Therapist Resilience in an Ever-Changing World: A Systematic Review

Abstract

Given the demands of a helping professions amidst an ever-changing world, therapists need resilience now more than ever. This systematic literature review had two purposes: to explore the international evidence of internal characteristics that contribute to therapist resilience and to investigate the common ground between previous literature about therapist resilience and the newly identified characteristics of highly resilient therapists. In all, 29 peer-reviewed original research articles were systematically collected and coded for themes. In all, 10 overarching themes were identified: (a) connection to community, (b) pursuit of continual growth, (c) emotional boundaries, (d) emotional support, (e) humor, (f) integration of personal and professional, (g) meaning and purpose, (h) positive sense of self, (i) self-awareness, and (j) spirituality. The themes reinforced the four core characteristics of highly resilient therapists. Implications to foster therapist resilience and ideas for future research are discussed.

Keywords

resilience burnout therapist counselor practitioner

There is significant evidence of the detrimental effects of being a psychotherapist through concepts such as burnout (Freudenberger, 1974), vicarious trauma (Pearlman & Saakvitne, 1995), compassion fatigue, and secondary traumatic stress (Figley, 1995, 2002). These concepts can be considered the professional hazards of practice (Skovholt & Trotter-Mathison, 2016). They are important to understand because therapist effects are greater than treatment effects (Wampold & Imel, 2015) and predict the quality of mental health service provision (Schiele et al., 2014). The more burned out a practitioner is, the lower quality their services become (Leon-Perez et al., 2016).

Psychotherapists are trained to treat clients’ distress through psychological science, yet they are not immune themselves to the detrimental effects of distress. Exposing oneself to human suffering is inherently part of a therapist’s role, yet that does not mean therapists are destined to burn out. Alongside the hazards of practice, there are also rewards or joys of practice (Skovholt & Trotter-Mathison, 2016). So much so that compared to psychological researchers, psychotherapists reported greater agreement that their job made them a better, wiser person (Skovholt & Trotter-Mathison, 2016). While stressors from the job and beyond will continue to exist, a significant protective factor from these professional hazards is resilience, which is defined as the ability to positively adapt to adversity (Fletcher & Sarkar, 2013).

External factors have been identified as contributing to resilience such as focusing on improving self-care practices (e.g., sleep hygiene, breaks from work, exercise, stress management, and emotional support) or workplace interventions such as creating more supportive work environments (e.g., Broome et al., 2009; Choi et al., 2014; Ducharme et al., 2007). While this evidence suggests external changes are beneficial for therapist resilience, there is little evidence for how counselor and psychotherapist internal characteristics may bolster sustainable, career-long resilience.

In their article Characteristics of Highly Resilient Therapists, Hou and Skovholt (2020) identified essential characteristics that sustain therapists to bounce back from adversity and foster resilience over years of practice. Using two levels of sample screening, peer nomination and self-rated measures, 10 highly resilient therapists were identified and interviewed. The results yielded four core characteristics including (a) drawn to strong interpersonal relationships, (b) actively engage with self, (c) possess a core values and beliefs framework, and (d) desire to learn and grow, and a central characteristic that interlinks with each characteristic: have a strong web of vibrant connectedness. Connectedness was the most salient theme across the core categories. These findings represent a pivot in the professional literature on therapist resilience from the previously mentioned external factors to internal characteristics of individual counselors and psychotherapists that foster resilience.

To further study the characteristics of highly resilient therapists (Hou & Skovholt, 2020), this systematic review sought to systematically investigate the findings of previous literature for evidence of internal characteristics promoting psychotherapist resilience. This present manuscript does not aim to describe highly resilient therapists themselves. Instead, the aim was to investigate how Hou and Skovholt’s (2020) findings are present in other resilience-related research, if at all. This methodological systematic review was an iterative process that included five steps: problem identification, review of literature with comprehensive search strategy, data evaluation, data analysis, and synthesis of data. The purpose of this systematic review of literature was to explore the international evidence of internal characteristics that contribute to therapist resiliency previously established in the resilience literature and to investigate the common ground between previously established internal characteristics of therapist resilience and the findings from characteristics of highly resilient therapists (Hou & Skovholt, 2020).

Method

Search Strategy

A systematic review of existing peer-reviewed literature was conducted using the database PsycINFO. Key search words were counselor OR therapist OR psychotherapist AND resilient(ce) OR self-care OR burnout OR compassion fatigue. Inclusion and exclusion criteria are outlined in Table 1. The inclusion criteria required original peer-reviewed research about counselors, therapists, and psychotherapists that focused on internal resources of therapist attributes or connectedness. Literature was excluded if it focused on counseling fields that generally have qualitatively different work than therapists, such as school counselors, genetic counselors, substance abuse counselors, and art therapists. Once articles were identified, hand-searching, PsycArticles, and Google Scholar were utilized to gather full-text articles from the sample’s reference lists that appeared to fit the inclusion criteria.

Table 1

Inclusion and Exclusion Criteria

Inclusion criteria	Exclusion criteria
Counselors, therapists, and psychotherapists	Solely focused on workplace factors
Focus on internal resources of therapist characteristics OR connectedness	Sample qualitatively different than therapists (e.g., school counselors, substance abuse counselors)
Original qualitative or quantitative research
Peer reviewed	Not original research
English language	Validation studies
Journal article	Trainees as sample

The Preferred Reporting Items for Systematic reviews and Meta-Analyses tool was utilized to organize the phases of the review and to maintain transparency (Figure 1). A total of 325 peer-reviewed articles were deemed relevant for this systematic review. Hand-searching of reference lists identified an additional 55 articles. Of these, six duplicates were removed. All 374 articles were screened for acceptability. There were 325 articles excluded leaving 49 eligible articles for full-text analysis. Of these, an additional 20 were removed because upon further examination, they were not original research, focused on only external or workplace factors, or were not available in English.

Figure 1.

PRISMA flow diagram.

Analysis

A total of 29 peer-reviewed articles were included for analysis and are presented in Table 2. The research team discussed biases we have about therapist resilience prior to analyzing the data. All authors reported believing the unique importance of resilience for helping professionals and that although external factors such as workplace norms matter, there are also traits and skills therapists can have within themselves that foster resilience. The researchers observed that we tend to think of resilience as self-preservation, yet acknowledge other aspects of resilience as well, such as how core values, beliefs, curiosity, and connection to self-relate to resilience. The authors who were analyzing and auditing the articles were all counseling psychologists, two who practice full time. There was also potential bias regarding the importance of resilience, as we saw how resilience prevented our own burnout due to being practitioners completing this systematic review during a global pandemic while also serving clients. The authors revisited their personal biases both separately and as a group throughout the analysis process in an attempt to stay mindful of what might be their personal views versus the actual findings of each study included in the analysis.

Table 2

Summary of Findings from Research Studies

Citations	Purpose/aim	Method	Findings
Bennett-Levy et al. (2015)	To investigate incidental findings from Bennett-Levy and Lee (2014) of CBT practicing therapists who practice CBT on themselves. Three key questions about motivation, application, and impact were explored.	Participatory action research (N = 5 counselors)	The primary finding was the readiness and desire of participants to use CBT for themselves. Findings also identified practitioner motivation to keep learning, a value to growth both professionally and personally, and that generational trauma leads to burnout when working in your own community; self-growth/reflection buffers from burnout.
Brucato and Neimeyer (2009)	To explore whether different epistemological positions of psychotherapists predict self-care and coping strategies in relation to stress	Questionnaire (N = 151 psychotherapists)	Epistemic styles predict therapist self-care strategies. Constructivist epistemic leanings engage in more self-care. Stronger constructivist epistemic commitments with higher levels of self-care. Self-care scores correlated with getting emotional social support.
Capner and Caltabiano (1993)	To assess whether volunteer counselors differed substantially from professional counselors on crucial variables implicated in the progression toward burnout. Variables included stressors, Type A personality, social support, strain, defensive coping, and counselor breakdown.	Questionnaire (N = 81 professional and volunteer counselors)	Social support may act as a buffer to burnout. More specifically, as counselors’ work becomes more stressful, those better able to cope are drawn to relationships. Combining findings into a heterogeneous group supports previous research findings on burnout for the professional counseling population.
Clark (2009)	To develop a grounded theory of resilient therapists. The goals were (a) to identify the process by which marriage and family therapists remain resilient, (b) to identify the factors that contribute to therapist longevity and enjoyment of the profession, and (c) to explore implications for newer therapists.	Qualitative grounded theory (N = 7 marriage and family therapists)	Integration of self and practice is the central concept related to remaining resilient. Other findings related to resilience: continuous quest for personal growth; trust in self through respect, acceptance, trust, and reverence; emotional attunement/attunement to body signals; relationships and connection were related to success.
Coster and Schwebel (1997)	To identify the factors that contribute to psychologists’ ability to function well	Study 1: Interviews (N = 6) Study 2: Questionnaires (N = 339)	Self-awareness and monitoring, support from others, values, and a balanced life collectively contribute to psychologist well-functioning.
De Lange and Chigeza (2015)	Exploration of the strength (fortigenic) qualities of psychotherapists that can buffer them against compassion fatigue	Qualitative interviews and thematic analysis (N = 7 psychologists in private practice)	Fortigenic qualities such as resilience, acceptance, appreciation and passion, humor, philosophy of life and a higher level of logic act as buffers against compassion fatigue.
Emery et al. (2009)	To investigate the construct validity of the Therapist Belief Scale, and to examine the relative contribution of demographics, workplace variables, and individual factors to burnout	Online questionnaires (N = 190 clinical psychologists)	More personal resources and greater beliefs related to control were associated with less burnout. Higher levels of personal accomplishment were significantly associated with a lower annual income, not having a mixed caseload, having more personal resources, and endorsing lower levels of therapist beliefs related to inflexibility and control.
Finlay-Jones et al. (2015)	To clarify the link between self-compassion and stress among psychologists	Questionnaires (N = 198 psychologists and graduate trainees in clinical work)	Self-compassion significantly negatively predicted emotion regulation difficulties and stress symptoms.
Hardiman and Simmonds (2013)	To examine the relationships between spiritual well-being and clinician burnout. An additional aim was to explore the influence of patient trauma on clinician spiritual well-being and burnout. It was anticipated that perceptions of severity of client trauma would be positively associated with burnout and spiritual well-being	Questionnaires (N = 89 counselors and psychotherapists)	Clinicians who reported high levels of existential well-being reported being better able to avoid emotional exhaustion. Social and existential well-being predicted greater personal accomplishment. Existential well-being overall predicted less burnout and even buffered against job-related stress of seeing clients with severe trauma.
Harrison and Westwood (2009)	To identify the protective practices that mitigate the risks of vicarious traumatization among mental health therapists	Questionnaires as screening tool followed by structured interviews (N = 6 mental health therapists)	Findings included nine major themes salient across clinicians’ narratives of protective practices: countering isolation (in professional, personal, and spiritual realms); developing mindful self-awareness; consciously expanding perspective to embrace complexity; active optimism; holistic self-care; maintaining clear boundaries; exquisite empathy; professional satisfaction; and creating meaning.
Hernández et al. (2007)	To investigate the formulation of a new concept: vicarious resilience	Semi-structured interviews (N = 12 psychotherapists)	Identified themes advance concept of vicarious resilience and how it can contribute to sustaining and empowering trauma therapists such as witnessing and reflecting on human beings’ immense capacity to heal and reassessing the dimensions of one’s own problems were the most common themes in this regard.
Kadambi and Truscott (2003)	To determine whether or not therapists working with sex offenders exhibit signs of vicarious traumatization, to identify predictive factors, and to explore the relationship between the construct of vicarious traumatization and burnout	Mailed questionnaires (N = 93 therapists)	No significant difference between participants scores on the Traumatic Stress Institute Belief Scale and those of a criterion reference group. Participants who reported having a venue to address the personal impact of their work were found to be more likely to score lower on the measure of vicarious trauma than those who did not. Other variables theorized to be related to vicarious trauma were not found to be related to scores on the measure assessing vicarious trauma.
Lakioti et al. (2020)	Investigation of factors that help therapists maintain their resilience to work stressors	Questionnaires (N = 163 mental health practitioners)	Findings indicate that perceptions of self-efficacy, meaning, positive emotions, and positive interpersonal relationships might protect therapists from burnout and secondary traumatic stress, as well as promote the satisfaction they derive from their work. Furthermore, an organizational work setting might be a risk factor for burnout and increased empathy a risk factor for secondary stress
Laverdière et al. (2019)	To explore the relationship of empathy to compassion satisfaction, burnout, and secondary traumatic stress among psychotherapists	Questionnaires (N = 240 psychotherapists)	Psychotherapists who strongly wish to alleviate others’ suffering may experience greater satisfaction from their work. Psychotherapists with tendencies toward personalizing the others’ difficult affects may be easily overwhelmed by their patients’ problems.
Lee et al. (2010)	Investigation of specific burnout typologies among professional counselors	Convenience sampling and cluster analysis (N = 137 counselors)	Three clusters were identified: well-adjusted, persevering, and disconnected counselors. Counselor job satisfaction and self-esteem were discriminating factors between the three clusters.
Lin (2012)	Investigation of burnout, self-care, and recovery experiences of female university counselors	Semi-structured interviews and thematic analysis (N = 9 university counselors)	Burnout is influenced by conflicts between work environment and family; burnout is influenced by changes on campus and in the counseling profession; self-awareness, self-assessment and action are keys to self-care and recovery requires the right balance between self, life, and work.
Liou (2014)	Investigation of perceived influence of regular ch’i-related exercises on counselor self-care	Post-structural semi-structured interview with narrative analysis (N = 12 senior counselors)	The core themes emerging from the study were (a) from the experiences of rupture and disconnectedness to the care of the self, (b) Ch’i-related exercises as a cultural resource for the permanent care of the self, and (c) a new self-view and new relations to others and the world.
Malinowski (2013)	Preliminary investigation to observe the relationship between different types of humor and various characteristics of job burnout among psychotherapists	Questionnaires (N = 133 psychotherapists)	Regression results indicated that self-defeating humor contributed to the job burnout characteristics of emotional exhaustion and depersonalization, whereas self-enhancing humor contributed to a therapist’s sense of personal accomplishment.
Melamed et al. (2001)	Investigation into how therapist feelings of loneliness impact burnout in public outpatient clinics	Mixed methodology using both qualitative interviews and questionnaires (N = 31 mental health therapists)	Therapists in community outpatient clinics experience resilience from all staff meetings, but fear burnout from workload.
Patsiopoulos and Buchanan (2011)	To explore how experienced counselors practice self-compassion and whether they use it to buffer the effects of work-related stress	Qualitative research using a narrative research design (N = 15 experienced counselors)	Three main themes emerged: counselors’ stances in session, workplace relational ways of being, and finding that balance through self-care strategies.
Pereira et al. (2017)	To investigate the role of resilience and mindfulness, alone and combined, in relation to the delivery of more and less effective practice with patients presenting with anxiety and depression in a stepped care model	Quantitative analysis comprised of practitioners (N = 37) and their patient data (N = 4,980)	Importance of mindfulness; mindful practice positively impacted client outcomes.
Råbu et al. (2016)	To investigate how psychotherapists lives and relationships are influenced by their work	Qualitative thematic analysis (N = 12 senior psychotherapists)	Working as a therapist seemed to imply a potential for developing openness, tolerance, and creativity, while being vulnerable to becoming overwhelmed with responsibility and feelings of inadequacy, isolation, and despair. The personal lives of therapists are enriched through a sense of being in a privileged and valuable professional role, characterized by positive personal learning in such areas of self-awareness, personal development, and quality of interpersonal relationship.
Richards et al. (2010)	To explore links between self-care practices, self-awareness, mindfulness, and well-being in mental health professionals	Questionnaires (N = 148 mental health professionals)	Mindfulness is a significant mediator between self-care and well-being.
Rzeszutek and Schier (2014)	To examine the severity of burnout symptoms and their relationship to temperament traits and social support	Quantitative survey (N = 200 therapists)	The level of burnout symptoms among all therapists was related to temperament traits, briskness, and perseveration, as well as to perceived social support.
Thompson et al. (2014)	To explore whether the transactional stress and coping perspective is impacted by gender, length of time in the field, working conditions, and personal resources related to levels of burnout and compassion fatigue	Questionnaires (N = 213 mental health counselors)	Counselors who reported less maladaptive coping, higher mindfulness attitudes and compassion satisfaction, and more positive perceptions of their work environment reported less burnout.
Valente and Marotta (2005)	To explore the impact of regular practice of yoga in the personal and professional lives of psychotherapists	Qualitative interviews (N = psychologists)	The perceived effects of yoga practice were categorized into common patterns and included four themes: internal/self-awareness, balance, acceptance of self and others, and yoga as a way of life.
Yip et al. (2017)	To investigate the mediating role of self-compassion in mindfulness effects among a group of therapists	Quantitative measures using cross-sectional questionnaire design (N = 77 clinical psychologists and trainees)	Results showed that the relationships between mindfulness with both burnout and secondary traumatic stress were mediated by self-coldness.
Yiu-Kee and Tang (1995)	To investigate the various existential correlates of burnout for mental health therapists	Quantitative questionnaire (N = 132 therapists)	Purpose in life was positively correlated with the personal accomplishment dimension of burnout, whereas motivation to seek purpose was positively related to the emotional exhaustion dimension.

Note. CBT = cognitive behavioral therapy.

The coding process followed the philosophical underpinnings of consensual qualitative research, which emphasizes multiple coders in the analysis process, consensus about the meaning of the data, and at least one auditor to check the work of the coding team (Hill et al., 2005). The findings of each article in the sample were treated as qualitative data. Two authors independently reviewed one-third of the articles and suggested themes found in the article findings. They met to compare themes they each identified and worked toward consensus to finalize the themes. Once an initial set of themes were determined, they independently reviewed the rest of the articles, again working toward consensus about each datapoint (i.e., article finding) that fit each theme. When discrepancies occurred, they discussed reasoning for their decisions until they reached consensus. Theme titles and descriptions were revised throughout the analysis process to fit the emerging data. The themes and related datapoints were then audited by a third author who had no part in acquiring or coding the articles. The analysts discussed the auditor’s comments and revised accordingly, to ensure accurate representation of the data. Last, the themes were compared to the characteristics of highly resilient therapists (Hou & Skovholt, 2020) and organized into categories that corresponded with each characteristic. Throughout the entire process, adjustments were made until there was consensus and satisfaction about the integrity of the analysis results.

Results

In all, 10 overarching themes were derived from the thematic analysis and are presented below.

Connection to Community

This theme relates to practicing within one’s own community and acknowledging how the collective trauma and healing impacts their well-being as a therapist. Generational trauma led to burnout for therapists when working within their own oppressed community (Bennet-Levy et al., 2015). Practicing the same strategies they provided to clients allowed for self-growth and reflection, which buffered from burnout (Bennet-Levy et al., 2015). For therapists working with survivors of political violence or kidnapping, vicarious resilience was found when storytelling about the collective history resonated deeply with all community members (Hernández et al., 2007).

Pursuit of Continual Growth

This theme is related to professional growth. Therapists who had a value of ongoing self-growth reported greater motivation and enjoyment in their work (Bennet-Levy et al., 2015; Clark, 2009). For example, self-reflection with intention to keep developing buffered against burnout (Bennet-Levy et al., 2015). Taking a stance of not knowing and maintaining a “beginner’s mind” supported therapists to stay curious and to maintain a desire to keep learning (Patsiopoulos & Buchanan, 2011). Findings not only connect to professional growth, but also relate to staying open to grow and development as a person (Råbu et al., 2016).

Emotional Boundaries

Maintaining clear boundaries also prevented burnout. When therapists maintained a sense of self as well as setting boundaries and limits when serving clients, burnout was prevented (Clark, 2009; Harrison & Westwood, 2009; Hellman et al., 1987). A factor related to therapists’ ability to set emotional boundaries was acceptance of the limits of their humanity (Valente & Marotta, 2005). Having a level of briskness protected them from burnout (Rzeszutek & Schier, 2014). Therapists were able to maintain self-care and recover from burnout when they took a less aggressive approach to their workload and professional trajectory (Lin, 2012). Therapists who did not maintain emotional boundaries had the tendency of personalizing client difficulties, which led to being easily overwhelmed by problems (Laverdière et al., 2019).

Emotional Support

This theme refers to social care and positive relationships with others. Relationships, either personal or professional where therapists felt supported, prevented burnout and compassion fatigue (Capner & Caltabiano, 1993; Emery et al., 2009; Kadambi & Truscott, 2003; Rzeszutek & Schier, 2014; Thompson et al., 2014) and predicted stronger self-care and satisfaction in their work (Brucato & Neimeyer, 2009; Clark, 2009; Coster & Schwebel, 1997; Melamed et al., 2001). Similarly, relationships that had extensive conflict predicted burnout (Hardiman & Simmonds, 2013; Lakioti et al., 2020; Lin, 2012).

Humor

The use of humor was also a theme related to therapist resilience. De Lange and Chigeza (2015) identified humor as a quality that buffers against compassion fatigue and stress. Humor can relieve exhaustion, instill calm, and bring focus (De Lange & Chigeza, 2015). Therapists who had greater emotion-focused coping practices, which included use of humor, reported less burnout (Thompson et al., 2014). However, the style of humor mattered and had different outcomes. Self-defeating humor predicted emotional exhaustion and depersonalization; self-enhancing humor predicted personal accomplishment (Malinowski, 2013). Self-defeating humor is laughing when putting yourself down in an attempt to hide feelings, whereas self-enhancing humor involves using humor to cope with stress by maintaining a humorous view with intention to cheer yourself up.

Integration of Personal and Professional

This theme is about a therapist’s ability to see the bigger picture of their life and the connection between their personal and professional experiences. The connection between personal and professional realms perpetuated resilience when the therapist acknowledged how the two realms connected to one another (Clark, 2009; Patsiopoulos & Buchanan, 2011), or burnout was likely when the severity of the stress was high between work and family (Lin, 2012). This theme includes therapists taking a holistic view of themselves and acknowledging that who they are as a person is connected to their work and success as a therapist (Clark, 2009). Therapists who saw their overall pattern as a person and the interrelation between professional, personal, and spiritual realms felt less isolation in their work (Harrison & Westwood, 2009). Senior therapists reported that their work allowed them to develop as a person, enriched and broadened their personal relationships, and was easier to carry out long-term when they constructed their own self-care strategies (Råbu et al., 2016). For therapists who practiced yoga, seeing their yoga practice as a way of life allowed them to integrate the learnings from their personal practice into their professional well-being strategies as a therapist (Valente & Marotta, 2005). It is not the yoga principles themselves that fit this theme but the concept of seeing their practice as a way of life that is integrated into their professional way of being.

Meaning and Purpose

Having a sense of meaning or purpose behind their motivation to become a therapist generally prevented burnout and promoted compassion satisfaction (Clark, 2009; De Lange & Chigeza, 2015; Harrison & Westwood, 2009). For example, “practitioners who believed that their lives have purpose and meaning and see their actions as valuable and worthwhile reported greater compassion satisfaction and fewer symptoms of burnout and secondary stress” (Lakioti et al., 2020, p. 566). Having a sense of meaning in their work had the strongest influence on therapist resilience even beyond positive emotions and relationships (Lakioti et al., 2020). Therapists’ strong wish to alleviate others’ suffering was associated with greater satisfaction from their work (Laverdière & Ogrodniczuk, 2019). Apart from having a sense of purpose as a motivation to be a therapist, lacking meaning and pursuing purpose were related to burnout in one article. Therapists who had a strong motivation to seek purpose in life also reported higher burnout (Yiu-Kee & Tang, 1995).

Positive Sense of Self

This theme encompasses therapists’ relationship with themselves. Having trust in themselves through respect, acceptance, and reverence was connected to their enjoyment in providing therapy (Clark, 2009) and motivation to do the work (De Lange & Chigeza, 2015). Viewing themselves as good enough and capable in their professional endeavors was identified as a protective factor against vicarious traumatization (Harrison & Westwood, 2009). Self-efficacy was the differentiating factor for therapists who were well-adjusted compared to others (Lee et al., 2010). Self-warmth was associated with less traumatic stress and buffered against burnout (Yip et al., 2017), and self-compassion predicted less emotion regulation difficulties (Finlay-Jones et al., 2015). Patsiopoulos and Buchanan’s (2011) findings discussed therapists “compassionately attending to [their] inner dialogue” (p. 303). Being mindful of their thoughts and responding compassionately to themselves when self-doubt, self-criticism, or negative reactions arose was related to enhanced therapist well-being (Patsiopoulos & Buchanan, 2011). Accepting their own limitations without judgment allowed them to be less demanding and critical of themselves when working with clients (Patsiopoulos & Buchanan, 2011; Valente & Marotta, 2005).

Self-Awareness

This theme involves attunement to one’s body, awareness of bodily signals, and mindfulness. Emotional attunement was connected to therapists’ sense of calling and purpose in their work (Clark, 2009). Higher mindfulness attitudes predicted less burnout (Thompson et al., 2014; Yip et al., 2017), with self-monitoring behaviors being associated with therapist well-being (Coster & Schwebel, 1997). This was possible through the ability to be mindful of their present experience and intentionally respond to themselves (Bennett-Levy et al., 2015; Harrison & Westwood, 2009; Patsiopoulos & Buchanan, 2011; Richards et al., 2010; Valente & Marotta, 2005). Therapists who ignored psychosomatic symptoms of stress, such as sleeplessness, led to burnout (Lin, 2012). Therapist self-awareness promoted resilience in such a way that it even accounted for some variance in client outcomes (Pereira et al., 2017).

Spirituality

Having a spiritual, religious, or existential framework protected against burnout-related factors. The findings related to this theme are not specific to organized religion and included therapists who had a general sense of harmony with the universe and others. Feeling a sense of unity in a spiritual realm countered feeling isolated in their work (De Lange & Chigeza, 2015; Harrison & Westwood, 2009). Existential well-being predicted greater personal accomplishment and less emotional exhaustion, depersonalization, and burnout, even when working with clients who had severe trauma (Hardiman & Simmonds, 2013). Therapists who had greater emotion-focused coping practices, which included religious beliefs, reported less burnout (Thompson et al., 2014). Consistent spiritual practices such as yoga and ch’i-related exercises contained teachings and principles that supported therapist well-being (Liou, 2014; Valente & Marotta, 2005). Existential and spiritual beliefs benefited the therapists such that it also enhanced their therapeutic relationship with their clients (Patsiopoulos & Buchanan, 2011).

Comparison to Characteristics of Highly Resilient Therapists

The second aim of this study was to compare the systematic literature review results with the characteristics of highly resilient therapists (Hou & Skovholt, 2020), which are (a) drawn to Interpersonal relationships, (b) desire to learn and grow, (c) possess a core values and beliefs framework, and (d) actively engage with self. It was found that each theme from the present study reinforced at least one of the characteristics in some way. Results are presented in Table 3.

Table 3

Study Themes Aligned with Characteristics of Highly Resilient Therapists

Characteristics of highly resilient therapists (Hou & Skovholt, 2020)	Present study themes
Possess a core values and beliefs framework	Connection to community Integration of personal and professional Meaning and purpose Spirituality
Drawn to interpersonal relationships	Connection to community Emotional support
Desire to learn and grow	Pursuit of continual growth Integration of personal and professional
Actively engage with self	Emotional boundaries Humor Integration of personal and professional Meaning and purpose Positive sense of self Self-awareness

Discussion

There is not just one factor that fosters therapist resilience and prevents burnout. Each of the themes identified in this study are distinct yet connected. The qualities and strengths of one theme can help a therapist develop resilient characteristics of the others. Below is a discussion about each theme including how they may connect to one another and how they relate to the characteristics of highly resilient therapists (Hou & Skovholt, 2020). The discussion will first explore how the themes are connected in a way that contribute to counselor and psychotherapist resiliency and then will elaborate on ways the findings of the present study provide support for the characteristics of highly resilient therapists (Hou & Skovholt, 2020).

Interconnectedness of Internal Characteristics

Each theme identified in this study contains nuances and relates to previous research and other themes from the present study. For example, the integration of personal and professional theme is more nuanced than the idea of simply fitting together one’s personal self with their professional role(s). Instead, it is a more holistic idea that an individual’s process follows them, and they are influenced by where they exist. Personal experiences, temperament, and ways of being impact how therapists are, and the experiences they have as therapists in turn shape their personal experiences and worldview. People are their congruent selves wherever they go, including therapists.

Rønnestad and Skovholt’s (2013) developing practitioner phases acknowledge that as therapists become senior professionals, they become more congruent in their professional role. Although the integration of personal and professional theme relates to the senior professional phase (Rønnestad & Skovholt, 2013), the present study’s finding is not isolated to senior professionals. Instead, the finding suggests that therapists have greater resilience if they perceive the broader connection of how their personal and professional selves are all one within their full self. Integration of personal and professional self is a component of the journey of professional development that can only happen over time. If one does not have a professional self, they do not need to integrate their professional and personal self. Apart from what professional development phase a therapist might be in, acknowledging integration and interconnectedness promotes resilience. Similar to the importance of interconnection in the integration of personal and professional theme, interconnection is also relevant in the connection to community theme. When therapists practice within their own oppressed communities with generational trauma, professional practice can add extra stress beyond their own experience of oppression. The same strategies that work for clients can also benefit them as therapists by promoting self-growth and reflection, which buffers against burnout (Bennet-Levy et al., 2015). The whole community can collectively continue their resilience. Resilience is not only fostered within the defined therapeutic setting, but can also vicariously impact the whole community, including the therapists, through storytelling about collective history (Hernández et al., 2007). A therapist’s resilience is not isolated to only themselves but is connected to the entire community.

It is plausible that feeling supported emotionally relates to a therapist’s sense of self and the positive sense of self theme. Having trust in themselves and feeling good enough and professionally capable are protective factors against vicarious trauma, which leads to burnout (Clark, 2009; De Lange & Chigeza, 2015; Harrison & Westwood, 2009). Supportive relationships with others and a positive relationship with self can go together in feeling efficacious and capable.

Besides having a general positive view of oneself, another intricacy of the positive sense of self theme is a therapist’s ability to respond compassionately to themselves in moments they notice self-judgment (Patsiopoulos & Buchanan, 2011; Valente & Marotta, 2005). Both while providing therapy and outside the therapy office, the ability to be aware of their thoughts and respond with self-compassion right when they have thoughts that require such response is one aspect of promoting a positive sense of self.

Beyond simply maintaining self-compassion through a positive sense of self, the theme of self-awareness relates to a therapist’s ability to be mindful of doubt and self-criticism they can be self-compassionate toward. Mindfulness predicted greater self-warmth (Yip et al., 2017). It seems that being mindfully present with oneself fosters self-warmth, which buffers against burnout and secondary traumatic stress (Yip et al., 2017). Even in the face of secondary traumatic stress, being mindfully present with oneself and maintaining a positive sense of self was enough to prevent therapist burnout (Thompson et al., 2014; Yip et al., 2017).

Mindfulness alone does not capture the self-awareness theme. This theme also includes emotional attunement and awareness of one’s body signals (Clark, 2009; Thompson et al., 2014; Yip et al., 2017). Ignoring somatic symptoms of stress leads to burnout (Lin, 2012), while attuning to body signals and responding to their needs promotes resilience (Bennet-Levy et al., 2015; Harrison & Westwood, 2009; Patsiopoulos & Buchanan, 2011; Valente & Marotta, 2005).

Maintaining self-awareness can support a therapist’s sense of purpose, which relates to the meaning and purpose theme. Emotional attunement was connected to therapists’ sense of calling and purpose in their work (Clark, 2009). Self-awareness of ways the profession fits for themselves can help develop meaning in a therapist’s work. In turn, a therapist who has a sense of purpose is more motivated, feels greater compassion satisfaction, and has less burnout (Clark, 2009; De Lange & Chigeza, 2015; Harrison & Westwood, 2009). Therapists who strongly wish to alleviate others’ suffering also reported greater satisfaction from their work (Laverdière et al., 2019). Perhaps continuously joining clients in their suffering is less detrimental when a therapist feels the strong purpose to alleviate that suffering.

A nuance to the meaning and purpose theme is that having a sense of purpose was the strongest influence on therapist resilience, even beyond positive relationships and emotions (Lakioti et al., 2020). However, seeking purpose in life is associated with burnout (Yiu-Kee & Tang, 1995). It could be that therapists who are feeling burned out need to redefine or discover their purpose or that therapists who are actively seeking a purpose develop burnout. Future research could continue to investigate this correlation. Investigating the causal relationship between burnout and seeking purpose in life was not part of the study findings. It seems there is a distinction between lacking a sense of purpose and seeking it out through one’s work (which is related to burnout) and having a sense of purpose and living it out through one’s work (which promotes resilience).

It could be that a therapist’s spirituality is connected to the meaning and purpose theme. Even though spirituality alone predicted therapist well-being and protected against burnout, it is probable that a therapist who has a spiritual framework also holds ideas about the purpose of life, which facilitates meaning and purpose in their work. Even though these concepts might be closely connected, they are distinct because one does not need to have a spiritual or religious framework to identify meaning in their work. Just as therapists having meaning and purpose promoted resilience, religious beliefs and consistent spiritual practices on their own also promoted resilience (Liou, 2014; Thompson et al., 2014; Valente & Marotta, 2005). More research could be carried out investigating the relationship between the concepts of meaning and purpose and spirituality to consider how they are distinct yet work together to promote therapist resilience.

Comparison to Characteristics of Highly Resilient Therapists

In accordance with the second aim of this study, the identified themes in this systematic literature review echo the characteristics of highly resilient therapists (Hou & Skovholt, 2020), which are (a) drawn to interpersonal relationships, (b) desire to learn and grow, (c) possess a core values and beliefs framework, and (d) actively engage with self.

The 10 themes from the systematic literature review map onto the framework of the characteristics of highly resilient therapists (Table 3). Furthermore, the results of this systematic review appear to have common ground with the characteristics of highly resilient therapists, which is a framework that could be used to understand therapist resilience in future research and practice. Discussion of the commonalities is presented below.

Drawn to Interpersonal Relationships

Hou and Skovholt’s (2020) characteristic of being drawn to interpersonal relationships refers to highly resilient therapists’ characteristics of being strongly connected to personal relationships, staying connected to valuable professional relationships, and having compassion for others. Being drawn to interpersonal relationships includes concepts from the emotional support theme of this present study. The highly resilient therapists reported being strongly connected to personal relationships and having valued, supportive professional relationships (Hou & Skovholt, 2020). The present study’s emotional support theme is about connected and supportive relationships. Having emotionally supportive relationships in their personal and professional life was associated with therapist resilience. Vice versa, conflictual relationships contributed to burnout.

Desire to Learn and Grow

Hou and Skovholt (2020) identify the characteristic of the desire to learn and grow that refers to the desire for ongoing intellectual development and commitment to ongoing personal growth. This characteristic mirrors the pursuit of continual growth theme of this present study. Specifically, both studies identified that therapists who have a desire for ongoing intellectual development and who are committed to ongoing personal growth are more likely to be resilient. The present study theme titled integration of personal and professional also relates to the desire to learn and grow characteristic because a therapist who is open to growing as a person through their professional work acknowledges some connection or holistic aspect to how their personal and professional selves relate.

Possess a Core Values and Beliefs Framework

The characteristic of possessing a core values and beliefs framework refers to using a theoretical approach as a roadmap and having a personal values or belief base. This characteristic relates to multiple themes of the present study. Most directly, the spirituality and meaning and purpose themes are about having a personal belief or value system and having a sense of meaning that drives a therapist’s work. Connection to community also aligns with aspects of the possess a core values and beliefs framework characteristic. Therapists who are serving their own communities could have a core value of community that drives their motivation and openness to connecting with community members. Integration of personal and professional also coincides with this characteristic. When a therapist can find congruence in how their personal beliefs or values are present in their professional work, that congruence can foster resilience.

Actively Engage with Self

Hou and Skovholt (2020) refer to actively engaging with self as having self-knowledge, compassion for self, vocational conviction, and a self-conservation mode. This characteristic has common ground with most themes from the present study. First, this study’s meaning and purpose theme connects to actively engaging with self because therapists who are living out their purpose in their work can have a sense of vocational conviction, which is part of how Hou and Skovholt (2020) describe actively engaging with self. The components of the positive sense-of-self theme that are about self-acceptance and compassion also relate to this characteristic. Similarly, this present study’s self-awareness theme also relates because of the self-knowledge it takes to know what one is thinking and actively respond to oneself.

Humor and emotional boundaries also relate to actively engaging with self. Self-enhancing humor connects to the lightheartedness and playfulness component of this characteristic. Having some level of self-conservation through emotional boundaries requires knowing what one’s limits are. The self-knowledge and compassion required to set emotional boundaries relates to what it takes to actively engage with self.

Have a Strong Web of Vibrant Connectedness

The central characteristic identified by Hou and Skovholt (2020) was interconnectedness among the four core characteristics of highly resilient therapists discussed above. In their study using grounded theory (Corbin & Strauss, 2014), Hou and Skovholt (2020) found the central characteristic of having a strong web of vibrant connectedness emerging throughout the entire coding process and how it richly interlinked with other categories. “The central characteristic was undeniably the driving force that sustains therapists to remain resilient” (Hou & Skovholt, 2020, p. 395). While superordinate connectedness was not a theme within this systematic literature review, Hou and Skovholt (2020) used grounded theory (Corbin & Strauss, 2014), which likely contributed to identifying a finding regarding how the other themes were connected. As interconnectedness of all the characteristics is not as concrete or measurable as the characteristics themselves, it is possible that it contributes to resilience but was not as easily captured in this systematic review. On the other hand, the results of this systematic review provided evidence for Hou and Skovholt’s (2020) recommendation that the central characteristic of connectedness has not been stressed in existing literature, and it requires more scientific investigation in the understanding counselor and psychotherapist resilience.

Implications for Therapists

The findings of this study have implications for helping professionals as we do our work in the ever-changing world. Not only is there added emotional stress just by the very nature of being a therapist, but the added stress that can arise from one own’s life events or global factors calls for therapists to intentionally take care of themselves and channel their resilience. The most general implication of this present study is that internal characteristics matter when promoting resilience and preventing burnout. This systematic literature review found similarities with Hou and Skovholt (2020), which bolsters the findings that internal characteristics matter. It is worthwhile for therapists to focus on the factors identified in these findings. Intentionally seeking ways to implement the characteristics of highly resilient therapists could benefit therapist resilience.

Although resilience-fostering characteristics are especially needed during acute times of stress (Skovholt & Trotter-Mathison, 2016), they can be fostered even at times of balance and calm. These internal characteristics can also be cultivated throughout a therapist’s career, starting when one is a novice practitioner. Training programs and supervisors alike could help prevent burnout in future therapists by supporting their trainees to develop these internal characteristics before they become independent practitioners. A Supervision model in social work has emphasized the importance of resilience (Mack, 2021). Other helping professions would do well to follow suit.

Results encourage therapists to maintain a curiosity of what they can learn about themselves and the world. Cultivate the resilience-bolstering characteristic of desiring to learn and grow. That curiosity can help foster growth. Maintaining a “beginner’s mind” can keep your mind open to personal development and growth (Patsiopoulos & Buchanan, 2011).

Implications of the results also encourage therapists to intentionally develop the characteristic of active engagement with self by taking time to know themselves and how they present themselves in their profession and community. Actively engaging with oneself through mindfulness, humor, and spiritual practices can foster resilience and prevent burnout. Those moments of self-engagement can also help a therapist know what boundaries need to be set. Limiting conflictual relationships and maintaining emotional boundaries can reduce burnout.

For many practitioners, increased remote work was precipitated by the COVID-19 pandemic, but it is also emblematic of the ongoing transformation in the labor force. Regardless of how a therapist provides their services, there is evidence that the characteristic of being drawn to interpersonal relationships bolsters resilience. Whether in one’s personal life or with professional colleagues, the results suggest that it is worthwhile for therapists to maintain relationships wherein they feel supported and safe and to create emotional boundaries in relationships with notable conflict. Therapists in a private practice or working from home may need to exert extra effort to feel connected in interpersonal relationships. The benefits of emotional support could balance out and bring greater benefit than the drawbacks it takes to maintain connection with those not in one’s immediate proximity.

Finally, the results also implicate the characteristics to possess a core values or beliefs framework. Religious or not, some framework that gives meaning to one’s work and helps therapists to feel connected with something greater than themselves fosters resilience. For therapists who do not currently have a beliefs framework, it could be helpful to identify their personal core values and how those values are part of their daily life. For therapists who do have a framework already in place, reflecting on how those values and beliefs are integral in their daily life and work could build the purpose felt in one’s work.

Implications for Future Research

This thorough systematic review of therapist resilience literature has brought together what we know about fostering resilience and preventing burnout. There continue to be areas that would benefit from future research to deepen what we know about therapist resilience. Given the body of evidence the present study identified that supports Hou and Skovholt’s (2020) findings, the authors recommend that the characteristics of highly resilient therapists be one model used to understand internal characteristics of resilient practitioners. For themes that overlap between this systematic literature review and the characteristics of highly resilient therapists (Hou & Skovholt, 2020), more investigation could be done about how each component of the characteristics function when fostering resilience and investigate the characteristic of connectedness that has not been recognized and stressed in the literature on therapist resilience. For example, although there are distinctions between a therapist having meaning and purpose and spirituality, these themes also relate. More research could be done investigating the relationship between these concepts to consider how they are distinct yet work together to promote therapist resilience.

The relationship between burnout and seeking purpose in life could also be investigated further. It seems there is a distinction between lacking a sense of purpose and seeking it out through one’s work versus having a sense of purpose and living it out through one’s work. The finding suggested that seeking a purpose is related to burnout but having a purpose and living it out leads to resilience.

The role of congruence, that is the integration of personal and professional, needs to also be investigated further. A holistic understanding of the connection of the personal and professional parts of themselves is related to therapist resilience; however, it is unclear if such a finding is only true at a therapist’s senior phase of their career. Most of the research supporting this finding focused on advanced practitioners. More research needs to be completed about whether this theme is more prominent in senior professionals or if it is connected to resilience regardless of the professional development phase.

Limitations

This study was a systematic review of peer-reviewed original research measuring therapist resilience and burnout with the aim to investigate how Hou and Skovholt’s (2020) characteristics of highly resilient therapists relates to previous findings. The results were limited by what peer-reviewed literature was available in English. We also only used one database to search for articles (PsycINFO). We did not include other databases due to the plethora of results located in PsycINFO.

It is possible that there is some level of confirmation bias. First, the personal views of the authors could have implicated the results of the analysis. Besides revisiting their biases with the attempt to stay mindful of how their personal ideas were the same or different from the findings of each study included in the analysis, there was no formal process for bracketing their personal views or otherwise accounting for them. Second, some confirmation bias may also have been in effect when considering how themes from previous resilience literature relate to Hou and Skovholt’s (2020) findings. However, the present study is not just replicating the literature review that led Hou and Skovholt to develop their research question. Even though the research identifying the characteristics of highly resilient therapists was based on previous research, this systematic review provides a meaningful contribution to those findings because of its systematic methods of identifying and coding previous peer-reviewed research. Instead of using a general literature search to identify a research question, this was a systematic review of the literature to rigorously evaluate common themes.

Another limitation is that the present study focused only on counselors, therapists, and psychotherapists and was not inclusive of other helping professions. Even though there was reason to focus only on therapists due to the differences their work has compared to other professions, such as school counselors, it is possible that there are commonalities in what fosters resilience in all helping professions.

There is evidence that external factors (e.g., workplace culture and environment) relate to resilience (e.g., Broome et al., 2009; Choi et al., 2014; Ducharme et al., 2007). This study solely focused on internal characteristics therapists have that can foster resilience and prevent burnout and did not address external contributions to therapist resilience.

Conclusions

This study systematically reviewed literature focused on internal characteristics of therapist resilience. In all, 10 themes were identified that comprise aspects of therapist resilience that are not dependent on a practitioner’s work environment or other external factors. Not only did the present study identify themes in the systematically identified articles, but those themes also reinforced Hou and Skovholt’s (2020) characteristics of highly resilient therapists. Furthermore, results seem to support the use of the characteristics of highly resilient therapists as a possible model of understanding internal characteristics that foster therapist resilience.

Future research could further examine the characteristics of highly resilient therapists as a core model of therapist resilience. Especially for therapists practicing during a time of heightened stress (Gruber et al., 2021), understanding what factors foster resilience and prevent burnout can support therapists to stay well and to keep serving clients. We cannot be reliant solely on external workplace factors that promote resilience. The findings of this present study contribute to what we know about internal characteristics therapists have that can foster steadfast and long-standing therapist resilience.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lily Walker

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