Counselling Psychology Quarterly ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/ccpq20 Effective burnout prevention strategies for counsellors and other therapists: a systematic review and meta-synthesis of qualitative studies Sancia Duncan & Rachael Pond To cite this article: Sancia Duncan & Rachael Pond (03 Oct 2024): Effective burnout prevention strategies for counsellors and other therapists: a systematic review and meta-synthesis of qualitative studies, Counselling Psychology Quarterly, DOI: 10.1080/09515070.2024.2394767 To link to this article: https://doi.org/10.1080/09515070.2024.2394767 © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 03 Oct 2024. 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This systematic review and meta-synthesis of qualitative literature examined what practicing therapists (including counsel- lors, psychotherapists, and psychologists) report being helpful in preventing and minimising burnout. A search by EBSCO Discovery Service across all major article databases and a complementary search using Google Scholar led to the identification of nine eligible studies (with 542 therapists). Studies were critically appraised, data were extracted, and findings synthesised using thematic analysis. Nine themes/helpful factors for preventing burnout in the thera- peutic profession were identified: time off, leisure activities, exer- cise, perspective (having a particular mindset or attitude towards the role), support and connections, boundaries and bal- ance, awareness/mindfulness of one’s internal state and the impact of work, spirituality/meditation, and professional growth and self- use of clinical approaches. Information about these strategies needs to be included and practised during therapist training programmes. Future research needs to investigate culturally preferred strategies for preventing burnout. Importantly, while practitioners are respon- sible for implementing self-care strategies for their well-being, it is critical that organisations take an active role in burnout prevention by putting policies in place, providing training to increase aware- ness of burnout, and supporting staff to manage pressures they face. ARTICLE HISTORY Received 19 February 2023 Accepted 16 August 2024 KEYWORDS Burnout prevention; counselling; therapists; systematic review; self-care Burnout is a common and debilitating occupational hazard. It has been officially recog- nised by the World Health Organization (2019) as a syndrome resulting from chronic workplace stress that has not been well managed. While it is not yet classified as a medical condition, it is included in the 11th revision of the International Classification of Diseases (World Health Organization, 2019). With the workforce in many countries being overly stretched and under strain, burnout is a widespread reality for many workers. Indeed, a recent study of over 12,000 full-time employees across a range of professions revealed that 76% had experienced burnout at some point in their job (Gallup, 2020). For some professions, the problem of burnout worsened during the pandemic because of CONTACT Rachael Pond R.L.Pond@massey.ac.nz COUNSELLING PSYCHOLOGY QUARTERLY https://doi.org/10.1080/09515070.2024.2394767 © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any med- ium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. http://www.tandfonline.com https://crossmark.crossref.org/dialog/?doi=10.1080/09515070.2024.2394767&domain=pdf&date_stamp=2024-10-03 additional stressors and demands and fewer available resources (Mockaitis et al., 2022; Moll et al., 2022). The single largest risk factor for developing burnout is engagement in human service work (Newall & MacNeil, 2010). Research evidence shows that mental health professionals (including therapists such as counsellors, psychotherapists, and psychologists) are one such group prone to burnout. For example, a recent meta-analysis consisting of 62 studies across 33 countries revealed that 40% of mental health professionals could be classified as experiencing burnout (O’Connor et al., 2018). An earlier review concluded that between 21% and 67% of mental health workers had experienced burnout (Morse et al., 2012). In New Zealand, where the authors of this paper are located, a survey of counsellors found that 25% were at high risk of burnout (Temitope, 2014). The rate of burnout for counsel- lors is an ongoing concern (Wardle & Mayorga, 2016), and this was heightened during the pandemic (Litam et al., 2021). Burnout is considered hazardous at multiple levels. It impacts the individual and their performance, the organisation, and the health and safety of the consumers/clients (Davis, 2020; Gallup, 2020). Within the context of counselling, counsellors’ mental, physical, and emotional wellbeing are impacted, leaving them feeling overextended and depleted of emotional and physical resources. This in turn can affect the relationship between the counsellor and client, resulting in poorer client care; the organisation is also impacted (Maslach & Leiter, 2017; Wardle & Mayorga, 2016). There is an ethical requirement that counsellors and related professionals engage in self-care activities to maintain wellbeing and meet professional standards and responsibilities (e.g. American Counseling Association, 2014; British Association for Counselling and Psychotherapy, 2016; New Zealand Association of Psychotherapists, 2018). Therefore, it is essential ethically, morally, socially, and economically to address the causes of burnout and to raise awareness about how individuals and organisations can prevent and manage it (Bailey, 2021). Definition of burnout Burnout, a concept first popularised in the literature by Freudenberger (1974) and then by Maslach (1976), is a progressive state, in which one’s strength and passion are gradually eroded over time. It arises in the work context as a result of continual pressures, conflicts and demands, and insufficient emotional rewards, acknowledgment, and perceived suc- cess (Pines & Aronson, 1988). It is defined as a condition that is “subjectively experienced as a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally draining” (Pines & Aronson, 1988, p. 9). Burnout occurs in response to chronic workplace stress that has not been effectively managed and consists of three distinct domains: exhaustion, depersonalisation (a defence mechanism where one practices emotional distance from one’s clients) and feelings of ineffectiveness (Maslach, 1982). Although there is evidence to the contrary (e.g. Koutsimani et al., 2019), some research shows that burnout may be similar to work-related depression, with the exhaustion and fatigue-related core of burnout overlapping with symptoms of depression (Schonfeld & Bianchi, 2021). Notably, it is not stress in and of itself that leads to burnout, but prolonged chronic stress that is not addressed that leads to feelings of overwhelm and then burnout (Rupert et al., 2015). 2 S. DUNCAN AND R. POND Notably, the term burnout is often used in conjunction with the terms secondary traumatic stress, compassion fatigue, and vicarious traumatisation. These latter terms are unique to being exposed to trauma in one’s work or practice (Newall & MacNeil, 2010). Secondary traumatic stress refers to the psychological response resulting from exposure to others’ (e.g. clients’) traumatic encounters (Cummings et al., 2021), with symptoms mirroring those of post-traumatic stress disorder (e.g. intrusive thoughts, traumatic memories, insomnia, nightmares, chronic irritability, and hypervigilance) (Newall & MacNeil, 2010). Compassion fatigue refers to the overall experience of emo- tional and physical fatigue that is experienced due to constant use of empathy when working with those who are suffering (Newall & MacNeil, 2010). It includes “a state of tension and preoccupation with the traumatized patients by re-experiencing the trau- matic events” (Figley, 1995, p. 1435). Vicarious trauma results in the therapist’s inner experience being negatively transformed (Pearlman & Saakvitne, 1995). It is defined as changes in the way the therapist sees the world, others, and their relationships as a result of the accumulation of exposure to client trauma (Cummings et al., 2021). Specific symptoms of vicarious trauma include a reduction in empathy, self-esteem, self- perception, motivation, efficacy, intimacy, safety, and trust. Unlike these specific trauma- related effects, burnout is a general phenomenon resulting from a combination of interpersonal and organisational stressors that may or may not include exposure to others’ trauma (Galek et al., 2011). Burnout and the possible ways that it can be prevented and/or managed is the focus of this systematic review. Explanations of burnout People can flourish in demanding roles if they feel valued, appreciated, and believe their work has a purpose; however, burnout can occur when stress begins to outweigh support and rewards (Pines & Aronson, 1988). The Job Demands–Resource model (Demerouti et al., 2001) proposes that burnout occurs when there is an imbalance between job demands and available resources. Job demands are aspects of the work that demand continuous physical, emotional, or cognitive effort. These demands (workload, stress, work pressure, and emotional labour) are key predictors of outcomes like exhaustion and other health complaints. Job resources refer to the physical, psychological, social, and organisational facets of the job that assist in achieving the workload, reducing demands, and stimulating personal development (e.g. professional development and supervision). The fundamental belief of this model is that burnout occurs when job demands are high and resources are limited (Chirico, 2016). Notably, both organisational and individual factors influence the likelihood of burnout (Cummings et al., 2021). Organisational factors include excessively high caseloads, lack of control over policies/procedures, unfairness, low peer/supervisory support, and inade- quate training (Newall & MacNeil, 2010). Unfortunately, in human service organisations it is not uncommon to see large numbers of clients assigned to one staff member due to limited staffing or cost/benefit calculations. In terms of individual factors, personality traits such as being reserved, unassertive, and submissive make helping professionals prone to burnout (Maslach, 1982). Those who have self-doubt, low self-esteem, a need for control, and difficulty setting limits are also at risk (Maslach, 1982; McAlpine, 2021). A relationship between age and burnout has also been identified, with younger less experienced COUNSELLING PSYCHOLOGY QUARTERLY 3 workers being more likely to experience burnout (Rupert et al., 2015). Rupert et al. explain that age brings maturity, experience, and increased personal resources to help cope with work demands. Causes of burnout specific to therapists To understand the phenomenon of burnout in the therapeutic profession we need to understand the demands of the job. Therapeutic work focuses primarily on clients’ problems (Maslach, 1982), with exposure to repeated narratives of suffering, conflict, loss, and trauma over the course of the day (Simionato et al., 2019). It involves constantly processing clients’ experiences and emotions (Maslach, 1982), and demands a high amount of emotional, cognitive, and physical energy (Chirico, 2016). Constant giving of oneself and one’s personal resources to help those in need is also a common requirement (Skovholt & Trotter-Mathison, 2016). In addition to the demanding and potentially dis- tressing nature of the work, Barnett and Coooper (2009) point out that therapists may feel invincible due to their education or want to appear strong to uphold their reputation. Yang and Hayes (2020) have grouped predicting features of burnout into three cate- gories: work factors, therapist factors, and client factors. Work factors consist of the work environment and setting in which one works, autonomy, or sense of control over the work tasks and workload, the physical and psychological demands of the job, and the support that is available to them. Therapist factors encompass the therapist’s personal mental health history (including their own exposure to trauma), countertransference, psychological dis- tress (from work or personal life), the sense of confidence one has in their professional ability, personality factors (such as emotional intelligence), coping strategies used to main- tain a sense of equilibrium, personal awareness/mindfulness, and demographic factors such as gender, race, age, education level and parental status. Lastly, client factors include the nature of the clients’ presenting issues, their level of responsibility or commitment to the therapeutic process and the speed at which the progress in therapy occurs. Farber (2000) has also proposed that therapists (and other professionals, such as teachers) experience burnout due to feelings of “inconsequentiality.” This occurs when a therapist perceives their efforts have been ineffective in helping others, when the task is endless, and there are no pending personal payoffs for their work (e.g. accomplishment, recognition, advancement). During the pandemic, therapists experienced numerous challenges on top of what was usual. As well as facing similar anxieties, uncertainties, and challenges as those who sought their services, demands increased as counsellors needed to support more clients than previously, learn new technology to provide online counselling, and deal with associated issues around confidentiality and privacy (Litam et al., 2021). Counsellors with a higher level of perceived stress were more likely to experience burnout (Litam et al., 2021). Preventing and managing burnout There is an extensive amount of literature focusing on burnout and the negative impact of working in the counselling and related professions, yet there is an increasing need for attention to be given to managing and preventing burnout. Despite this consistent call for 4 S. DUNCAN AND R. POND action, progress has been modest and much remains to be accomplished (Leiter et al., 2014). Given that burnout is such a common and debilitating occupational hazard, it is critical that burnout is addressed, and prevention strategies are made known. Several quantitative studies have suggested that external factors such as job control reduce the risk of burnout (Rupert et al., 2015). Those who feel a sense of control in their work report less emotional exhaustion, less depersonalisation, and a greater sense of personal accom- plishment (Rupert et al., 2015). Workplace support (e.g. from a supervisor and/or co- workers) has also been found to be positively related to personal accomplishment, decreasing emotional exhaustion and depersonalisation (Rupert et al., 2015). In addition to job resources (like workplace support), the personal resources one brings to the profes- sion like self-care activities and related cognitive coping strategies (e.g. self-awareness, a constructive perspective on one’s work, being able to reflect on satisfying experiences) are helpful tools for preventing burnout (Rupert et al., 2015). Self-care activities, such as recreational activities and interests, maintaining a work–life balance, and social support (including supportive family and friends), have been identified as useful (Rupert et al., 2015). While the concept of self-care for professionals is not that well established in the literature (Jiang et al., 2021), it can be defined as an ongoing process of caring for yourself, making a conscious effort to do things to maintain, improve and restore your mental, emotional, physical, and spiritual wellness (Baker & Gabriel, 2021; Barnett & Homany, 2022). It includes but is not limited to strategies that are physical (e.g. exercise, nutrition), psychological and emotional (e.g. self-compassion), social, spiritual, leisure-oriented, and/ or professional (e.g. workload management and professional development) (Lee & Miller, 2013). In addition to promoting wellness, there is evidence that self-care mediates the relationship between stress and the domains of burnout (exhaustion, depersonalisation, and diminished personal accomplishment) for helping professionals. Simply put, self-care activities can help improve wellbeing, reduce stress, and be a preventive factor against burnout for helping professionals (Hricová, 2020; Rupert & Dorociak, 2019). While there is rich qualitative research about burnout prevention strategies that counsellors and other therapists have experienced and interpreted to be personally helpful, there is no known review of these studies to date. This systematic review will hence be a valuable resource that is based on therapist experiences of what they have found helpful in preventing and ameliorating burnout. Research aim With more people turning to counsellors and related professionals for help, it is essential that burnout is addressed to reduce the potential impact it has on these practitioners’ wellbeing, job performance and client care. So, how do counsellors and related profes- sionals personally prevent, minimise, and manage burnout? This systematic literature review of qualitative studies aims to explore and answer this question by synthesising research findings about counsellor and related professionals’ experiences and perspec- tives of what they have found helpful in preventing, minimising, and managing burnout. By focusing on qualitative studies, the systematic review aims to increase our under- standing of these practitioners’ experiences of preventing burnout, so that training programmes and practitioners can benefit from this knowledge. COUNSELLING PSYCHOLOGY QUARTERLY 5 Methods A qualitative systematic review – or more specifically, a meta-synthesis of qualitative studies using thematic analysis – was conducted to critically identify patterns in the findings of qualitative literature specific to burnout prevention in counsellors (and related practitioners). Systematic reviews are considered the best way to identify, assess, and synthesise findings across studies that investigate the same research question. Unambiguous search procedures, rigorous quality assessment and transparent methods of data synthesis are utilised. The strength of this approach is that it draws together comprehensive amounts of data to address a specific research question (Petticrew & Roberts, 2006). Qualitative systematic reviews can lead to a greater understanding of the lived experiences of a particular phenomenon, and richer conclusions due to the depth of analysis (Gough et al., 2012; Sandelowski et al., 1997). Ultimately, they aim to provide a concise yet comprehensive representation of findings across selected studies to improve practice, outcomes, research, and policy (Dawson, 2019; Timulak & Creaner, 2022). Search strategy EBSCO Discovery Service was utilised for the scoping and main searches, with the final search taking place in April 2021. EBSCO Discovery Service searches across most of the resources subscribed to by the host university, including but not limited to Psych Info, Scopus, Web of Science, CINAHL, ERIC, Medline, Academic Source Premier and Business Source Complete. A supplementary search using Google Scholar, and handsearching the reference sections of key articles, were performed to check for any additional relevant articles. The key search terms used in EBSCO Discovery were as follows: (counsel* OR therapist* OR psychotherapist* OR psychologist*) AND (“burnout prevent*” OR “prevent* burnout*” OR “beat* burnout” OR “overcom* burnout” OR “minimi* burnout” OR “avoid* burnout” OR “manag* burnout”) AND “burnout prevention” (as a subject term) AND (perspective* OR perception* OR attitude* OR view* OR experience* OR outlook OR account* OR narrative* OR qualitative OR “mixed methods” OR interview* OR “focus group*” OR “case study*” OR phenomenology* OR “grounded theor*” OR ethnograph* OR “thematic analysis” OR “content analysis”). The key search terms used in Google Scholar were as follows: “burnout prevention” AND (counsellors OR counselors OR therapists OR psy- chotherapists OR psychologists). To increase precision, Google Scholar searched for these words in the title of articles. Inclusion and exclusion criteria Titles and abstracts were screened using the SPIDER tool, which is a tool that was developed specifically for synthesis of qualitative evidence (Cooke et al., 2012). See Table 1 for specific inclusion criteria. Only peer reviewed scholarly literature written in English was included in this systema- tic literature review. Studies that focused on the experience or cause of burnout were excluded if they did not also examine what therapists do to prevent, minimise, or manage 6 S. DUNCAN AND R. POND burnout. Studies about compassion fatigue, secondary traumatic stress and vicarious traumatisation or their prevention were also excluded as they focused on related but different concepts to burnout. Reviews, commentaries, and grey literature were also omitted. Data extraction A data extraction table was created for the tabulation of the following data: setting, participants, methodology, data collection, and data analysis methods; factors contribut- ing to burnout; and the strategies therapists use to prevent burnout. Quality appraisal The aim of the quality appraisal is to assess whether the studies have been designed, conducted, and reported in a way that is reliable and provides meaningful answers to the research question. In this systematic review, the Critical Appraisal Skills Programme (CASP) Qualitative Checklist (CASP, 2018) was utilised as it can appraise all types of qualitative research (Butler et al., 2016). The CASP consists of 10 questions that facilitate an evalua- tion of the theoretical approach, study design, data collection, analysis, and ethics of a study. Data synthesis The aim of data synthesis is to gather together collective discoveries of the studies into a set of statements or themes that represent and interpret the phenomena under investigation. In this systematic review, we were interested in meaning-based, descriptive themes that stayed close to the findings about burnout prevention in the studies (versus higher order analytic themes for theory development). We utilised reflexive thematic analysis (Braun & Clarke, 2012; Braun et al., 2019) as it is widely recognised as a valuable method for qualitative data analysis and has been effectively used in many qualitative systematic reviews. It also provides a clearer step-by-step method of identifying themes than typically used in thematic synthesis methods for systematic reviews. For reflexive thematic analysis, the researcher systematically identifies, organises, and offers insight into patterns of meaning across a data set (Braun & Clarke, 2012; Braun et al., 2019). This method provides a platform enabling the researcher to identify and make sense of commonalities in the way an issue is talked/written about. This review used an inductive approach where codes and themes were derived from the content of data itself. It is Table 1. SPIDER inclusion criteria. Sample Practicing therapists, including counsellors, psychotherapists, or psychologists (trainees to very experienced) Phenomenon of Interest Strategies to prevent, minimise, or manage burnout Design Qualitative methodologies like narrative or grounded theory that use qualitative data collection methods like interviews, focus groups, and open-ended survey questions Evaluation Accounts of counsellors lived experiences Research type Qualitative COUNSELLING PSYCHOLOGY QUARTERLY 7 important to note, however, that it is impossible to be purely inductive as we inevitably bring something of ourselves – personal, cultural, and theoretical viewpoints and knowl- edge – to the data we analyse (Braun & Clarke, 2012; Braun et al., 2019). Braun and Clarke’s thematic analysis consists of six phases involving (1) familiarising oneself with the data by closely reading and re-reading findings of the selected articles that relate to the review question; (2) generating initial codes line-by-line coding; (3) identifying preliminary themes; (4) reviewing preliminary themes; (5) defining and naming themes; and (6) producing the report. The first author did the initial coding and identification of pre- liminary themes. These were then collaboratively reviewed, discussed, critiqued, and refined with the second author. Ethics Due to this study being a systematic review, no formal ethics approval was required by the University’s human ethics committee. However, ethical issues related to systematic review methodology were considered, including the importance of representing findings of selected studies accurately and fairly, and ensuring publication of the systematic review would not negatively impact individuals, groups, and communities. Results Selection of studies As shown in Figure 1, 208 papers were initially identified through electronic database searching. Once duplicates were removed, 75 unique citations remained. Titles and abstracts of these 75 citations were screened and assessed for relevance using the inclusion and exclusion criteria and 64 citations were excluded. The remaining 11 articles were read and screened using the inclusion criteria, and 4 more articles were excluded (due to being quantitative or their focus being on something other than burnout prevention). Two additional articles were located in a final Google Scholar search resulting in a total of nine studies being included in the systematic review. Characteristics of the included studies Table 2 shows the characteristics of the nine included studies. These were published between 2000 and 2020, with four studies being published within the last 5 years. Eight studies were conducted in the United States, and one was conducted in Canada. Therapist participants practised in a range of areas, including drug and substance abuse and eating disorder treatment centres. They ranged from graduates to very experienced, highly accomplished practitioners. One of the larger studies consisted of therapists who use Dialectical Behaviour Therapy (DBT) and one study included peer nominated therapists who were described as resilient practitioners. Five of the nine studies had sample sizes of 10, two had approximately 30 participants, one had 135 participants, and the largest sample size was 298. A total of 542 mental health practitioners and therapists participated in the included studies. The main ethnicity was white American, and the majority of participants were female. 8 S. DUNCAN AND R. POND Eight out of the nine studies were qualitative studies using methodologies like grounded theory, phenomenological and narrative approaches. The other study used a mixed method approach. Reported contributing factors of burnout for the therapist participants included external factors, such as high caseloads, office politics/pres- sures, lack of client success, and isolation. Internal factors contributing to burnout included personal issues. Three articles did not discuss factors contributing to burn- out. As seen in Table 2, a variety of strategies were utilised by therapists to prevent burnout. Quality of included studies Table 3 shows the results of the CASP Quality Checklist that was utilised. Each article in this systematic review presented a clear research aim that was appro- priately addressed using qualitative methods and analysis. The data collected clearly answered the research question and each article presented a precise In cl u d ed g ni neerc S Records identified through database searching (n = 208) ytili bi gil E n oitacifit ne dI Additional records identified through Google Scholar (n = 2) Records after duplicates removed (n = 75) Title and abstract of records screened (n = 75) Records excluded (n = 64) Full-text articles assessed for eligibility (n = 11) Full-text articles excluded, with reasons (n = 4) Quantitative research (n = 1) Main focus not burnout prevention (n = 3) Reason 3 (n = #) etc Studies included (n = 9) Figure 1. Flowchart detailing the study selection process. COUNSELLING PSYCHOLOGY QUARTERLY 9 Table 2. Study characteristics and findings. Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Beitel et al. (2018) USA 31 drug counsellors: 18 women, 13 men White (77%) Hispanic (13%), African/American (10%). Mean age: 47 years. Mean years of counselling experience: 16.5. 36% denied experiencing burnout; 39% reported some symptoms; 26% reported having burnout Grounded theory – semi structured interviews. Ruminating about work. Not completing expected work. Annoyance at co- workers. Physical tiredness. Stressed & overwhelmed. Prevalence of self-care strategies: ● 52% utilised plea- surable activities- like spending time with loved ones. ● 32% used supervi- sion-formal/infor- mal insight. ● 32% used exercise. ● 26% said paid time off pre- vented burnout. ● 23% said it was important to take breaks during the workday. ● 23% said collegial relations were helpful. ● 19% said work/life balance was important. ● 13% reported relaxation as beneficial. ● 10% said that applying clinical skills to self was helpful. ● 10% said that venting/sharing stressors with col- leagues was helpful. (Continued) 10 S. DUNCAN AND R. POND Table 2. (Continued). Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Grafanaki et al. (2005) Canada 10 counsellors/ psychologists: 5 men, 5 women Age range: 39–55 years. 5 Roman Catholic 3 Christian 1 Jewish. 1 Agnostic Narrative theory - semi- structured interviews. Contributing factors to burnout not discussed. Four themes about how structuring leisure into everyday life alleviates burnout: (1) Leisure mind: engaging in a state of mind where there are fewer demands, less pressure/ worry. (2) Leisure space: getting into nat- ure, engaging in physical activity, meditation, prayer, music & the arts. Leisure space relates to spiritual moments where one is con- nected to some- thing higher than themselves. (3) Connection: with self, family & the wider community. (4) Rewards: leisure provides a sense of balance & enabled partici- pants to cope with daily life offering escape & providing an opportunity for relaxation & renewal. (Continued) COUNSELLING PSYCHOLOGY QUARTERLY 11 Table 2. (Continued). Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Hou and Skovholt (2020) USA 10 therapists that were identified as highly resilient: 5 males, 5 females 1 African American 1 Latina 1 East Asian/ European/American 7 European American Minimum of 10 years’ experience. Grounded theory - semi- structured interviews. Focus of this article was on highly resilient therapists and protective factors to burnout not contributing factors. Four core categories with subthemes: (1) Strong interper- sonal relationships. (2) Close connec- tions in personal life. (3) Being connected in valuable pro- fessional relationships. (4) Compassion for clients. (5) Actively enga- ging with self. (6) Self-knowledge - being aware of personal strengths & weaknesses & accepting limita- tions & shortcomings. (7) Compassion for self. (8) Vocational con- viction – ensur- ing that the workplace is the right fit. (9) Self- conservation – intentionally engaging in self- care. (10) Possess core values & beliefs. (11) Theoretical mod- els/approaches to guide work with clients. (12) Personal values & beliefs which serve as an anchor. (13) Desire to learn & grow. (14) Having a desire & love for intel- lectual learning. (15) Being com- mitted to ongoing perso- nal growth. (Continued) 12 S. DUNCAN AND R. POND Table 2. (Continued). Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Jergensen (2018) USA 135 mental health therapists practicing as DBT practitioners: 121 females, 12 males 1 transgender Mean age: 46 years. 9% experiencing burnout. Triangulation mixed methods. Qualitative – thematic analysis. Open ended questions. Not reported. Two key findings: (1) Personally utilis- ing DBT skills was helpful in life & work – partici- pants reported this enables them to be grounded & calm. (2) Skill use directly reduced stress & burnout – learn- ing how to man- age emotions & problem solve. Lindo et al. (2015) USA 10 female graduate counselling students. 1 Iranian American 2 African Americans 7 White Americans Phenomeno- logical study - individual interviews. Overload of work. Feelings of isolation. Four themes: (1) Accountability – support received by instructors & peers through regular check-ins. (2) Self-care – estab- lishing wellness goals & imple- menting manage- able strategies. (3) Burnout symp- toms – recognis- ing physical & emotional responses to stress. (4) Healthy coping strategies – activ- ities identified for managing stress like walking, TV, music, exercise, sleep, meditation, eating well & spending time with family. Magnuson et al., (2018) USA 10 highly accomplished leaders in the counselling profession: 6 women, 4 men 2 African Americans 8 Caucasians Mean years of counselling experience: 21. Qualitative - thematic coding. Face-to-face interviews. Contributing factors to burnout not reported. Four themes: (1) Professional passion (2) Engaging in a variety of sti- mulating and challenging activities (3) A balanced life- style – between work and family/ fun activities. (4) Taking care of self. (5) Vacations. (Continued) COUNSELLING PSYCHOLOGY QUARTERLY 13 Table 2. (Continued). Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Mullenbach and Skovholt (2000) USA 10 peers nominated mental health practitioners. Ethnicity, age, and gender were not reported. Qualitative design Semi- structured interviews. Inductive approach Lack of client success. Non reciprocated giving. Overwork. Difficult client behaviours. Discouraged by slow progress. Isolation. Personal issues. Administrative demands. Eight themes: 1. Role limits & boundaries – establishing clear boundaries and limits in role and workplace responsibilities. Growth of confidence with time & mindset of attachment and separation being a natural process. 2. Creating a positive work structure – mentors and enriching peer support, as well as supervision and variety in role (types of clients). Creating an environment that was spacious, aesthetically pleasing, and comfortable. 3. Confront and resolve personal issues. 4. Professional learning. 5. Maintaining balance of professional and personal life 6. Restorative activities – leisure 7. Personal supportive relationships with good friends and family. 8. Internal processes – self-examination, personal therapy. Oser et al., (2013) USA 28 substance abuse treatment counsellors: 36% male; 64% female 10 participants from rural counties; 18 participants from urban counties 11% African American 89% White Grounded theory. Content analysis of audio recordings. Coding and memo writing. Difficult to treat clients. High caseloads. Paperwork. Office politics. Low prestige associated with the job. Three subthemes: (1) Co-worker support (2) Clinical supervision (3) Self-care (Continued) 14 S. DUNCAN AND R. POND statement of findings. The relationship between the researcher and the participants was not always clear. Ethical issues were likely considered but not always reported. All studies were judged to be somewhat or very valuable. Data synthesis findings Utilising thematic analysis, several themes were identified across the studies as factors that prevent, minimise, or manage therapist burnout. These are discussed in turn below. Notably, strategies represented in the themes included drawing on external factors such as supervision, peer support, and positive connections, as well as internal factors, like cognitive strategies (e.g. having a particular perspective, self-awareness), and engagement in personal restorative activities. The importance of having regular breaks and time off, and a work–life balance, was also mentioned as valuable preventative measures. In general, the identified themes fitted under the overarching theme of self-care, which as mentioned earlier, can be defined as an ongoing process of caring for yourself, making a conscious effort to do things to maintain, improve and restore your mental, emotional, physical, and spiritual wellness (Baker & Gabriel, 2021). Self-care requires one to be aware of one’s internal state, identifying personal needs and protecting oneself in the face of difficult work (Baker & Gabriel, 2021; Barnett & Homany, 2022). System-level changes were not a focus of the studies and were infrequently mentioned. Theme 1: time off Eight of the nine articles discussed time off for vacations and breaks through the working day as being very important (Beitel et al., 2018; Grafanaki et al., 2005; Hou & Table 2. (Continued). Source Setting Participant demographics & burnout (when reported) Methodology/ data collection/ analysis Findings: Contributing factors of burnout Findings: Strategies utilised to prevent burnout Warren et al., (2012) USA 298 professional treatment providers (psychotherapists, psychologists, psychiatrists) working with patients who have eating disorders: 92% female, 8% male Mean age: 44.4 years. Mean years of counselling experience 13 years. 88% White American 5% Jewish 4% mixed race 2% Latino/Hispanic 1% Asian/Indian <1% Black/African American Qualitative – thematic coding - inductive approach - open ended questions. Nature of disorder. Patient characteristics. Work related characteristics. Therapist variables (e.g. worry, frustration) 92% of participants reported engaging in self-care as a way of avoiding burnout. Self-care included: ● Exercise ● Social support ● Hobbies ● Taking time off work ● Eating well ● Relaxing ● Detaching from work ● Life/work balance ● Personal time ● Sleeping ● Meditating COUNSELLING PSYCHOLOGY QUARTERLY 15 Ta bl e 3. Q ua lit y fin di ng s of C AS P. St ud y 1. W as th er e a cl ea r st at em en t of t he re se ar ch ? 2. Is t he qu al ita tiv e m et ho do lo gy ap pr op ria te ? 3. W as t he r es ea rc h de si gn a pp ro pr ia te to a dd re ss t he a im s of t he r es ea rc h? 4. W as t he re cr ui tm en t st ra te gy ap pr op ria te t o th e ai m s of t he re se ar ch ? 5. W as t he d at a co lle ct ed in a w ay th at a dd re ss ed th e re se ar ch is su e? 6. W as t he r el at io ns hi p be tw ee n re se ar ch er an d pa rt ic ip an ts b ee n ad eq ua te ly co ns id er ed ? 7. H av e et hi ca l is su es b ee n ta ke n in to co ns id er at io n? 8. W as t he da ta an al ys is su ffi ci en tly rig or ou s? 9. Is t he re a cl ea r st at em en t of fin di ng s? 10 . H ow va lu ab le is th e re se ar ch ? Be ite l e t al . (2 01 8) Y Y Y Y Y N Y Y Y So m ew ha t G ra fa na ki et a l. (2 00 5) Y Y Y ? Y N N Y Y So m ew ha t H ou a nd Sk ov ho lt (2 02 0) Y Y Y Y Y Y Y Y Y Ve ry Je rg en se n (2 01 8) Y Y Y Y Y N ? Y Y So m ew ha t Li nd o et a l. (2 01 5) Y Y Y Y Y Y Y Y Y Ve ry M ag nu so n, N or em , an d W ilc ox in (2 01 8) Y Y Y Y Y Y ? ? Y Ve ry O se r, Bi eb el , Pu lle n, a nd H ar p (2 01 3) Y Y Y Y Y ? ? Y Y So m ew ha t M ul le nb ac h an d Sk ov ho lt (2 00 0) Y Y Y Y Y ? ? Y Y Ve ry W ar re n, Sc ha fe r, Cr ow le y, an d O liv ar di a (2 01 2) Y Y Y Y Y ? ? Y Y Ve ry Y = y es ; N = n o; ? = c an ’t te ll. 16 S. DUNCAN AND R. POND Skovholt, 2020; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Oser et al., 2013; Warren et al., 2012). Magnuson et al., Oser et al., and Warren et al. spoke specifically of the need to take vacations to enable therapists to completely detach from work and maintain much-needed work–life balance. Ninety-two per cent of respondents in Warren et al. said taking time off, engaging in leisure activities and going on vacation were forms of self-care that avoided burnout. Twenty-six per cent of participants in Beitel et al. said it was important to take paid days off to relax and 23% said setting aside times to take breaks during the workday was helpful. One participant in the same article mentioned they had “learned at least a few times a day to shut my office door and just kind of take a breather” (p. 214). Another participant said, “taking time off, that’s helpful and I always feel supported in that” (p. 213). Theme 2: leisure activities Eight out of nine studies mentioned that participating in activities that are enjoyable and not work-related helps to prevent burnout (Beitel et al., 2018; Grafanaki et al., 2005; Hou & Skovholt, 2020; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Oser et al., 2013; Warren et al., 2012). In Beitel et al., 52% said engaging in pleasurable activities prevented burnout. “I do a lot of cooking. I love baking. I enjoy spending time with my pets” (p. 213). In Lindo et al., participants acknowledged the importance of self- care activities that were adaptable to their personal lives and preferences. For some, this involved socialising with friends, and for others it was scheduling in more alone time: “I choose to socialise with friends; I tend to stay at home; just having more time for me” (p. 37). Magnuson et al. confirmed the importance of looking after oneself by engaging in a variety of pursuits, “I take care of me. Music. I get a massage every two weeks, a manicure every week. I do yoga” (p. 22). Multiple leisure activities were also mentioned in Mullenbach and Skovholt: “I love mystery stories; I like movies; I love sports; I do a lot of knitting and crocheting” (p. 238). The range of activities that participants utilised across the studies varied and incorporated different things for different people. For most of the participants in Grafanaki et al., leisure was the path that led to a more balanced and meaningful life. Theme 3: exercise Exercise was mentioned in six of the nine studies (Beitel et al., 2018; Grafanaki et al., 2005; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Warren et al., 2012). This included yoga, walking, swimming, kayaking, and gardening. A participant in Mullenbach and Skovholt reported, “[It is helpful] doing things personally like physical kinds of things . . . There are some days when I just feel I need to go out and kick something and just kind of biking real hard or walking real fast” (p. 238). A participant of another study mentioned, “Things that help me cope . . . yoga after work . . . kayaking that’s also very relaxing for me” (Beitel et al., 2018, p. 213). In another study, a participant said, “I would spend 30 minutes a day doing physical activities or going outdoors with my son” (Lindo et al., 2015, p. 38). Lindo et al. suggest that exercise is a way of decompressing and Beital et al. suggest that it is a way to relax. COUNSELLING PSYCHOLOGY QUARTERLY 17 Theme 4: perspective This theme comprised a perspective that practitioners possessed, including their values, worldview, and cognitive mindset towards their profession, that prevented or mitigated burnout. This theme was common in eight out of nine studies (Beitel et al., 2018; Grafanaki et al., 2005; Hou & Skovholt, 2020; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Oser et al., 2013; Warren et al., 2012). Knowing one’s values/beliefs supported practitioners to be grounded in their perspective and enabled them to have faith and hope despite the ambiguity they are faced with in sessions. “I think I have a really core belief that every person has within themselves what they need to change and get better” (Hou & Skovholt, 2020, p. 394). “I feel like I have the ability to see beyond the suffering and see the beauty in people and wholeness” (Hou & Skovholt, 2020, p. 394). Trusting in the therapeutic process and embracing a hopeful perspective was something resilient practitioners possessed (Mullenbach & Skovholt, 2000). Participants also spoke of being positive, and loving their job (Magnuson et al., 2018; Mullenbach & Skovholt, 2000). Loving and finding interest in their work and being passionate about their profession was a deterrent to burnout: “I think just loving it and doing what I do” (Magnuson et al., 2018, p. 21). Highly resilient practitioners (Mullenbach & Skovholt, 2000) developed attitudes that preserved professional vitality, viewing attach- ment and separation with clients as a natural process. Resilient practitioners had a hopeful, positive, and optimistic perspective, believing the client has what they need to make change (Hou & Skovholt, 2020). Warren et al. (2012) discussed the importance of not taking oneself too seriously and maintaining a sense of humour. Theme 5: formal and informal support & connections Support received through various connections was mentioned in eight of the nine articles reviewed (Beitel et al., 2018; Grafanaki et al., 2005; Hou & Skovholt, 2020; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Oser et al., 2013; Warren et al., 2012). Connecting with family, friends, colleagues, and supervisors was a buffer to burnout and enabled therapists to maintain wellness and enjoy life (Hou & Skovholt, 2020). Hou and Skovholt studied the characteristics of highly resilient therapists and found connected- ness was the driving force enabling resilience. Their participants reported that personal and professional connections were crucial: “If I cannot talk to people and be close to people, have friendships and close relationships with my family, I suffer for that. If I do those things, I am well connected, and my life is good” (Hou & Skovholt, 2020, p. 391). A participant in another study said “We do a lot of family celebrations. Socializing, having people over for dinner” (Mullenbach & Skovholt, 2000, p. 240). Participants in Oser et al. (2013) study talked about the importance of being able to go to colleagues to bounce ideas around about challenges and to help each other out. Support from colleagues was imperative, as they often recognised warning signs of burnout and offered suggestions of how to alleviate it (Ose et al., 2013). Networking with colleagues at professional development was seen as more beneficial than the content of the workshop itself (Magnuson et al., 2018) and staff-wide encounters where participants were given opportunities to connect was something participants asked for 18 S. DUNCAN AND R. POND more of (Beitel et al., 2018). Lindo et al. (2015) spoke of the importance of connecting with colleagues and family through regular check-ins. Supervision was useful for minimising burnout for one third of participants in Warren et al. (2012) study. Forty-two per cent recommended beginning therapists utilise super- vision to prevent burnout. Participants in Oser et al. (2013) reported that burnout could be prevented through both co-worker support and clinical supervision. Counsellors in Beitel et al. (2018) emphasised the importance of supervision for reducing stress and gaining perspective and recommended it as a system-level change to prevent burnout. Theme 6: boundaries & balance Work/life balance and boundaries were an important factor across the studies in prevent- ing burnout. Therapists reported the ameliorative effects of establishing and maintaining work–life balance (Beitel et al., 2018). It was considered important in six of the nine articles to have clear boundaries around role limits, levels of responsibility and caseloads (Beitel et al., 2018; Grafanaki et al., 2005; Jergensen, 2018; Magnuson et al., 2018; Mullenbach & Skovholt, 2000; Warren et al., 2012). Beitel et al. found that it was vital for counsellors to leave work at work in order to engage in self-care and pleasurable activities outside of employment. Leisure brought equilibrium and balance for practitioners (Grafanaki et al., 2005). Lindo et al. (2015) referred to balance as the key to maintaining wellness. Setting boundaries, self-preservation, and being aware of one’s limitations was essential in maintaining resiliency (Hou & Skovholt, 2020). Balancing caseloads and having boundaries around hours worked per week was highlighted as important in Warren et al.: “I cancel a day of clients if I’m really spent” (p. 184). Therapists who are early in their career were encour- aged to maintain a work/personal life balance through taking time off, engaging in self- care and maintaining boundaries (Warren et al., 2012). Finally, counsellors in leadership roles with at least 15 years’ experience added, “I’ve tried to stay balanced as best I can, I try to put my family first, my professional activities come after that” (Magnuson et al., 2018, p. 22). Theme 7: awareness/mindfulness Awareness is the state or condition of being aware or conscious, to be informed and alert; similarly, mindfulness is the state of being mindful or aware of something (Dictionary. com, 2021). Seven of the nine studies mentioned either being mindful or having aware- ness as a factor that prevented burnout (Grafanaki et al., 2005; Hou & Skovholt, 2020; Jergensen, 2018; Lindo et al., 2015; Mullenbach & Skovholt, 2000; Oser et al., 2013; Warren et al., 2012). Practitioners encountered internal and external stressors and having an awareness of how these stressors impacted oneself was essential (Mullenbach & Skovholt, 2000). Through involvement in the therapeutic process, personal issues could emerge, and it was considered critical that practitioners were aware when this happened so that they could work through what arose. Being aware of what as happening internally enabled practitioners to be conscious of their well-being and need for self-care. This awareness also aided therapists to support and assist clients in their journey of self-care (Lindo et al., 2015). COUNSELLING PSYCHOLOGY QUARTERLY 19 Awareness also included early career therapists being aware of who held the respon- sibly for change: “there’s only so much you can do, and the client has to be working as well” (Warren et al., 2012, p. 187). In Oser et al. (2013), participants highlighted the importance of being mindful of what is going on internally, whether one was tired, in need of a vacation or needed to debrief with a co-worker. Being mindful of one’s internal state enabled therapists to recognise when it was time to step back, take a break or seek support; doing so was found to prevent burnout. Jergensen (2018) found that mind- fulness was the skill that practitioners utilised most. Being mindful or aware enabled therapists to be present in daily life, aware of what was transpiring in the outside world as well what was going on internally. Engaging in activities such as mindfulness enabled participants to be deeply con- nected with self, contributing to increased self-awareness (Jergensen, 2018). The ability to connect with oneself was important and facilitated therapists to be honest and recognise when they were not a good fit for clients. Through this awareness decisions were made that enabled therapists to do what was needed for both the client and themselves. In Jergensen, respondents discussed the power and benefits of mindfulness practice: “mind- fulness has helped me a great deal in terms of slowing down my thoughts at times and helping me get grounded; mindfulness has been key to my stress management; it has also helped me with setting boundaries”; “mindfulness has been the core to becoming more aware of my emotions and relationships and where I want them to be” (p 195). Awareness and mindfulness can be considered cognitively oriented strategies that support self-care and burnout-prevention. Theme 8: spirituality/meditation Some form of spiritual connection was mentioned in five of the nine articles (Grafanaki et al., 2005; Hou & Skovholt, 2020; Lindo et al., 2015; Oser et al., 2013; Warren et al., 2012). In Hou and Skovholt, participants described having a strong connection with their own world view. This gave them a way of understanding themselves, others and human suffering and helped them make meaning of challenges they faced at work and in their personal lives. “There’s a spiritual belief in the wholeness of a person that is suffering . . . it keeps me very hopeful and grounded because it’s connection with beauty; it’s a connection with wholeness, and it’s spiritual” (p. 394). In Lindo et al. (2015), several participants referred to relaxation and meditative activ- ities, acknowledging that when they feel burnout, they “take a little time for meditation, that kind of stuff . . . , and just give me time to decompress” (p. 38). Participants in Grafanaki et al. (2005) mentioned that taking moments to engage in leisure enabled them to have spiritual moments where they felt connected to something bigger and were able to “come closer to their spirituality” (p. 35). This spirituality, which consisted of meditation and prayer, gave participants a greater sense of balance, purpose, and mean- ing in their lives, bringing them closer to others. Warren et al., (2012) mentioned spiri- tuality, although it was less endorsed by participants, and Oser et al., (2013) mentioned meditation as a form of self-care but did not elaborate. Grafanaki et al., Hou and Skovholt (2020), and Warren et al., (2012) reported some sort of faith, spirituality, and/or something bigger than themselves; that this connection kept participants grounded. 20 S. DUNCAN AND R. POND Theme 9: professional growth and use of clinical skills Six of the nine studies mentioned engaging in professional activities and/or using clinical skills as a way of minimising burnout (Beitel et al., 2018; Hou & Skovholt, 2020; Jergensen, 2018; Lindo et al., 2015; Magnuson et al., 2018; Mullenbach & Skovholt, 2000). Nine of the 10 participants in Hou and Skovholt indicated that it was their love of learning that enabled them to be resilient, embrace a growth mindset and be lifelong learners. “Participants kept wanting to know more and were determined to do a better job” (Hou & Skovholt, 2020, p. 394); “I focus on learning to become the best couple’s therapist I could be” (p. 393). A love of learning and a curiosity towards new knowledge was found to be common factor for resilient practitioners (Hou & Skovholt, 2020; Magnuson et al., 2018). Lindo et al. mentioned that setting goals and reporting on how well therapists thought they were doing were useful, as this kept them on track and accountable. One of the dominant themes in Jergensen’s (2018) study was the application of clinical skills. The use of DBT skills helped in work and life and was found to directly reduce therapists’ levels of stress and burnout. “They allow me to continue to work effectively without burning out. They also help me recognize when I am feeling burned out and provide me with concrete ways to manage emotions and problem solve” (p. 195). Beitel et al. (2018) referred to applying clinical skills to oneself as being useful for preventing burnout: “I always try to do the same things I recommend to clients” (p. 214). System-level changes In addition to self-care, system level or organisational changes were reported, albeit in only one study (Beitel et al., 2018). This study reported four system-level changes that were helpful in preventing and/or managing burnout: (1) facilitating staff wide encounters, e.g. “I think trainings help us . . . Also having moments where staff can get together during work time” (p. 214); (2) improved communication between management and staff including affirming counsellor input, e.g. “I think validating the staff helps too” (p. 214); (3) increased accessible paid time off, e.g. “I know for some people an extra day off of their own choosing is very helpful for them to not be burnt out” (p. 214), and (4) enhanced supervision, e.g. “having teams of supervisors meet more frequently might reduce burnout” (p. 214). Table 4 shows the studies that each theme was evident in. Discussion The present systematic review drew on the experiences and perspectives of 542 therapists in nine qualitative studies and identified several useful strategies practitioners utilise to prevent and manage burnout. Most of the strategies can be considered forms of self-care (Baker & Gabriel, 2021), such as time off, engaging in leisure activities, exercise, having work/life balance, and getting the support needed from a supervisor, colleague, and family or friends. Other self-care strategies, like personal awareness, a constructive per- spective, spirituality/meditation, and an investment in professional growth and use of clinical skills were also common themes across the included studies. Only one study reported on system level or organisational changes that were helpful in preventing burnout. COUNSELLING PSYCHOLOGY QUARTERLY 21 Ta bl e 4. P re se nc e of t he m es a cr os s st ud ie s. Th em e Be ite l e t al . (2 01 8) G ra fa na ki e t al . (2 00 5) H ou & S ko vh ol t (2 02 0) Je rg en se n (2 01 8) Li nd o et a l. (2 01 5) M ag nu so n et a l., (2 01 8) M ul le nb ac h an d Sk ov ho lt (2 00 0) O se r et a l., (2 01 3) W ar re n et a l., (2 01 2) Ti m e off ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Le is ur e ac tiv iti es ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Ex er ci se ✓ ✓ ✓ ✓ ✓ ✓ Pe rs pe ct iv e ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Su pp or t & c on ne ct io ns ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Bo un da rie s & b al an ce ✓ ✓ ✓ ✓ ✓ ✓ ✓ Aw ar en es s/ m in df ul ne ss ✓ ✓ ✓ ✓ ✓ ✓ ✓ Sp iri tu al ity /m ed ita tio n ✓ ✓ ✓ ✓ ✓ Pr of es si on al g ro w th & u se o f cl in ic al s ki lls ✓ ✓ ✓ ✓ ✓ ✓ 22 S. DUNCAN AND R. POND These findings add to the body of literature about the use of self-care strategies for preventing burnout. Rupert et al., (2015) narrative review of quantitative (cross- sectional, correlational) studies suggests that a range of self-care activities play an important role in fostering a positive attitude towards work and are a valuable resource in the prevention of burnout. The role that self-care strategies play in reducing stress seems particularly important. For example, Hricová (2020) found that self-care helps reduce stress and all three domains of burnout (exhaustion, depersonalisation, and diminished personal accomplishment) for helping profes- sionals. Furthermore, Rupert and Dorociak’s (2019) recent study found that several self-care strategies (professional support, professional development, life balance, cognitive awareness, and daily balance) predicted lower stress, and subsequently less burnout and higher life satisfaction for psychologists. Importantly, their findings indicate that proactive and ongoing engagement in multiple forms of self-care is particularly important in reducing stress and preventing the progression to burnout; that self-care is less effective once stress has built up (Rupert & Dorociak, 2019). Hence, the self-care strategies identified as helpful in the present systematic review are best used together in an intentional, ongoing, and preventative way (Barnett & Homany, 2022). The self-care burnout prevention strategies identified across the studies can be considered in relation to the Job Demands–Resource model (Demerouti et al., 2001). This model proposes that reducing job demands and increasing resources decreases the likelihood of burnout. Some identified strategies would reduce the demands and associated stress of the job, for example: taking time off for breaks during the day or having vacations; maintaining boundaries and a healthy work–life balance; and having a perspective of hope and optimism for clients and trusting in the therapeutic process (instead of feeling solely responsible for unrealistic levels of client change). Some of the self-care strategies can be considered job-related resources, for example: formal supervision and support from colleagues; engaging in professional activities and using clinical skills for oneself. Finally, some of the self-care strategies can be considered personal resources, for example: being aware of the effect of stressors and the need to take action that will support health and wellbeing; drawing on spiritual beliefs or practices or engaging in meditation; connecting with family and friends. The system-level/organisation changes mentioned in one study would also alleviate demand (e.g. having a paid day off when required) or increase resources (e.g. quality supervision). There is some quantitative evidence for specific self-care strategies. For exam- ple, while Rupert and Dorociak’s (2019) study found several self-care strategies effective, three stood out in particular: life balance (cultivating relationships and activities outside of work), cognitive awareness (monitoring work stress and reac- tions), and daily balance (structuring the day and managing demands). Johnson et al. (2020) found a small, significant association between supervision and burnout, specifically quality (but not frequency) of supervision and the disengagement (but not emotional) dimension of burnout. A meta-analysis that quantitatively examined the antecedents and consequences of burnout (Lee et al., 2011) indicated a need to use a range of ways to deal with psychotherapist burnout symptoms due to the effect that different strategies have on the different dimensions of burnout. In COUNSELLING PSYCHOLOGY QUARTERLY 23 particular, they recommended that reducing job demands by reducing caseloads and maintaining appropriate boundaries may be particularly effective for reducing emotional exhaustion, while strengthening resources through peer support, super- vision, and professional development opportunities may improve depersonalisation and personal accomplishment. However, putting too much emphasis on employees utilising self-care strategies to prevent and manage burnout has been critiqued, as it shifts responsibility from employers (Moss, 2020). Awa et al. (2009) reviewed a total of 25 quantitative studies (consisting of person-directed and organisation-directed burnout preven- tion strategies) and found that 82% of person-directed interventions led to a substantial reduction in burnout. While person-directed interventions reduced burnout in the short term (approximately 6 months), they found that a mix of person and organisation-directed interventions had a greater lasting positive impact. Clearly, the organisations in which counsellors and related professional work also need to initiate strategies to reduce burnout. Implications for clinic practice and training Ongoing engagement in self-care is important to maintain and promote practi- tioner wellbeing and meet professional responsibilities (e.g. American Counseling Association, 2014). It is hence critical that training programmes, such as counsellor education, create a culture of self-care (Barnett & Coooper, 2009) early on, by informing training therapists about the potential for burnout, equipping them with self-care strategies to help prevent and manage it, and role-modelling self- care. The self-care strategies identified in this systematic review and other publica- tions (e.g. Barnett & Homany, 2022) offer a range of options that can be encour- aged and practised in an intentional, integrated, and ongoing way. Indeed, some of these – specifically formal and informal support and professional growth – will be facilitated through ethical requirements that therapists participate in formal super- vision and professional development (e.g. American Counseling Association, 2014; British Association for Counselling and Psychotherapy, 2016, New Zealand Association of Counsellors, 2020; New Zealand Association of Psychotherapists, 2018). Even the most knowledgeable, well-trained professionals may benefit from learning about or being reminded of these self-care strategies, so that they resi- liently flourish in their roles. Organisations also need to take an active role in burnout prevention (Maslach, 2017). As well as promoting self-care through regular training and professional development (Via et al., 2020; Yang & Hayes, 2020), policies and strategies could address the demands in the workplace by ensuring counsellors have a fair and sustainable workload, meaningful work opportunities, some choice and control, a supportive work community, sufficient resources to do their role well, and recognition and reward (including being valued and appreciated) (Maslach, 2017). 24 S. DUNCAN AND R. POND Strengths and limitations Overall, the quality of the included studies was good, offering credible insight into what therapists do to prevent, minimise, or manage burnout. However, a substantial limitation is the lack of reported data on what organisations need to do to prevent burnout, especially considering burnout is strongly related to the demands placed on workers. Also, the research participants in the included studies tended to represent a specific geographic location (North America), gender (mostly female) and ethnicity (mostly white Americans). Therefore, it is difficult to conclude that the identified self-care strategies are the only relevant strategies for male, indigenous, and minority therapists in the United States and other countries. There are also limitations associated with the systematic review itself. Despite the effort to find all relevant studies, it is always possible that a study was missed. Considering the similarity of findings between the studies, it is questionable, however, whether an omitted study would have added anything new or different to the findings. Additionally, the steps of the systematic review (e.g. search, screening, quality assessment) were mostly carried out by one researcher (the first author), although the process and various issues were discussed often with the second author, and the developed themes were jointly considered to mitigate personal bias. Recommendations for future research Future research needs to identify personal and organisation burnout prevention strategies that are preferred and align with the cultural identity of culturally diverse therapists. This will support retention in the profession, which is critical for support of culturally diverse client groups. For example, in New Zealand, where the authors are based, Māori/indigenous counsellors may have culturally meaningful ways of preventing burnout and enhancing wellbeing. Identifying these and promoting them (alongside other burnout strategies) may contribute to retaining Māori coun- sellors and psychologists in the workforce (Hemopo, 2004). Research about burnout vulnerabilities and prevention strategies following the COVID-19 pandemic also deserve investigation considering the increased use of online therapy. Determining whether burnout prevention strategies need to be tailored for practitioners working with different client groups and in different settings (e.g. private practice, school, clinic, community organisation, or hospital setting) may also be useful. Future research is also needed about how the curriculum of therapy training pro- grammes can best prevent burnout of therapists in training (and long-term) (Wardle & Mayorga, 2016; Yang & Hayes, 2020). This is especially important considering the criticism that trainee counsellors (and potentially other therapists) are not sufficiently informed about the emotional stress and impact of working in the therapeutic profession (Barton, 2019). COUNSELLING PSYCHOLOGY QUARTERLY 25 Conclusion Therapists have limited control over external factors when working for an organisation, however there are strategies that they can employ to manage the demands of the job and buffer the effects of stress to prevent burnout. Looking after oneself through the various forms of self-care identified in this systematic review (such as having regular time off, engaging in leisure activities, and ensuring one has sufficient support and is well connected) is critical to surviving and thriving in the therapist role. It also has a positive flow on effect for clients, organisations, and others in therapists’ lives. Notably, organisations must also put in place measures that prevent and manage burnout. Further research is required to better understand burnout strategies for culturally diverse therapists. Disclosure statement No potential conflict of interest was reported by the author(s). Notes on contributors Sancia Duncan has a Master of Counselling Studies and Postgraduate Diploma in Education (Counselling and Guidance) from Massey University. She worked as a school counsellor before shifting into private practice. Alongside her private practice, she manages the Kapiti Loss & Grief Centre. Sancia is trained in a pluralistic approach and works with young people through to the elderly. Sancia is passionate about supporting organisations and individuals who work in the helping profession to prevent burnout. Dr. Rachael Pond coordinates student research in the Master of Counselling Studies programme at Massey University. She is committed to fostering research relevant to contemporary counselling practice, and has co-authored several systematic reviews with graduates. 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POND https://www/10.1080/10640266.2012.668476 https://www/10.1080/10640266.2012.668476 https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases https://www/10.1037/pst0000317 Abstract Definition of burnout Explanations of burnout Causes of burnout specific to therapists Preventing and managing burnout Research aim Methods Search strategy Inclusion and exclusion criteria Data extraction Quality appraisal Data synthesis Ethics Results Selection of studies Characteristics of the included studies Quality of included studies Data synthesis findings Theme 1: time off Theme 2: leisure activities Theme 3: exercise Theme 4: perspective Theme 5: formal and informal support & connections Theme 6: boundaries & balance Theme 7: awareness/mindfulness Theme 8: spirituality/meditation Theme 9: professional growth and use of clinical skills System-level changes Discussion Implications for clinic practice and training Strengths and limitations Recommendations for future research Conclusion Disclosure statement Notes on contributors References