contributing, to identify
successful coping strategies used
by psychologists
Papadomarkaki & To capture, explore and describe 6 counselling psychologists Different mental health Semi-structured Thematic analysis
Lewis (2008), the way counselling psychologists working in different mental health care settings, including interviews (did not informed by interpretive
United Kingdom experience work-related stress, care settings NHS services and private specify recruitment phenomenological
focussing on their professional practice in the UK techniques) analysis
behaviour and the impact on their
personal lives and ways of coping
with stress
Reitano (2021), To explore how psychological 6 participants (3 counsellors, 2 Oncology settings, Semi-structured Interpretive
United Kingdom therapists perceive occupational psychotherapists and a counselling including an acute hospital interviews phenomenological
stress and team environment in psychologists) working in oncology and a cancer care charity in (purposive analysis
oncology settings, including the settings the UK recruitment
specific aspects they find most techniques)
challenging and what helps them
to promote and maintain
resilience
Sciberras & To explore the issues faced by 7 psychologists working in public Public mental health Semi-structured Interpretive
Pilkington psychologists working in MDT’s mental health services services in Malta interviews phenomenological
(2018), Malta in public mental health services, (purposive analysis
where the leading treatment recruitment
philosophy is based on the techniques)
medical model, to explore how
psychologists cope with these
issues and what would help them
to cope better
Sim et al. (2016), To examine thriving, burnout and 14 staff psychologists working at Different college and Semi-structured Consensual qualitative
United States coping strategies (and what college and university counselling university counselling interviews research
contributes to these) of early and centres centres located in the US (snowball
later career psychologists working recruitment
at college and university techniques)
counselling centres in the US, to
explore whether early and later
career psychologists differ in
terms of thriving, burnout and
coping strategies
Turnbull & Rhodes To explore psychologists’ lived 17 psychologists (2 groups, 10 Various services, including Semi-structured Narrative inquiry
(2019), Australia experience in relation to burnout, participants self-identified as child protection, private interviews
recovery and wellbeing having experienced burnout, 7 and public hospitals, non- (snowball
participants self-identified as not profit organisations and recruitment
having experienced burnout) independent practice in techniques)
working across a wide variety of Australia
services

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

Table 3 Table 3 (continued )

Summary of results of included studies. Study Main findings Additional notes related to
Study Main findings Additional notes related to findings
findings
mortality; compassion
Clarke et al. (2020), 3 main themes: - Emotion management at fatigue (dealing with
Australia - Personal growth work leading to personal deaths and grief)
- Feeling depleted and growth through emotional experienced as inability to
exhausted expansion and awareness; listen to patients,
- Craving space free from being on a journey of self- rumination and insomnia
people and work-related discovery, self-learning and (‘I just didn’t want to hear
emotion self-reflection; therapists it, any more bad stuff’),
reporting an increased un­ avoidance of emotionally
derstanding of their challenging sessions
emotional experiences and - Clinical psychologists’
interpersonal interactions, expectations to be infallible
and more able to empathise experts on emotions and
with clients distress, and able to contain
- Managing emotions linked other people’s emotions;
to burnout, feeling awareness of emotional
depleted, exhausted and impact on self even when
fatigued; ‘being there but able to manage distress
not being there’, experienced by other
experiencing compassion people; difficulty
fatigue as inability to feel containing own emotions
the emotion for the patient; and need to share this with
feeling depleted of their team and managers
emotional resources, (‘I’m a human being too’)
unable to engage well Hammond et al. 5 main themes: - Therapists unaware and
interpersonally; reduced (2018), Australia - Demanding aspects of unequipped to face burnout
emotional availability; working as a clinical - Physical, emotional and
reduced capacity to psychologist psychological effects of
provide emotional support - Symptoms of burnout burnout (including
due to emotion - Precursors of burnout ‘enduring’)
management with clients; - Protective factors of - Physical and mental
becoming more intolerant burnout precursors; work-related
and frustrated a with - Barriers to overcoming and personal; transference
family and friends; burnout - Knowledge, experience and
dissatisfaction and trusting long-term
frustration with personal relationships
interactions perceived as - Prioritising clients’
trivial and lacking depth expectations and needs
- Need for space from other over their own; financial
relationships, reduced costs in private practice;
stimulation, tendency to lack of knowledge and
avoid work-related emo­ education about self-care;
tions; not seeking social time constraints
contact and wanting to Norrman Harling 5 main themes: - Wide range of different
spend time alone in less et al. (2020), - Mission impossible tasks (e.g., excessive
stimulating environments; Sweden - Emotional strain admin, coordination),
less engagement in - Consequences clinical complexity and
emotionally taxing re­ - Interpersonal factors high caseloads;
lationships and leisure ac­ - Shielding and dissatisfaction with
tivities; avoiding content strengthening factors framework and policies
that is likely to re-evoke - ‘Jesus complex’, being
negative work-related always expected to show
emotional states compassion; forcing
Cramond et al. 3 main themes: - Experience of working in compassion; ethical stress
(2020), United - Commitment: ‘More palliative care a privilege, and lack of resources
Kingdom draining but also more rewarding, making a - Annoyance, categorical
rewarding.’ difference. Knowing that thinking, numbness and
- Existential impact on the fixing (people) is not isolation as signs of
self: ‘You can’t walk needed, just sitting with compassion fatigue
through water without people’s difficulties. Threat - Support from colleagues;
getting wet.’ of patient death leads to amplification of each
- The Oracle: ‘[The team] uncertainty in the other’s complaints through
see me as some kind of therapeutic relationship. talking; role of leadership;
emotional robot who can Pressure of organisational friends and family as a
kind of manage it all.’ changes, ‘trying to do more source of support and
for less’, managerial tasks distraction; personal
most stressful ones relationships exacerbating
- Therapists affected by difficulties
work, being unable to - Noticing own struggles,
separate themselves from well-being strategies; being
their patients (‘You’re just realistic, lowering expecta­
like me’); awaiting sadness tions and taking control of
(patient death); more the situation; implement­
awareness of their own ing self-care; job
(continued on next page)

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

Table 3 (continued ) Table 3 (continued )

Study Main findings Additional notes related to Study Main findings Additional notes related to
findings findings

satisfaction and profes­ Building a positive team

sional development culture to help therapists
Papadomarkaki & 4 main themes: - Organisational changes feel less isolated and
Lewis (2008), - Uncertainty experienced as stressful, exposed. Importance of
United Kingdom - Relationship with threatening psychologists’ being able to talk freely
significant others identity; uncertainty about about own vulnerabilities.
- ‘Being me’ role and personal conflicts Identifying common values
- Criticism of professional with the medical model; at work. Balancing power
identity need to be recognised by dynamics in the team and
the employer; experience build collaborative
of time pressures, working practice. Being committed
long hours; complex clients to doing their best for
leaving therapists with patients; fostering a
difficult feelings, doubting flexible and caring
own work; stress from approach to practice;
working solo with high-risk offering and receiving
clients support when needed,
- Work having a significant staying connected with
impact on therapists’ peers
relationships with family - Building resilience key to
and friends (being reducing occupational
available and supportive, stress and preventing
feeling depleted, and burnout; importance of
having distorted roles and self-awareness, self-care,
expectations) reflection and self-
- Ability to be themselves, compassion; keeping
working in line with own boundaries in place and
values; importance of good being mindful of own limits
supervision providing (e.g., ‘not having to fix
reassurance and validation; people’). Accepting one’s
supportive families that own vulnerability, devel­
listen to their needs; peer oping ability to recognise
support as an important and accept own difficulties.
factor to increase self- Clinical supervision and
esteem and reduce work promoting therapists’ well­
stress; need to feel part of a being outside of work to
community, which allevi­ prevent stress (e.g., mind­
ates isolation and fulness and relaxation)
uncertainty Sciberras & 3 main themes (one was not - Therapeutic work as main
- Concerns about the way Pilkington discussed): source of satisfaction;
psychologists are viewed in (2018), Malta - Client-work as a source of seeing improvements in
their departments, satisfaction and a source patients’ quality of life,
experiencing criticism, of stress feeling appreciated and
derogatory views and lack - The psychologist in the seeing work as a learning
of recognition context of the experience; negative
Reitano (2021), 3 main themes: - Lack of understanding of multidisciplinary team emotions arising from
United Kingdom - Lack of understanding of therapist’s role. Challenges - Focus on the self working with patients,
the therapist’s role faced in the medical model, - Other systemic problems particularly complex
- The value of team lack of collaborative (theme not discussed) mental health problems
support approach. Organisational and suicidal ideation;
- Self-care and self- pressures and unrealistic impact on therapists’
awareness expectations as the greatest personal lives and and
source of occupational experiences; lack of
stress. Expectation to training to work with
contain not only patients’ complex presentations;
distress but also other therapists turning
professionals’ stress. Need negativity into an
to challenge other enriching experience
professionals to work through reflection
ethically. Pressures from - Professional issues and
increased workload, lack of negative emotions related
resources, operational to clinical approach in the
rules, long waiting lists, MDT; perceiving mental
little time to prepare in health system as dominated
between sessions and by the medical model,
miscommunication with rather than based on a
other professionals. collaborative approach;
Occupational stress from implied acceptance that the
focus on targets and psychiatrist is the most
diagnoses, rather than important professional in
clients’ needs the team; dominant values
- Team support as the most in the service clashing with
valuable resource to therapists’ beliefs; service
prevent and reduce not empowering patients
occupational stress. choice and focus on
(continued on next page)

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Table 3 (continued ) Table 3 (continued )

Study Main findings Additional notes related to Study Main findings Additional notes related to
findings findings

symptoms; psychology health concerns, feeling

perceived as an adjunct to depressed and worried
the medical treatment and about the future
power dynamics leading to - Interpersonal and social
therapists’ helplessness and support; self-care, engaging
powerlessness; therapists in wellbeing and leisure
not feeling trusted and activities (e.g., exercise,
valued, feeling mediation, yoga, healthy
demotivated eating and hobbies);
- Enthusiasm, motivation increasing self-awareness,
and positive feelings adopting new perspectives
replaced by demotivation; and thinking about change;
leaving public services due behavioural strategies such
to lack of trust, not feeling as setting boundaries and
valued, lack of involvement adjusting work schedule;
in decision-making, diver­ use of personal therapy
gence with the medical Turnbull & Rhodes 3 main themes (from the - Sudden and long-term
ideology; focussing exclu­ (2019), Australia burnout group): impact of burnout leading
sively on client-work to - The experience of to being unable to work.
keep motivated and burnout Emotional exhaustion,
recover from burnout; self- - Attributions of burnout depersonalisation and
awareness to manage - Recovery reduced professional effi­
negative environments, cacy. Burnout gradually
personal therapy, further building over time
education and outside su­ - Burnout explained as a
pervision; support from combination of workplace,
colleagues; need to be systemic and
accepted and share similar organisational factors,
values at work personal difficulties and
Sim et al. (2016), 3 main domains: - Recognition for the culture of psychology
United States - Thriving achievement, clients (stigma about own mental
- Burnout improving and health difficulties) and
- Coping appreciating therapists’ training (lacking self-care
support, receiving praises and focus on therapist’s
from colleagues, support values); difficulty estab­
from colleagues and lishing boundaries between
managers or directors, a work and professional life
sense that staff work well - Implementing personal and
together, therapist workplace self-care;
autonomy, respect for finding meaning in
limits at work and social everyday work; establish­
activities with colleagues at ing boundaries and letting
work; supervising, training go of responsibility for cli­
and mentoring new ents’ well-being outside of
colleagues perceived as therapy; good quality su­
very satisfying; client pervision; seeking own
improvement, therapy; recovery and self-
opportunities to progress care strategies leading to
and develop further pre-burnout functioning;
- Challenges related to burnout as a process of
therapists’ work, such as personal change
non-clinical and crisis/
clinical work, lead to
burnout (e.g., ‘not doing relationships’ (Clarke et al., 2020, p. 7).
things as well as they like, Participants stressed how the experience and impact of burnout were
feeling drained and
exhausted, defeated, low
entangled with their personal circumstances. One of the therapists
satisfaction, staying shared the sense of failure that pervaded professional and personal as­
afloat’); lack of time for pects of their life:
clinical and crisis work ‘It was like a perfect storm, I was feeling like a failure in the three big
contributing to burnout;
aspects of my life, as a mum, as a wife, and as a psychologist’ (Turnbull
imbalance between
perceived demands and re­ and Rhodes, 2019, p. 55).
sources available; chal­
lenges related to 3.4. Factors contributing to burnout
professional relationships,
including colleagues and
peers; difficult relation­ Eight studies identified factors that contributed to the development
ships with supervisors and and experience of therapist burnout. These factors ranged from organ­
directors (e.g., ‘not sleeping isational and systemic issues to personal difficulties experienced by
and functioning well,
therapists. However, systemic and organisational pressures were
‘sense of anger and insecu­
rity’), lack of mentors; described as the most significant factors contributing to therapist stress
personal difficulties, lone­ and burnout:
liness, sadness, isolation; ‘I find myself today hanging on to my client-work to keep me moti­
vated because it’s the system that sometimes feels like an obstacle to my

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Table 4
Summary of critical appraisal using the qualitative CASP checklist (CASP, 2017).
Summary of Assessment of Study 1 Study 2 Study 3 Study 4 Study 5 Study 6 Study 7 Study 8 Study 9
Methodological Quality using
CASP checklist (CASP, 2017)
Hammond Norrman Turnbull & Papadomarkaki & Cramond Reitano Sciberras & Clarke Sim
et al. (2018) Harling et al. Rhodes Lewis (2008) et al. (2020) (2021) Pilkington et al. et al.
(2020) (2019) (2018) (2020) (2016)

1. Was there a clear statement √ √ √ √ √ √ √ √ √

of the aims of the research?
2. Is a qualitative √ √ √ √ √ √ √ √ √/Х
methodology appropriate?
3. Was the research design √ √ √ √ √ √ √ √ √/Х
appropriate to address the
aims of the research?
4. Was the recruitment √ √ √ Can’t tell √ √ √ √ √/Х
strategy appropriate to the
aims of the research?
5. Was the data collected in a √ √ √ √ √ √ √ √ √
way that addressed the
research issue?
6. Has the relationship √ √/Х √/Х Х √ √/Х √ √ √
between researcher and
participants been
adequately considered?
7. Have ethical issues been √ √ √/Х Can’t tell √ √ √/Х √/Х Can’t
taken into consideration? tell
8. Was the data analysis √ √ √ √ √ √ √/Х √/Х √
sufficiently rigorous?
9. Is there a clear statement of √ √ √ √ √ √ √ √ √
findings?
10. How valuable is the √ √ √ √/Х √ √ √ √ √
research?

Note. √: fully met; √/Х: partially met; Х: not met; Can’t tell: unable to assess.

work...’ (Sciberras and Pilkington, 2018, p. 154). sector. Their experience of burnout was associated with the challenges
The lack of adequate resources, time pressures, working overtime, faced within a medical system that was perceived as rigid and hierar­
the impact of non-clinical work, such as administration and managerial chical, where doctors and psychiatrists would take the most important
tasks, high caseloads, poor quality supervision, and the clinical decisions, including those related to the provision of psychological in­
complexity of their work were the most commonly faced challenges. terventions. Therapists reported conflicting feelings stemming from
Therapists identified the lack of training to support their clients ethical dilemmas and disagreeing with the dominant values of the
adequately, a poor understanding of their role in the teams, the subse­ medical model, which did not focus on developing a collaborative and
quent ambiguity and uncertainty about the nature of their work, and the empowering approach to supporting clients. As one of the participants
ethical challenges caused by the disparity between increasing demands described:
and poor resources as significant factors contributing to burnout. These ‘My role in the mental health system is something that often does
factors fuelled their sense of powerlessness and hopelessness, as one of make me feel anxious because I feel that (…) I don’t sort of fit in with the
the participants stated: medical model, which is the prevalent view in the service that I work in,
‘It’s straining when we don’t have the resources, when we know that and (…) I have a lot of doubts about what I am doing sometimes,
we could have done something, but the resources aren’t enough. (…) So whether we really help people that much in the long run or not’
we don’t feel like we can stand behind what we deliver’ (Norrman (Papadomarkaki and Lewis, 2008, p. 44).
Harling et al., 2020, p. 8).
Three studies (Papadomarkaki and Lewis, 2008; Reitano, 2021; 3.5. Strategies that help to prevent and reduce burnout
Sciberras and Pilkington, 2018) linked the ethical issues experienced by
the therapists to the difficulties of working within a medical model. All the included studies highlighted strategies that can help to pre­
Therapists reported facing ethical dilemmas such as being asked to vent and reduce burnout. All bar two of the included studies (Clarke
persuade their clients to engage in therapy, following the recommen­ et al., 2020; Papadomarkaki and Lewis, 2008) identified implementing
dations of the medical team (Reitano, 2021), and doubting the value of self-care strategies as a way of reducing and preventing burnout. Par­
their input, particularly when being requested to provide short-term ticipants described self-care as a set of tools to embed in their routine,
interventions, perceived as inflexible and unhelpful (Papadomarkaki including looking after themselves physically (e.g., eating and sleeping
and Lewis, 2008; Reitano, 2021). The experience of these challenges well), seeing family and friends, and nurturting hobbies and interests in
conveyed a sense of powerlessness that left therapists frustrated at not their spare time. Participants saw self-care as an essential component in
feeling ‘trusted’ and ‘valued’ (Sciberras and Pilkington, 2018). As one ‘building resilience’ (Norrman Harling et al., 2020; Reitano, 2021) and
participant highlighted: developing a true and ‘authentic self’ (Turnbull and Rhodes, 2019). One
‘I felt that I was not valued as a professional. My work was not being participant described how the implementation of self-care strategies
seen and valued for what it was . . . so when I started to experience this, I helps to prevent stress and fatigue:
said: ‘This is not why I became a psychologist, this is not exactly how I ‘I’m much better at noticing my compassion fatigue now. I can see
wanted to work! . . . I was not trusted and that was my major issue with what’s happening (…) and I can try and change things. (…) Like ‘oh,
this’ (Sciberras and Pilkington, 2018, p. 154). now this happened, I have to change tracks here’ (Norrman Harling
These studies emphasised the tensions that burnt-out therapists et al., 2020, p. 10).
experienced within the medical model, both in the public and private Seven studies discussed the impact of supervision on therapist

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burnout. Participants described good quality supervision as a funda­ working within services that adopted a medical model as their organ­
mental space to process difficult feelings and emotions related to their isational framework difficult. The clash of perspectives and beliefs,
work, while maintaining adequate standards of good practice. This particularly in relation to offering collaborative, patient-centred and
‘great source of support’ (Reitano, 2021) allowed them to share their psychologically informed care to clients, appeared to raise ethical con­
challenges without feeling judged: cerns that made participants feel devalued and unappreciated, which
‘Supervision has taken the pressure off me; it’s allowed me to share contributed to the development of burnout. As others have suggested
what’s going on for me (…). Sometimes the supervisor can help me to (Simionato et al., 2019), exploring the ethical and values-based impli­
see something in a different way, to look something in a different way cations of burnout can help to gain a deeper and more comprehensive
and I’ll think: ‘oh, yeah!’ and I’ll go on from that way’ (Papadomarkaki understanding of the issues faced by psychological therapists.
and Lewis, 2008, p. 45). The findings of this review have emphasised the importance of in­
Five studies (Norrman Harling et al., 2020; Papadomarkaki and dividual and systemic coping strategies to reduce therapist burnout.
Lewis, 2008; Reitano, 2021; Sciberras and Pilkington, 2018; Sim et al., Implementing self-care strategies was perceived as one of the most
2016) explored the role of peer support in reducing burnout. Partici­ effective ways to prevent and alleviate burnout. It seems that partici­
pants described the support they receive from other colleagues as ‘vital’ pants found the prompt use of self-care and wellbeing tools essential to
and ‘invaluable’ for managing work-related stress. One participant, for prevent burnout and foster wellbeing. The wide range of tools
example, talked about the restorative nature of peer support: mentioned by the participants suggests that self-care strategies can be
‘[At lunchtime I] go into the staff lounge because there’s a good mix personalised and customised to meet their individual needs. It has been
of people in there … we jokingly refer to it as the no empathy zone … we theorised that self-care acts as a buffer, enhancing professional satis­
laugh at ourselves … it’s restorative’ (Sim et al., 2016, p. 392). faction and thus protecting against the effects of burnout and preserving
Five studies (Cramond et al., 2020; Norrman Harling et al., 2020; wellbeing (Rupert and Dorociak, 2019). This review also validated the
Sciberras and Pilkington, 2018; Sim et al., 2016; Turnbull and Rhodes, role of systemic and organisational strategies in preventing and man­
2019) highlighted the importance for therapists to find meaning in their aging burnout, such as effective supervision and peer support. Partici­
professional role. Job satisfaction achieved through finding meaning pants found good quality supervision very valuable in preventing
and purpose in their day-to-day work was seen as a helpful strategy to burnout and maintaining wellbeing, particularly when processing their
alleviate burnout. Therapists described working with people in distress own feelings and emotions. Adding to existing literature in the area
as ‘a privilege’ and ‘an absolute humbling honour’ (Cramond et al., (Connor et al., 2018; Simionato et al., 2019), the review found that this
2020). Seeing improvements in clients’ quality of life was highly valued focus on self-reflection, rather than case-management, plays a key role
by therapists and seen as ‘the biggest reward you can get’ (Sciberras and in reducing stress and promoting therapist wellbeing, and can provide
Pilkington, 2018). opportunities to consider and address organisational and systemic fac­
tors contributing to burnout. The findings of the present review high­
4. Discussion lighted the key role of peer support when facing work-related adversity
and burnout. Participants talked about peer support and supervision as a
The present review aimed to explore therapist burnout from a restorative space where difficulties are normalised, both formally and
qualitative perspective, synthesising studies to develop a richer under­ informally. It seems that the flexible nature of peer networks allows
standing of the difficulties and challenges experienced by psychological therapists to maximise opportunities to give and receive support, thus
therapists, as well as their professional and personal coping strategies. addressing a wide range of therapist needs (Rothwell et al., 2019).
The findings appear to validate the dynamic and fluid nature of burnout Finally, finding meaning in day-to-day work was also seen as an effective
(Maslach and Leiter, 2016), highlighting that the experience of burnout coping strategy to mitigate therapist burnout. Participants valued being
in therapists is complex, affecting a number of areas, including their able to help others and being part of their recovery journey. Seeing
physical and emotional wellbeing, and the boundaries between personal improvements in clients’ wellbeing and quality of life enables therapists
and professional lives. Participants talked about feeling depleted and to feel valued and experience a sense of purpose. Being able to
emotionally disconnected from their role, and being unable to support conceptualise work-related stress in relation to meaning and purpose
their clients effectively. This is consistent with existing research on has been shown to be a healthy coping mechanism that increases stress
therapist burnout and its impact on their wellbeing and professional tolerance and decreases work-related ambiguity and uncertainty (Ian­
effectiveness (Morse et al., 2012; Simionato et al., 2019). nello et al., 2017).
The impact of burnout on therapists’ personal lives was also evi­
denced, leading to reduced social engagement and lessened ability to 4.1. Clinical implications and recommendations
connect and empathise with others. It appears that therapists’ reduced
effectiveness and motivation impaired their ability to engage in thera­ The findings of this review demonstrate the impact that therapist
peutic work meaningfully, thus reinforcing their dissatisfaction. These burnout can have on their ability to work effectively, which has
findings contribute to existing research on therapist burnout, stressing important implications in terms of staff absenteeism, turnover and
the link between the manifestations of burnout, therapist effectiveness, retention. This appears to be in line with previous findings suggesting
absenteeism and turnover (Connor et al., 2018; Maslach, 1982; that lower therapist wellbeing is associated with increased likelihood to
McCormack et al., 2018; Simionato and Simpson, 2018; Simpson et al., leave their roles (Summers et al., 2021). Services should consider pro­
2019). moting a culture in which staff wellbeing is safeguarded. National
The review also highlighted some important contributing factors to guidelines and policies are increasingly recognising that preserving and
developing burnout. Participants identified the systemic and organisa­ maintaining staff wellbeing also has longer-term economic benefits, as a
tional challenges they faced as the most significant contributing factors. recent report by the National Health Service (NHS) in England under­
It appears that therapists perceive systemic and organisational chal­ scored (Health Education England, 2019). Managers and supervisors
lenges as something they have little or no control over, which fuels their should be trained to discuss and review burnout factors and related
sense of powerlessness and hopelessness. Some of these organisational difficulties regularly with their supervisees, offering access to additional
difficulties seemed to foster the awareness of clashing values, with support and training when needed (Simionato et al., 2019).
related ethical implications. Therapists experience ethical dilemmas Supervision remains a cost-effective preventative measure for ther­
stemming from dealing with systemic issues they do not feel in control apist burnout. The findings of this review provide evidence that thera­
of, which can increase the sense of responsibility they carry (McCor­ pists utilise supervision to manage and reflect on their own feelings and
mack et al., 2018; Simionato et al., 2019). Similarly, participants found emotions. As highlighted in the present review, in addition to offering

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M. Vivolo et al. Mental Health& Prevention 33 (2024) 200253

case-management, effective supervision should provide a space for which staff wellbeing is protected. Further research on therapist burnout
therapists to reflect on systemic and organisational challenges, and the using different methodological approaches and larger samples is needed
impact this has on their clinical work. Given its focus on emotional to increase transferability. Adopting distinct conceptualisations of
challenges, self-reflection in supervision may be a more effective mea­ burnout and including other kinds of psychological therapists could
sure to prevent therapist burnout (Jones and Thompson, 2017; Rothwell provide further insight into the experiences of therapist burnout.
et al., 2019; Simionato et al., 2019). Relying on peer support was also
validated as an invaluable coping strategy. Whilst peer support Author declaration template
commonly features as an important aspect of practice in the professional
work of many psychological therapists, services should pro-actively We wish to confirm that there are no known conflicts of interest
facilitate relational and peer-based activities, such as mindfulness and associated with this publication and there has been no significant
self-compassion classes, offering therapists opportunities to engage financial support for this work that could have influenced its outcome.
meaningfully with their colleagues (Lomas et al., 2019; Simionato et al., We confirm that the manuscript has been read and approved by all
2019). Evidence shows that relational networks increase awareness of named authors and that there are no other persons who satisfied the
wellbeing-related difficulties, promote compassion within the work­ criteria for authorship but are not listed. We further confirm that the
place (Simpson et al., 2020), and address needs that formal supervision order of authors listed in the manuscript has been approved by all of us.
tends to neglect (Rothwell et al., 2019). Finally, this review highlighted We confirm that we have given due consideration to the protection of
that finding meaning in their work and appraising stress in relation to intellectual property associated with this work and that there are no
values and beliefs systems helped therapists to manage burnout-related impediments to publication, including the timing of publication, with
challenges. Services should consider psychoeducational training and respect to intellectual property. In so doing we confirm that we have
practices that enhance self-reflection, such as mindfulness and reflective followed the regulations of our institutions concerning intellectual
practice, to encourage therapists to get in touch with their values and property.
embrace work-related stress as a natural part of their work (Lomas et al., We understand that the Corresponding Author is the sole contact for
2019; Simionato et al., 2019). the Editorial process (including Editorial Manager and direct commu­
nications with the office). He is responsible for communicating with the
4.2. Strengths, limitations and future research other authors about progress, submissions of revisions and final
approval of proofs. We confirm that we have provided a current, correct
To our knowledge, this is the first systematic review synthesising email address which is accessible by the Corresponding Author.
qualitative studies on burnout in psychological therapists. The meth­
odological appraisal of the included papers was discussed and consensus
Declaration of Competing Interest
reached with the second (J. O.) and third author (P. F.).
One of the limitations of this review was related to the definition of
None.
psychological therapist. This encompassed a number of professionals,
including different kinds of psychologists and psychotherapists, but
excluded other professionals, such as sport psychologists, counsellors, Acknowledgements
trainees, and students. Studies including these professionals could pro­
vide further insight into the experiences of burnout in psychological We would like to thank Lia Tostevin, Children’s Wellbeing Practi­
therapists. This review included studies on psychological therapists tioner in the Cambridgeshire and Peterborough Emotional Health and
practising in both public and private sectors. Future research could Wellbeing Service, for her role as an independent reviewer of papers at
differentiate these sectors to explore differences and similarities, and title and abstract and full-text review stages.
whether the experiences and processes of burnout differ depending on
the context in which therapists operate. Taking into account the expe­ Supplementary materials
riences of therapist burnout in education and training settings through
the recruitment of trainees and students could help to gain a more Supplementary material associated with this article can be found, in
comprehensive understanding of this phenomenon early in their pro­ the online version, at doi:10.1016/j.mhp.2022.200253.
fessional development, thus uncovering further learnings. All the studies
included in this review used qualitative methodologies with small References
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