Received: 30 January 2023 Revised: 28 June 2023 Accepted: 28 August 2023

DOI: 10.1002/cpp.2909

COMPREHENSIVE REVIEW

The emotionally exhausted treating the mentally unwell?

A systematic review of burnout and stress interventions for
psychologists

Caitlin Bell 1 | Genevieve L. R. Roberts 1 | Prudence M. Millear 1 |

Andrew Allen 1 | Andrew P. Wood 1 | Lee Kannis-Dymand 1 |
Celine M. Jona 1 | Jonathan Mason 2

1
School of Health, University of the Sunshine
Coast, Sippy Downs, Australia Abstract
2
Faculty of Psychology, Counselling and Healthcare providers are at high risk of occupational burnout, which has negative
Psychotherapy, Cairnmillar Institute, Hawthorn
East, Australia
implications on the individual, their profession, the organisation and their patients.
Psychologists are particularly susceptible to the repercussions of burnout due to the
Correspondence
Jonathan Mason, Faculty of Psychology, emotionally draining nature and content of their work. However, research has failed
Counselling and Psychotherapy, Cairnmillar to outline and evaluate effective interventions for burnout within the profession. This
Institute, 391-393 Tooronga Rd, Hawthorn
East, Victoria 3123, Australia.
study aimed to investigate the treatment effectiveness of burnout through a system-
Email: [email protected] atic literature review. Systematic searches of four databases using Preferred Report-
ing Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were
conducted. A total of 4832 articles were identified, and 15 were included in the final
analysis. The search was limited to scholarly and peer-reviewed journals published in
the English language, which measured and utilised a form of intervention for the
treatment of burnout or stress and included participants within the psychology pro-
fession. Interventions identified included mindfulness, training courses, self-care and
other therapy-based forms of interventions. Approximately 60% of study participants
reported moderate to high levels of stress. Interventions were largely variable in
modality, frequency and duration of sessions and follow-up period. Of the 15 studies
included within the review, only four measured burnout as an outcome variable,
while the others measured stress. Findings of this systematic review indicate that
mindfulness-based interventions may be a starting point for reducing stress; how-
ever, the most effective intervention for psychologists who have reached burnout is
largely unclear. It is recommended that future studies focus on the identification and
measurement of burnout, are more rigorously designed and reported and consider
peer-based online support approaches.

KEYWORDS
burnout, mental health, psychological interventions, psychology, stress

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1 | I N T RO DU CT I O N
Key Practitioner Message
Occupational stress and burnout are global phenomena. While
• Psychologists are at high risk of stress and occupational
transient occupational stress is inevitable and not necessarily harmful,
burnout due to the emotionally demanding nature of the
the implications of burnout are more serious, impacting both the
profession.
worker and the delivery of high-quality healthcare. Whereas stress
• Only 15 studies have attempted to provide an interven-
can usually be understood as the short term psychological and physio-
tion for stress and burnout.
logical wear and tear that occur when workplace demands temporarily
• While mindfulness-based interventions show promise,
outweigh an individual's perceived coping resources (Lazarus &
further research is required to understand the most suc-
Folkman, 1984), chronic experiences of this nature can lead to burn-
cessful and effective interventions for the management
out. This is commonly understood as a combination of exhaustion,
of stress and burnout in psychologists.
cynicism and mental detachment towards one's job, resulting in
decreased professional efficacy (WHO, 2019; Maslach et al., 1997;
Maslach & Jackson, 1981). The 11th Revision of the International
Classification of Diseases (ICD-11) has recently included and classified
occupational burnout as ‘a syndrome conceptualized as resulting from Tyler, 1992; Skovholt & Rønnestad, 2003; Vredenburgh et al., 1999).
chronic workplace stress that has not been successfully managed’ The uniqueness and complexity of individual client presentations
(World Health Organization [WHO], 2022). results in high rates of ambiguity relating to diagnosis, ethical decision
Maslach and Jackson (1981) conceptualised burnout as compris- making and treatment which, particularly for a novice clinician, can be
ing emotional exhaustion, depersonalisation and reduced personal associated with significant stress (Pica, 1998; Skovholt &
accomplishment, resulting from prolonged stress in the workplace. Rønnestad, 2003). Moreover, the skills required for the practice of
The first concept, emotional exhaustion, refers to feelings of emo- professional psychology are gained through a demanding level of per-
tional depletion and lack of emotional resources, causing the worker sonal investment and intense study, involving the juggling of multiple
to feel as though they are no longer capable of giving themselves at a competing demands of theory acquisition, clinical research, consulta-
psychological level (Maslach et al., 1997). The second, depersonalisa- tion and practice, professional development, all while being regularly
tion, refers to negative, cynical attitudes towards one's feelings, assessed for proficiency (Schwartz-Mette, 2009).
patients or work in general. Lastly, personal accomplishment describes High levels of occupational stress and burnout may also impact
the tendency to evaluate oneself and work negatively (Maslach & service provision. Burnout has been noted to reduce a practitioner's
Jackson, 1981; Stalker & Harvey, 2002). While stress does not neces- ability to establish strong rapport with their clients (Enochs &
sarily equate to distress, impairment or burnout if managed effec- Etzbach, 2004), which is known to be a vital component of the psy-
tively, it is presumed that chronically high levels of stress increase the chotherapy process. With a crucial element of therapy being able to
risk of burnout (Barnett et al., 2007; Myers et al., 2012). Importantly, appropriately respond to the emotional demands of others, it is con-
burnout is not an endpoint from which there is no return; on the con- cerning that emotional exhaustion has been the most commonly
trary, individuals can use preventative strategies to reduce the chance reported dimension of burnout amongst psychologists (McCormack
of burnout or implement strategies to reverse the effects of burnout et al., 2018). Furthermore, stress and burnout can impede ethical
(Kristensen et al., 2005). decision-making, increasing the incidence of harmful boundary viola-
Due to the emotionally taxing job requirements inherent in the tions (Barnett & Cooper, 2009). Overall, the high degree of stress and
profession, psychologists are at high risk of occupational stress and burnout in psychologists has important ramifications for the effective
burnout (Dattilio, 2020; Rupert et al., 2015). Over half of psycholo- and ethical provision of care.
gists experience at least moderate-high levels of job-related stress While other reviews have highlighted the aetiology, prevalence
(Hannigan et al., 2004; Simionato & Simpson, 2018); given that and implications of stress and burnout (e.g., Hannigan et al., 2004;
prolonged, chronic stress is the main predictor of burnout McCormack et al., 2018; Simionato & Simpson, 2018), relatively little
(Maslach, 2003), it is unsurprising that more than one in five of attention has been given to the treatment of burnout in psychologists,
Australian psychologists also report personal and work-related burn- and no research to date has examined the most effective interven-
out (Di Benedetto & Swadling, 2014). The high rates of occupational tions for burnout. This is surprising given the alarming rates of stress
stress and burnout are concerning for individual practitioners, their cli- and burnout reported in psychologists and the potential detrimental
ents and the psychology professional more widely. impact on clinical practice. Developing a better understanding of the
More broadly, burnout has been linked to an increased risk of most effective and successful interventions for burnout has implica-
anxiety and depression (Radeke & Mahoney, 2000; Tyssen tions for the ability to treat and hopefully prevent burnout in
et al., 2001), reduced self-esteem (Butler & Constantine, 2005) and psychologists.
disrupted personal relationships (Myers, 2013; Rupert et al., 2009). The purpose of this systematic review was to examine the exist-
Significant levels of stress are also reported amongst psychologists in ing literature on psychological interventions for burnout and stress in
training and in the earlier stages of their career (Cushway & professional psychologists and to provide a synthesis and appraisal of
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BELL ET AL. 3 of 14

this research. The objectives were (1) describe the psychological inter- mental health care worker OR psychotherapist*), burnout (work
vention approaches for burnout in psychologists and (2) evaluate the related stress OR burnout OR stress) and interventions used
evidence of current intervention approaches for burnout. (psychotherapy* OR programme OR intervention OR treatment OR
therapy OR reduc* OR manag*). The search was limited to scholarly
and peer-reviewed journals and published in the English language.
2 | METHODS Index terms searched were limited to text within title headings and
abstracts. A PRISMA flowchart of the search strategy, depicting the
The systematic review was conducted in accordance with the selection of articles, is presented in Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-analysis
(PRISMA) guidelines (Page et al., 2021). No ethical approval was
required for the systematic review as no recruitment of participants 2.2 | Study selection and eligibility criteria
was necessary.
Studies were eligible for review if they met the following criteria:
(a) utilised a form of intervention for the treatment of burnout or
2.1 | Data sources and search strategy stress, (b) measured burnout or stress and (c) included participants
within the psychology profession or academic pathway (viz., psychol-
Electronic database searches were performed in August 2020, using ogy professionals, or psychology graduate or undergraduate students).
PsychInfo, PsychArticles, Scopus and Proquest psychology database. Studies that analysed data using purely qualitative methods were
An updated search was completed in November 2022, which revealed excluded as changes in mean stress and/or burnout scores were not
no additional empirical studies to meet the inclusion criteria. The able to be analysed and compared. Studies were eliminated if they
search was conducted using terms related to psychologists examined various mental health professionals where the data for psy-
(psychologist* OR psychology student* OR psychology trainee OR chologists were not distinguishable. No date restrictions were applied.

F I G U R E 1 PRISMA flowchart detailing the

study selection process.
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4 of 14 BELL ET AL.

2.3 | Data extraction and analysis reported or unable to be categorised into severity levels for 4 out of
11 studies measuring stress (Hopkins & Proeve, 2013; Moyer
Titles and abstracts of the search results were reviewed for inclusion. et al., 2017; Pakenham, 2015; Stafford-Brown & Pakenham, 2012). Of
Upon articles being deemed relevant, full text screening occurred to the four studies that considered burnout, participants in three studies
assess the records against the eligibility criteria. Data extracted reported burnout in the moderate to high range (Eriksson et al., 2018;
from the relevant articles consisted of population information Reyes Ortega et al., 2019; Robins et al., 2019). All studies were pub-
(i.e., participants and setting), study design, measures used, (including lished in peer reviewed journal articles.
those related to burnout and stress and other non-related measures),
the type of intervention used (e.g., duration and frequency), character-
istics relating to intervention fidelity (e.g., was it manualised), statisti- 3.3 | Methodological considerations
cal analysis and results.
The initial search yielded a total of 4831 articles. Duplicates were The studies identified for the systematic review were assessed for key
removed using Endnote. The final data extraction process was inde- sources of bias, the results of which are presented in Table 3. Two
pendently conducted by author CB, with additional consultation with authors worked independently to determine the applicability of
a second reviewer (GR) where necessary. several factors known to impact bias for each study included in the
systematic review. The overall quality of the studies used are pre-
sented in the table (low, moderate or high risk of bias) and were
3 | RESULTS reviewed and agreed upon by the authors of the paper. Authors used
The Revised Cochrane Risk of Bias tool for randomised trials (RoB 2;
3.1 | Search results Sterne et al., 2019) and the Risk Of Bias In Non-randomised Studies
of Interventions (ROBINS- I; Sterne et al., 2016) as guidelines to
A total of 4831 records were retrieved and evaluated for inclusion determine the level of bias present in articles included for the system-
or exclusion. Following removal of duplicates (n = 255) and reports atic review. For example, Sterne et al. (2016) determined bias for
that were clearly not relevant to the area of study (n = 4498), missing data (attrition bias) as low risk if the study met the following
78 studies remained. Sixty-three were subsequently removed follow- criteria: data were reasonably complete; proportions of and reasons for
ing full text review against the inclusion criteria (see Figure 1). missing participants were similar across intervention groups; or the analy-
Table 1 provides a brief description of characteristics for each sis addressed missing data and is likely to have removed any risk of bias.
included study (n = 15). Table 2 provides additional characteristics of Further details on how to assess risk of bias are outlined by the RoB-2
each study. and ROBINS- I (Sterne et al., 2016, 2019).
Ten of the 15 included studies reported statistically significant
differences based on stated hypotheses or research questions, but
3.2 | Study characteristics only eight also reported effect sizes (see Table 1). Where possible,
effect sizes (Standardised Mean Difference) for those studies that did
The majority of studies were either conducted in the United States not report them were calculated separately by the last author. Miller
(Burkhart, 2014; Call et al., 2014; Cohen & Miller, 2009; Miller et al.'s (2017) participant stress levels significantly increased rather
et al., 2017; Moyer et al., 2017) or Australia (Finlay-Jones et al., 2017; than decreased (d = 0.84), and both Packenham's (2015) participants
Hopkins & Proeve, 2013; Pakenham, 2015; Robins et al., 2019; (d = 0.26) and Burkhart's (2014) participants (d = 0.11) also experi-
Stafford-Brown & Pakenham, 2012), with respective studies con- enced a small increase in stress, confirming the non-significant find-
ducted in England (Rimes & Wingrove, 2011), Brazil (Damásio ings reported in their studies. Despite small participant numbers,
et al., 2014), Sweden (Eriksson et al., 2018), Mexico (Reyes Ortega Rimes and Wingrove's (2011) data indicated stress reductions in their
et al., 2019) and Italy (Cozzolino et al., 2020). The sample size across first-year clinical psychology trainees (d = 0.59), but less impact in
all studies was 730 participants, sourced from universities and the the second year (d = 0.23) and an increase in stress in the third year
psychology community. The majority of participants in the studies (d = 0.65), despite the ongoing intervention. Effect sizes were not
examined were female. Four studies measured burnout (Damásio able to be calculated for the Cozzolino et al. (2020), Hopkins and
et al., 2014; Eriksson et al., 2018; Reyes Ortega et al., 2019; Robins Proeve (2013) or Moyer et al. (2017) studies due to the absence of
et al., 2019), and 11 studies measured stress (Burkhart, 2014; Call reported means and standard deviations for stress or burnout scores.
et al., 2014; Cohen & Miller, 2009; Cozzolino et al., 2020; Finlay- Generally, studies reported unclear or relatively large attrition figures,
Jones et al., 2017; Hopkins & Proeve, 2013; Miller et al., 2017; Moyer but selection bias was poorly reported or described throughout the
et al., 2017; Pakenham, 2015; Rimes & Wingrove, 2011; Stafford- included studies, making conclusions in this regard difficult. A large
Brown & Pakenham, 2012). Participants in five of the 11 studies that portion of the studies failed to address how they attempted to blind
measured stress reported mean stress scores in the moderate to high researchers to intervention groups, and the lack of randomised control
range (Cohen & Miller, 2009; Finlay-Jones et al., 2017; Miller trial designs was notable, with only two using randomised allocation
et al., 2017; Rimes & Wingrove, 2011). Mean scores were either not and concealment of participant groups. Information allowing for an
 BELL ET AL.

TABLE 1 Characteristics of reviewed studies.

Burnout/stress
Author/year Study design Country Participant sample Intervention/duration measurement Key outcomes
Burkhart (2014) Mixed methods research design USA Psychology graduate students Ten weekly 90-min meeting Stress (PSS) No significant change in stress
quasi-experimental pre post (N = 5). integral life practice self-care levels. Participants' pre
design module intervention stress scores in
the low range.
Call et al. (2014) RCT USA Undergraduate psychology Three weekly 45 min sessions. Stress (DASS) Hatha yoga and body scan
students (N = 91) Pre-recorded body scan or groups had significantly
hatha yoga greater reductions in stress
compared to controls (partial η
2
= 0.06). No significant
difference in overall reduction
of stress for hatha yoga
condition compared to body
scan condition. Participants'
pre intervention stress levels
in the normal range.
Cohen and Miller Pre-test to post-test design USA Post graduate psychology Interpersonal mindfulness Stress (PSS) Compared to pre-test data,
(2009) students (N = 21) (gender training 6-week 90 min significant decrease in
ratio not stated) perceived stress from,
(d = 0.545). Participant's
preintervention mean stress
scores were in the high range.
Cozzolino et al. Between-group pre-test to post- Italy First-year university students Mind–body transformation Stress (distress Likert Compared to pre-test data, post-
(2020) test? Uncontrolled quasi- (N = 58) (MALES; 50%), post therapy (MBT-T), single scale) treatment stress was
experimental design graduate psychology students session (unsure how long) significantly lower.
(N = 101; males 22.8%) Participants' pre intervention
mean stress was low.
Damásio et al. Quasi-experimental pre-test to Brazil Psychologists (N = 30) CBT group therapy course Burnout (MBI) Emotional exhaustion and
(2014) post-test design. Comparison Ten 5-h monthly modules reduced professional efficacy
group levels remained stable from
T1-T2. Significant decrease in
depersonalization (r = 0.37).
Burnout subscales increased
significantly for control group.
Participants' preintervention
mean burnout scores in the
low range.

(Continues)
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 TABLE 1 (Continued)
6 of 14

Burnout/stress
Author/year Study design Country Participant sample Intervention/duration measurement Key outcomes
Eriksson et al. RCT waitlist control Sweden Practising psychologists ‘Mindfulness and compassion Burnout SMBQ and Compared to pre-test data, there
(2018) (N = 101) with self and others’ online stress (PSS) was a significant decrease in
6-week programme (10 h of burnout scores for the
training) intervention group compared
to the control group
(d = 0.44).Participants' pre
intervention mean burnout
score for tension and
listlessness at clinically
significant level (SMBQ
≥3.75). Participants' mean PSS
was in the moderate stress
range (25.78; 16–26 indicates
moderate stress).
Finlay-Jones et al. Pre experimental repeated Australia Postgraduate psychology Online self-compassion 6 Stress (PSS) Compared to pre-test data,
(2017) measures design trainees (N = 37 (89% female) module programme (1–2 h per DASS significant reduction in
module) perceived stress post-test and
follow-up (d = 0.49–0.52).
Participants' pre intervention
mean PSS score were in the
moderate range. DASS stress
subscale in the severe range
Hopkins and Repeated measures design, Australia Trainee clinical psychologists MBCT 8-week course Stress (PSS) Compared to pre-test data, there
Proeve (2013) mixed methods (N = 11) were no statistically significant
changes in stress scores. No
means provided for stress
scores.
Miller et al. (2017) Single-group pre-post-test USA Third-year psychology students 12 5-min sessions 3-min Stress - self ratings 0– Compared to pre-test data,
(N = 115) (90.4% female) MBCT breathing 6 (6 highest stress significantly increased.
stressed) Participants' pre-intervention
mean stress levels were in the
moderate range.
Moyer et al. Repeated measures design USA Clinical (N = 3) and counselling ACT university course 3 h Stress (PSS) Compared to pre-test data, 3
(2017) (n = 7) doctoral students lessons 15 weeks students had reliable change
scores in stress scores. No
mean stress scores reported.
Pakenham (2015) Cohort study single-group pre- Australia Clinical psychology trainees 12 weekly 2-h university ACT Work-related stress There was no significant change
post-test (N = 51) students attending workshop (MHPSS) in work-related stress. Unable
an ACT training course to ascertain stress cut off
scores from MHPSS scale.
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 TABLE 1 (Continued)
BELL ET AL.

Burnout/stress
Author/year Study design Country Participant sample Intervention/duration measurement Key outcomes
Reyes Ortega et al. Quasi experimental non Mexico Psychiatrist (N = 1), Helping the helper programme Burnout (MBI) Compared to pre-test data,
(2019) randomised control trial, psychologists (N = 5) working (HTHP) functional analytic significant reduction in
repeated measures at a BPD clinic (50% female) psychotherapy online training emotional exhaustion,
protocol (six weekly online depersonalisation, and
sessions, 2 h each) personal accomplishment (R-
IRD range = 0.4–1).
Participants' preintervention
mean burnout scores in each
subscale were all in the high
range.
Rimes and Single-group England Clinical psychology doctoral 8-week MBCT Stress (PSS) First year and second year
Wingrove Pre-test to post-test design trainees (N = 20) students showed a significant
(2011) decrease in stress. Third year
students showed an increase
in stress. Participants pre
intervention mean stress
scores were in the high range.
Robins et al. Non-randomised control trial Australia Master-level psychology Modified DBT programme from Burnout (MBI) Compared to control group,
(2019) students (N = 17) (females; the DBT skills training manual exhaustion levels and cynicism
94.12%) 8  2 h sessions significantly decreased for
intervention group (effect size
range 0.8–1.1). Exhaustion
levels remained stable in
control group. Follow up
found a significant decrease in
cynicism scores for the
intervention group.
Participants' pre intervention
burnout scores were in the
moderate range.
Stafford-Brown A waitlist control-controlled Australia Clinical postgraduate trainees Sequence of standard ACT Stress (MHPSS) Professional self-doubt
and Pakenham design (N = 56) concepts, exercises, and significantly decreased for
(2012) interventions (4 weekly 3-hour treatment group and increased
session) for the control group (partial η
2
= 0.075). Unable to
ascertain stress cut off scores
from MHPSS scale.

Abbreviations: ACT, Acceptance and Commitment Therapy; CBT, Cognitive Behavioural Therapy; DASS, Depression Anxiety and Stress Scale; MHPSS, Mental Health Professional Stress Scale; PSS, Perceived
Stress Scale; RCT, randomised control trial; SMBQ, Shirom Melamed Burnout Questionnaire.
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 8 of 14

TABLE 2 Intervention characteristics of included studies.

Acceptance and Six or more

Burnout Stress Practising Student commitment Cognitive Other sessions - Online
measured measured psychologist sample Mindfulness therapy Self-care component intervention intervention component
Burkhart (2014) X X X X
Call et al. (2014) X X X
Cohen and Miller (2009) X X X X
Cozzolino et al. (2020) X X X
Damásio et al. (2014) X X X X
Eriksson et al. (2018) X X X X X X X
Finlay-Jones et al. (2017) X X X X X
Hopkins and Proeve (2013) X X X X X
Miller et al. (2017) X X X X X
Moyer et al. (2017) X X X X
Pakenham (2015) X X X X
Reyes Ortega et al. (2019) X X X X X
Rimes and Wingrove (2011) X X X X X
Robins et al. (2019) X X X X X
Stafford-Brown and X X X
Pakenham (2012)
Total 4 12 3 12 7 3 3 4 3 12 3
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BELL ET AL. 9 of 14

TABLE 3 Assessment of risk of bias.

Statistically Random allocation Adequate

significant Effect Selection and concealment Performance Attrition Reporting follow-
Authors findings1 size2 bias3 of group4 bias5 bias6 bias7 up8
Burkhart (2014) N/A

Call et al. (2014)

Cohen and Miller (2009) N/A

Cozzolino et al. (2020) N/A N/A

Damásio et al. (2014)

Eriksson et al. (2018)

Finlay-Jones et al. (2017) N/A

Hopkins and Proeve (2013) N/A

Reyes Ortega et al. (2019)

Moyer et al. (2017) N/A

Pakenham (2015) N/A

Reyes Ortega et al. (2019)

Rimes and Wingrove (2011) N/A

Robins et al. (2019)

Stafford-Brown and
Pakenham (2012)

low risk of bias unclear risk of bias high risk of bias

1
Statistically significant findings = were the research findings significant? Did the research report misleading interpretation (e.g., discussing no significant
results as if they were significant).
2
Effect Size = J. Cohen (2013) suggested that d = 0.2 be considered a ‘small’ effect size, 0.5 represents a ‘medium’ effect size and 0.8 a ‘large’ effect size.
3
Selection bias = were groups similar at baseline or were differences controlled for?
4
Were the randomised control trial (RCT) groups blinded/concealed and randomised? N/A = indicates the study did not endorse a randomised control trial
design.
5
Performance bias = systematic difference between groups in terms of how they are treated, or differences in the behaviour of participants due to
knowledge of the allocated interventions.
6
Attrition bias = systematic differences in dropouts between groups, where <5% attrition leads to little bias, while >20% poses serious threats to validity.
7
Reporting bias = were outcomes pre-specified and reported?
8
Adequate follow up = was a follow up time point included, and was the long-term effectiveness of the intervention stated.

evaluation of the expertise of the therapists/facilitators using recog- et al., 2014). Evaluating the skills of the facilitators for the less recog-
nised evidence-based interventions was generally lacking; being a psy- nisable interventions (e.g., Burkhart's, 2014 Integral Life Practice inter-
chologist or therapist with training, previous experience and vention, Call et al.'s (2014) yoga intervention and Cozzolino et al.'s
supervision in the modality on offer was reported by Hopkins (2020) mind–body transformation intervention) was also problematic.
and Proeve (2013; MBCT) and Robins et al. (2019; DBT) but no sub- Finally, many studies lacked adequate follow-up data, making conclu-
stantive information was reported for the studies describing the use sions on the long-term effectiveness of the interventions used diffi-
of ACT (Moyer et al., 2017; Pakenham, 2015) or CBT (Damásio cult to draw.
 10990879, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cpp.2909 by Faculdade Medicina De Lisboa, Wiley Online Library on [16/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 of 14 BELL ET AL.

3.4 | Interventions and outcomes professionals implementing group therapy. The efficacy of the pro-
gramme was characterised by a significant decrease in depersonalisa-
3.4.1 | Mindfulness interventions tion, as measured by the MBI.

Of the studies included within the review, a mindfulness-based

approach was the most predominantly used intervention (6 of the 3.4.3 | Self-care interventions
15 studies). Of these, two studies used an entirely mindfulness-based
approach, with a sample of post-graduate and undergraduate psychol- Two studies utilised a self-care intervention approach for burnout and
ogy students, delivered by either a clinical psychologist (Cohen & stress. Burkhart (2014) outlined a 10-week Integral Life Practice
Miller, 2009) or a meditation teacher (Call et al., 2014). Cohen and self-care intervention for clinical psychology trainees. While specific
Miller's (Cohen & Miller, 2009) intervention consisted of primarily characteristics of the intervention were unclear (e.g., delivery and pro-
experiential mindfulness meditations, including sitting meditations gramme outline), the intervention did not find a significant change in
that increased in length over the course of the training. Call et al. participants' levels of stress. Finlay-Jones et al. (2017) outlined a
(2014) implemented a body scan or hatha yoga, delivered over a six-module online self-compassion programme examining stress in
three-week period. Both interventions were effective in reducing par- postgraduate psychology trainees, developed by the authors. The
ticipants' levels of stress. intervention consisted of self-compassion, mindfulness and self-
Three studies used a manualised mindfulness-based cognitive kindness. The intervention was effective in significantly reducing par-
therapy programme (Hopkins & Proeve, 2013; Miller et al., 2017; ticipants' perceived stress pre-test to post test and pre-test to follow-
Rimes & Wingrove, 2011). Miller et al. (2017) only utilised the breath- up.
ing component of the programme in a sample of undergraduate psy-
chology students. The remaining two studies examined the
effectiveness of a mindfulness-based intervention amongst post- 3.4.4 | Other interventions and interesting findings
graduate clinical psychology trainees and were delivered by post-
graduate trainees in mindfulness (Rimes & Wingrove, 2011) or clinical The remaining four studies varied in the interventions they used.
psychologists (Hopkins & Proeve, 2013). Of these three studies, only Stafford-Brown and Pakenham (2012) outlined a four session ACT
one demonstrated a significant decrease in stress for participants and Relational Frame Theory based intervention for reducing stress in
(Rimes & Wingrove, 2011). clinical psychology trainees. The intervention consisted of relationship
Eriksson et al. (2018) outlined a six-week mindfulness-based self- to thoughts, acceptance, mindfulness, values and self-compassion.
compassion intervention, evaluating burnout and stress in a sample of The efficacy in reducing a component of work-related stress was sup-
practising psychologists. The efficacy of the intervention was charac- ported, as self-doubt significantly decreased for the treatment group
terised by a significant decrease in burnout scores for the intervention and increased for the control group.
group compared to the control group. Robins et al. (2019) evaluated an eight-session dialectical behav-
iour therapy (DBT) intervention for burnout in psychology master's
students, facilitated by a clinical psychologist. The intervention cov-
3.4.2 | Training courses ered all skills outlined in the DBT skills training manual for treating
borderline personality disorder (Linehan, 1993). Post intervention
Two studies included in the review evaluated the effectiveness of an measures indicated that the subscales of exhaustion and cynicism sig-
Acceptance and Commitment Therapy (ACT) intervention, which was nificantly decreased for the intervention group compared to those in
conducted with psychology trainees over a 12–15-week semester the control group.
(Moyer et al., 2017; Pakenham, 2015). Moyer et al. (2017) delivered Reyes Ortega et al. (2019) outlined a six-week online intervention
an ACT course facilitated by lecturers, and Pakenham (2015) also based on functional analytic psychotherapy as an intervention for
used an ACT-based intervention but did not state who delivered burnout in a group of psychologists. While the intervention methodol-
it. Both courses taught core ACT techniques, such as acceptance, dif- ogy was unclear, the intervention consisted of a narrative exercise
fusion, mindfulness, self-as context and values committed action. The and sharing of personal mission and passion statements. The efficacy
efficacy of the programmes in reducing students' stress varied. of the intervention was characterised by large effect size changes in
Pakenham (2015) found no significant changes in participants work emotional exhaustion, depersonalisation and personal accomplish-
related stress, and three out of nine participants in Moyer et al. ment. Cozzolino et al. (2020) outlined a one session mind–body trans-
(2017) study demonstrated a reliable change in stress scores post formation therapy intervention with undergraduate and postgraduate
intervention. psychology students. The intervention consisted of focusing aware-
Damásio et al. (2014) outlined a 10-week CBT group training pro- ness on thoughts and feelings, problem review, problem solving and
gramme, which investigated the effects of the training on psycholo- self-care. The study reported a significant reduction in participants
gists' level of burnout. The course consisted of theoretical and stress levels post intervention; however, no follow up was completed
practical aspects of group CBT and involved participants supervising to test its long-term effectiveness.
 10990879, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cpp.2909 by Faculdade Medicina De Lisboa, Wiley Online Library on [16/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BELL ET AL. 11 of 14

4 | DISCUSSION that may come with the symptoms of burnout. Of the studies
included, four used a ‘cognitive’ based intervention (i.e., CBT or DBT);
The current study aimed to synthesise and review the current litera- however, only one of which measured burnout (Damásio et al., 2014).
ture on psychological interventions for stress and burnout in psychol- Further investigation may need to focus on differentiating common
ogy students, trainees and psychologists and to evaluate them. distortions and signs of stress and burnout.
Understanding the efficacy of interventions for burnout may help psy-
chologists to provide treatment for their patients, while simulta-
neously caring for their own wellbeing. 4.1 | Clinical implications
The findings from the systematic review indicate that stress and
burnout is prevalent within the psychology profession, occurring in Findings of this systematic review indicate that mindfulness-based
higher frequencies in psychology trainees or those practicing in the interventions may be a starting point for reducing stress; however,
earlier stages of their career. In studies that reported participants' the most effective intervention for psychologists who have reached
mean stress or burnout scores (11), around 60% of participants burnout is unclear. Since burnout can be conceptualised as the end
reported moderate to high stress (see Table 3). This finding highlights point of stress, it may be that reducing psychologists' stress is the
the importance of research in this area as burnout or stress may be most effective approach to reducing burnout (WHO, 2019). However,
having a significant impact on the wellbeing of a large proportion of a lack of randomised control trials and longitudinal studies make this
psychologists or psychology trainees. link unclear. Moreover, psychologists are not all equally at risk of
While a total of 15 studies met inclusion criteria, the psychologi- developing burnout, as factors such as age, experience and gender
cal interventions were variable, ranging from group-based interven- mediate the risk (McCormack et al., 2018). Therefore, it cannot be
tions, online training courses and programmes and concurrent expected that all psychologists will equally benefit from interventions,
techniques. Comparisons between studies were further complicated and the extent to which interventions are effective may be influenced
by diversity between participants, study designs, settings, target vari- by other factors.
able being measured (i.e., stress and burnout) and the measures used
to capture this. Further, intervention format such as frequency, dura-
tion and follow-up varied. For example, three studies examined the 4.2 | Limitations
effect of an ACT training course on reducing burnout; one (Stafford-
Brown & Pakenham, 2012) found statistically significant intervention This systematic review is the first to date that directly examines the
effects for a reduction in professional self-doubt (‘feeling inade- evidence for interventions to reduce burnout and stress in psycholo-
quately skilled for dealing with emotional needs of clients’) in clinical gists. However, there are some limitations to the review. First, few
psychology trainees based on a 4 week intervention, whereas the studies explicitly defined theoretical underpinnings of stress and burn-
remaining two ACT interventions spanned 12–14 weeks (Moyer out; thus, the foundation and justification of the research are lacking.
et al., 2017; Pakenham, 2015) and did not yield significant interven- Although the studies reviewed utilised different methodologies,
tion effects. This inconsistency may be attributed to numerous consistent limitations of studies, as shown in the risk of bias table,
sources of variations between the studies, such as measurements were the absence of power analyses, inadequate sample sizes, imbal-
used, length and delivery of intervention and population. ance of gender, lack of RCTs, poor reporting of therapist/facilitator
Of the 15 studies included within the review, only four measured qualifications and experience and poor reporting of means, standard
burnout as an outcome variable, while the others measured stress. deviations and effect sizes. The quality of burnout and stress mea-
This is likely to be reflective of several factors, including the potential sures used in the studies also varied, so reliability and validity of the
for stress to develop in to burnout, making early intervention an construct measured may be poor. Due to the limited amount of
attractive proposition, sampling issues (occupational stress is likely to research on interventions for psychologists, the systematic review's
be experienced by most health professionals at some point, whereas inclusion criteria were expanded to include psychology undergraduate
burnout is more serious and less prevalent), measurement issues and postgraduate students. This diversity in samples may limit ade-
(measures of stress are easier to source) and ethical issues (burned quate comparison of results due to populations' unique experiences
out clinicians may be placing their clients at risk, which raises ques- of stress and burnout.
tions of how to appropriately manage this within research). While
extensive research has examined burnout in other professions
(i.e., doctors and nurses), it is surprising that burnout amongst psy- 4.3 | Future directions
chologists has been neglected, despite the profound impact it can
have on the clinician and the safety and wellbeing of their patients. Since a major finding of this systematic review is that there is a lack of
Almost half of the studies incorporated a mindfulness component research on interventions targeting burnout, future research could
in their intervention, which is not surprising as this is a commonly focus on interventions specifically measuring and targeting burnout in
used treatment for stress. However, using a ‘mindful’ approach to psychologists. Furthermore, given that the risk of bias evaluation
thoughts and feelings fails to address potential maladaptive cognitions revealed that only two of 15 studies randomised participants' and had
 10990879, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cpp.2909 by Faculdade Medicina De Lisboa, Wiley Online Library on [16/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12 of 14 BELL ET AL.

a control group, it is recommended that future studies employ a ran- strengthen the evidence base of this field. Psychological interventions
domised control design—the gold standard for evaluating the effective- to target burnout in psychologists also require further investigations
ness of treatment. As highlighted in the risk of bias evaluation, to at both an organisational and individual level, to target the various fac-
improve the robustness of future interventions in this area, it is recom- tors that may contribute to stress and burnout in psychologists.
mended that studies take measures to prevent selection bias by ensur-
ing group characteristics are similar and do not differ (e.g., ensure CONFLIC T OF INTER E ST STATEMENT
similar levels of participant burnout or stress between groups). Further, The authors report no conflict of interest.
to decrease the risk of performance bias, it is recommended that stud-
ies use objective outcome measures (rather than self-report data) or DATA AVAILABILITY STAT EMEN T
employ a different researcher to analyse outcome data, if researchers The data supporting the study findings are available within the pub-
are unable to be blinded to the intervention (Banerjee et al., 2019). It is lished studies.
also recommended that studies include follow-up measures, so long-
term effectiveness of interventions can be evaluated. ET HICS S TAT E MENT
Currently, there does not appear to be ‘gold standard’ definition Not applicable in a scoping review of existing literature.
nor clear symptomology established for burnout, resulting in difficulty
reaching unanimous conclusions within the research field at hand.
OR CID
Future research may benefit from the further exploration of the theo-
Prudence M. Millear https://orcid.org/0000-0002-9423-6107
ries and definitions associated with burnout and its related symptom-
Andrew Allen https://orcid.org/0000-0001-7873-4264
atology. The consideration of a burnout as a formal diagnosis may be
Andrew P. Wood https://orcid.org/0000-0002-0045-258X
useful, as it may help to differentiate the symptoms of burnout and
Lee Kannis-Dymand https://orcid.org/0000-0002-1882-6121
other mental health disorders (e.g., depression, which often shares
Celine M. Jona https://orcid.org/0000-0003-0240-1329
common symptoms with those seen in burnout Established criteria
Jonathan Mason https://orcid.org/0000-0002-8085-6137
and symptomology of a disorder are useful for clinicians treating men-
tal health problems, as they act as a set of guiding criteria that can be
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