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Couns Psychother Res. 2022;00:1–9.
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1wileyonlinelibrary.com/journal/capr
1 | INTRODUCTION
Burnout is a public health challenge, particularly in human service
professions. The syndrome was defined in the 1970s as a reaction
to long- lasting work- related stress, especially experienced by people
working in human service professions. It comprises three different
reactions: emotional exhaustion, depersonalisation and reduction
in personal accomplishment (Maslach et al., 2001). Burnout is a
problem for individuals and an economic burden for society due to
healthcare costs, sick leave and high turnover (Borritz et al., 2005,
2010; Eliacin et al., 2018; Lee et al., 2011; Peterson et al., 2008).
Research has linked burnout to a variety of health problems such as
Received: 21 December 2021
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Revised: 17 March 2022
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Accepted: 17 March 2022
DOI: 10.1002/capr.12532
ORIGINAL ARTICLE
Self- perceived clinical competence, gender and workplace
setting predict burnout among psychotherapists
Åsa Spännargård | Simon Fagernäs | Sven Alfonsson
This is an open access article under the terms of the Creative Commons Attribution- NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. Counselling and Psychotherapy Research published by John Wiley & Sons Ltd on behalf of British Association for Counselling and
Psychotherapy.
Centre for Psychiatr y Research,
Department of Clinical Neuroscience,
Karolinska Institutet, Stockholm Health
Care Services, Region Stockholm, The
Centre for Psychotherapy, Education &
Research, Stockholm, Sweden
Correspondence
Åsa Spännargård, Centre for Psychiatry
Research, Department of Clinical
Neuroscience, Karolinska Institutet,
Stockholm Health Care Services, Region
Stockholm, The Centre for Psychotherapy,
Education & Research, Liljeholmstorget 7,
SE- 117 63 Stockholm, Sweden.
Emails: asa.spannargard@ki.se;
sven.alfonsson@ki.se
Abstract
Work- related stress, or burnout, is elevated among healthcare staff but the specific
risk factors for psychotherapists are not clear, which makes it difficult to design inter-
ventions to target this population. Therefore, the aim of this study was to investigate
a set of background variables and work- related risk factors for burnout among psy-
chotherapists. Potential protective factors such as level of education, number of years
in the profession and access to clinical supervision were investigated. Symptoms of
burnout were measured with the Copenhagen Burnout Inventory, and data were col-
lected from 327 psychotherapists. In this group, 62% reported moderate or high levels
of burnout symptoms, with significantly higher levels of personal- and work- related
burnout than client- related burnout. Being female, having low self- perceived compe-
tence and working in the public sector were associated with higher levels of burnout.
Other factors, such as age, work experience, level of education or having clinical su-
pervision, were not associated with burnout after controlling for gender, perceived
competence and workplace setting. These results confirm previous research that un-
derlines the importance of perceived competence and control over one's work envi-
ronment, and that women are at higher risk of burnout, possibly because of factors
outside of work. The importance of perceived competence as a protective factor sug-
gests that methods that increase therapeutic competence may play an important role
in countering work- related stress. In conclusion, there may be a need to continue to
develop and integrate specific burnout prevention interventions for psychotherapists.
KEYWORDS
burnout, carers, clinical supervision, mental health, psychotherapy
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SPÄNN ARGÅRD et Al .
depression, insomnia and cardiovascular problems (Lee et al., 2011;
Peter et al., 1998; Peterson et al., 2008). Common consequences of
burnout, such as depression and other mental ill- health, might have
a negative impact on workplace functioning and safety of patients
(Gärtner et al., 2010). It is kn own that people with symptoms of bur n-
out have difficulties getting relevant help from the healthcare sys-
tem. Findings in a qualitative study by Engebretsen and Bjorbækmo
(2020) indicate that burnout is often interpreted as a state of de-
pression, which simplifies the problem and does not mirror the com-
plexity and suffering of the individual. In another qualitative study,
Engebretsen and Bjorbækmo (2019) found that participants expe-
rienced a lack of support from their doctor and described that no
diagnosis verified their suffering. In the same study, participants de-
scribed that they felt shame and loss of self- confidence as a conse-
quence of the lack of support regarding their suffering (Engebretsen
& Bjorbækmo, 2019). The specific risk and protective factors for
burnout are, however, likely to be different in different healthcare
sectors. In a qualitative study of psychotherapists working in pri-
vate prac tice, it was found that a professional identity crisis occurred
for some of the participants as a part of the experience of burnout.
Another experience the participants described in that same study
was that the impact of burnout made them question their capacity
to perform their work effectively (Finan et al., 2022). Clinical staff
in mental healthcare services seems to be exposed to work- related
stress to a high degree. Several studies have investigated burnout in
mental health providers, and 40% to 70% are estimated to have high
levels of burnout (Johnson et al., 2020; Morse et al., 2012; Shanafelt
et al., 2015; Westwood et al., 2017). For example, a study of the
Improving Access to Psychological Therapies (IAPT) programme in
the United Kingdom found elevated levels of burnout among the
clinical staff (Westwood et al., 2017). Specifically, the group defined
as ‘Psychological wellbeing practitioners’ reported high levels of
stress, with almost 70% classified as having high levels of burnout.
For cogniti ve behavioural the rapists in the s ame programme, t he cor-
responding figure was somewhat lower, at 50%. In the same study, it
was also found that for every hour of overtime worked, the level of
burnout increased, and overtime work was interpreted as the most
important predictor of burnout. Time pressure and work overload
have also been confirmed as predictors of burnout in other studies
of mental health practitioners (Weigl et al., 2016). The same pattern
was found in a meta- analysis by Lim et al. (2010) that included 15
studies on burnout among 3,613 mental health professionals. The
results indicated that work setting, total amount of working hours,
and younger age were important risk factors for burnout. In sum-
mary, workload and high demands at mental health workplaces,
and in private practice, have been found to be important risk fac-
tors for burnout in several studies (Hammond et al., 2018; Morse
et al., 2012; Westwood et al., 2017).
Demands at work are most likely multifaceted and vary depend-
ing on the type of organisation and work content. Presumably, there
is a conflict between administrative demands and other forms of
non- clinical tasks, on the one hand, and the specific nature of pro-
viding psychological care on the other (Eliacin et al., 2018). This
conflict may be further enhanced in psychiatric services by the fact
that patients’ needs are often greater than the resources or inter-
ventions at hand. In other words, therapists who meet patients in
distress may be affected by their emotional states and may be frus-
trated for not being able to meet each and ever y patient's needs
(Eliacin et al., 2018, Simionato & Simpson, 2018). It is easy to feel
inadequate and to strive to give as much as possible to every pa-
tient at the expense of one's own time and energy. Psychotherapists
are trained to focus on the therapeutic relationship and therefore
tend to have a strong sense of loyalty to their patients. Hammond
et al. (2018) found that psychologists working in private practice ex-
perienced that their clients’ expectations were more important than
their own well- being and they repor ted a lack of education regarding
self- care. Client engagement and demands for empathy might have a
role in burnout (Simionato & Simpson, 2018 ). In a meta- analysis that
investigated burnout in psychotherapists specifically, it was found
that over- involvement was strongly associated with emotional ex-
haustion, which is a central aspect of burnout (Lee et al., 2011). To
moderate these risks, interventions at an organisational level might
be used by management to protect their employees. For example,
Peterson et al. (2008) found that a percieved positive climate at
work and an empowering leadership were associated with lower lev-
els of burnout. Taken together, staff working in psychotherapy and
other psychological treatments are at risk of experiencing high levels
of demands and low levels of control, which is a well- known risk fac-
tor for unhealthy stress reactions (Karasek, 1979; Peter et al., 1998).
On the other hand, one factor that is recurrently found to be pro-
tective against burnout is the perception that one has the resources,
skills and opportunities to help patients in a relevant way, but there
are only a handful of studies that have investigated this (Simionato &
Simpson , 2018). In the study by Lim a nd colleagues, it w as shown that
Implications for Practice and Policy
• This study investigated a number of potential risk fac-
tors for stress symptoms among therapists in different
clinical settings, but only gender, perceived clinical com-
petence and work setting were associated with moder-
ate and high levels of burnout. Being female and feeling
less clinically competent were risk factors for stress,
while working in private practice was associated with
less stress.
• This study points towards the vulnerable groups and
work settings that may need further study and possible
interventions to reduce the risk of stress, increased sick
leave and turnover.
• However, the results also indicate that effective inter-
ventions to increase competence may have a positive
effect on therapists’ stress and promote a healthy work
situation.
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SPÄNNARGÅR D et Al.
staff members of older age showed lower levels of burnout, which
was assumed to be associated with a sense of competence that may
come with more years of clinical experience (Lim et al., 2010). A par-
ticipating psychologist in Hammond et al.'s study stated that knowl-
edge and years in the profession and trusting long- term relationships
were protective factors against burnout (Hammond et al., 2018).
Other possible explanations are that experienced clinicians develop
coping strategies that might protect them from burnout, or that peo-
ple who are unable to cope with the work seek out other careers.
However, several studies have shown that emotional support from
colleagues may ameliorate problems of work- related stress and frus-
tration among mental health professionals (Carpenter et al., 2013;
O'Donovan et al., 2011; Watkins, 2012). For example, in the study
of staff in the IAPT programme, it was found that therapists who
participated in clinical supervision reported fewer symptoms of
burnout (Westwood et al., 2017). In conclusion, there is a need to
better identify the specific risk and protective factors for developing
burnout among psychotherapists in order to adjust or design inter-
ventions for this population.
1.1 | Aims
The overall aim of this study was to map the level of work- related
burnout and fatigue among psychotherapists working in clinical set-
tings and to investigate the relation bet ween burnout and (a) person-
related factors such as age, training, level of education, years in
profession and perceived competence; and (b) work- related factors
such as type of clinical setting, satisfaction with the work situation
and access to clinical supervision.
2 | METHODS
2.1 | Procedure
The study was cross- sectional and collected data through an on-
line survey with a questionnaire constructed for the purpose of the
study, as well as a previously published measure of burnout, de-
scribed below.
2.2 | Measures and instruments
2.2.1 | Background variables and work-
related factors
Participants’ gender (woman/man), age (years), profession (psycholo-
gist/nurse/social worker/medical doctor/other), psychotherapeutic
orientation (cognitive/behavioral/psychodynamic/interpersonal/sys-
temic/psychanalytic/other), clinical work experience (years), advanced
psychotherapy training corresponding to 2.5 years of full- time train-
ing (yes/no), setting of clinical practice (primary mental health care/
psychiatric outpatient care/psychiatric inpatient care/addiction care/
residential mental health treatment environment/occupational health
care/private practice/somatic health care/other) weekly client work-
load (% of working time), participation in clinical supervision (yes/no),
supervision format (individual/small group/large group) and supervi-
sion frequency (weekly or bi- weekly/once or twice a month/more sel-
dom) was collected by a survey constructed for this study.
2.2.2 | General work satisfaction
To assess whether the participating therapists were satisfied with
their working situation and clinical work, they were asked to rate
three different aspects of work satisfaction: (a) satisfaction with
their own level of competence to be able to provide psychotherapy
in a satisfactory manner, (b) satisfaction with their general work
environment, and (c) satisfaction with the clinical work they were
doing. The scale for measuring each question was between 0 and
100 (0 = not at all satisfied and 100 = totally satisfied).
2.2.3 | The Copenhagen Burnout Inventory (CBI)
Work- related stress and fatigue were measured with the
Copenhagen Burnout Inventory (CBI; Kristensen et al., 2005). The
scale was developed to address the limitations of the earlier pre-
dominantly used scale, the Maslach Burnout Inventory (MBI) (for
an overview of the critique, see Kristensen et al., 2005). The CBI is
theoretically referring to the two dimensions of burnout, fatigue and
exhaustion, and closely follows the framework of Shaufeli (Schaufeli
& Greenglass, 2001). The scale consists of 19 items and has three
different subscales: (a) personal burnout (a generic subscale), refer-
ring to how much a person perceives that he or she is exhausted
and fatigued, regardless of occupational status and age; (b) work-
related burnout (related to the person's work situation); and (c)
client- related burnout (related specifically to working with clients).
Each item of the CBI is scored on a Likert scale where 1 = high levels
of burnout and fatigue and 5 = low levels of burnout and fatigue.
The total score on the 19 items is recalculated into a score between
0 and 100, with lower scores indicating lower levels of burnout and
fatigue and higher scores indicating higher levels of burnout and
distress. A score lower than 25 indicates low levels of burnout, 25–
50 moderate levels, and over 50 indicates high levels of burnout
(Caesar et al., 2020). The three- factor structure of the CBI and the
overall psychometric properties have been confirmed in several
studies (Thrush et al., 2020; Walters et al., 2018; Montgomery et al.,
2021). However, since other studies have suggested a two- factor
solution, an exploratory factor analysis of the CBI was conducted
and resulted in a suggested three- factor solution with alpha = 0.87
for the personal subscale, alpha = 0.74 for the work- related subscale
and alpha = 0.84 for the client- related subscale, indicating that the
results from the CBI could be analysed in their original form (Eng
et al., 2021).
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SPÄNN ARGÅRD et Al .
2.3 | Participants
The study population was clinically active psychotherapists with
different professional backgrounds, working in psychiatric care or
other mental health settings in Sweden. The criterion for partici-
pation was to currently work with psychological treatment and/or
psychotherapy. To get in contact with therapists, the researchers
contacted the boards of associations for professions working with
psychotherapy and psychological treatment. Their members were
then contacted via email. The researchers also used social media and
email lists to invite psychotherapists to take part in the study. The
email contained a brief description of the study, an invitation and a
link to the questionnaire survey. In total, 327 psychotherapists in
different clinical settings and with various therapeutic profiles par-
ticipated in the survey and provided data for analysis.
Two hundred and sixty (80%) of the participants were women.
The mean age was 47.4 (SD = 10.6) years, and the mean clinical work
experience was 12.5 (SD = 8 .0) years. One hundred and eight y- three
(56%) had advanced training in psychotherapy. The mean weekly per
cent of client work was 71% (SD = 27.2%). A majority (n = 243, 74%)
of psychotherapists in this study participated in clinical supervision,
which was conducted individually (n = 59, 24%), in a group of up
to five people (n = 153, 63%) or in a larger group (n = 31, 13%).
Supervision typically took place bi- weekly (n = 59, 24%), once a
month (n = 148, 61%), or more seldom (n = 36, 15%). Participants’
profession, therapeutic orientation and clinical setting are presented
in Table 1.
2.4 | Analyses
Linear regression analyses were used to identify predictor variables
for work- related burnout. Based on the research literature (Yang
& Hayes, 2020), the selected predictor variables were gender, age,
years of wor king experienc e, client workload , work setting , advanced
training in psychotherapy, therapeutic orientation, perceived clini-
cal competence, and access to and context of clinical supervision.
Nominal variables with several categories (e.g., profession) were re-
coded into dummy variables (e.g., profession psychologist = yes/no)
before being entered in the regression analyses and ordinal variables
(e.g., frequency of supervision) were treated as continuous variables.
While ordinal variables can be analysed in linear regression, the re-
sults must be interpreted with caution. Predictor variables were
first investigated in bivariate linear regression analyses, and all vari-
ables that were threshold significant (p < .05) were entered into a
multiple regression model using a backward deletion method. Final
models were confirmed with bootstrap methods to confirm the re-
sults. Differences between groups were analysed with independent
t- tests, while differences within groups were analysed with depend-
ent t- tests. A p- value of .05 was used as a threshold for statistical
significance in all analyses. Cohen's d was used as a measure of ef-
fect size with d = 0.2 indicating a small effect, d = 0.5 indicating a
medium effect and d = 0.8 indicating a large effect.
3 | RESULTS
3.1 | Work satisfaction
The participants’ self- perceived competence was M = 76.9
(SD = 15.1). The perceived satisfaction with the work environment
was M = 69.5 (SD = 22.6), and the perceived satisfaction with the
clinical work was M = 83.0 (SD = 13.0). The difference in perceived
satisfaction between work environment and clinical work was sig-
nificant (t = 10.65, p < .001, d = 0.68).
3.2 | Work- related burnout and fatigue
The mean total score on the CBI was M = 31.5 (SD = 14.6), which cor-
responds to moderate levels of burnout. Using the categorisation cut-
off values for the CBI total scores, 124 (38%) participants reported low
levels, 164 (50%) moderate levels and 39 (12%) high levels of burnout.
The results for each of the three subscales are presented in Table 2.
TABLE 1 Participants’ profession, therapeutic orientation and
clinical setting (N = 327)
n (%)
Profession
Psychologist 193 (59%)
Nurse 24 (7%)
Social worker 68 (21%)
Medical doctor 4 (1%)
Other 44 (13%)
Psychotherapeutic orientation
Cognitive behavioural 190 (58%)
Psychodynamic 60 (18%)
Interpersonal 30 (9%)
Systemic 23 (7%)
Psychoanalytic 2 (0.5%)
Othera71 (22%)
Setting of clinical practice
Primary mental health care 81 (25%)
Psychiatric outpatient care 133 (41%)
Psychiatric inpatient care 7 (2%)
Addiction care (inpatient/outpatient) 13 (4%)
Residential mental health treatment
environments
16 (5%)
Occupational health care 10 (3%)
Private practice 53 (16%)
Somatic health care 13 (4%)
Otherb55 (17%)
aSome participants reported using combinations of therapeutic
orientations.
bParticipants could choose more than one clinical setting.
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SPÄNNARGÅR D et Al.
Pairwise comparisons showed that the participants scored sig-
nificantly higher on the personal burnout subscale compared to both
the work- related burnout (t = 8.25, p < .001, d = 0.46) and the client-
related burnout (t = 8.95, p < .001, d = 0.49) subscales. The CBI
client- related burnout subscale mean was significantly lower than
the CBI work- related burnout (t = 4.70, p < .001, d = 0.26) subscale.
3.3 | Factors associated with burnout and fatigue
Of the suggested predictor variables, five were significantly associ-
ated with burnout and fatigue in the bivariate regression analyses,
as seen in Table 3. Gender, professional background, percentage of
working time spent on client work, therapeutic model, having clinical
supervision or the context of supervision (setting, frequency) were
not significant predictors for CBI total score. The same patterns
were seen for each of the subscales with the exception of gender,
which was a significant predictor for the CBI personal (B = 6.56,
SE = 2.34, b = 0.15, t = 2.81, p = .005) and work- related subscales
(B = 4.39, SE = 2.09, b = 0.12, t = 2.10, p = .037), with women report-
ing higher levels of burnout than men. Gender was not a significant
predictor for the client- related subscale.
After entering the statistically significant variables from the bi-
variate analyses into a multiple regression analysis, only perceived
competence and working in a private practice remained significant
predictors for CBI total score.
In multiple regression analyses for each subscale of the CBI, gender
(B = 6.80, SE = 2.32, b = 0.16, t = 2.93, p = .004), perceived compe-
tence (B = −0.16, SE = 0.07, b = −0.13, t = 2.41, p = .017) and work-
ing in private practice (B = −5.09, SE = 2.20, b = −0.13, t = −2.32,
p = .021) were significant predictors for the CBI personal subscale. The
same pattern with gender (B = −4.73, SE = 2.03, b = −0.13, t = −2.32,
p = .021), perceived competence (B = −0.20, SE = 0.06, b = −0.20,
t = −3.56, p = .001) and working in private practice (B = −5.88, SE =
1.93, b = −0.17, t = −3.05, p = .002) as significant predictors was seen
for the work- related burnout subscale. For the client- related burnout
subscale, only perceived clinical competence (B = −0.23, SE = 0.06,
b = −0.21, t = −3.85, p = .001) and working in private practice (B = 5.16,
SE = 1.99, b = 0.14, t = 2.59, p = .01) were significant predictors.
4 | DISCUSSION
One aim of this study was to explore potential risk and protec tive fac-
tors for burnout among psychotherapists. This is important in order
to better understand how to design interventions to reduce burnout
in this population. Furthermore, it is important to differentiate fac-
tors that are presumably more easy to intervene with or prevent in
comparison with others. As an example, changing the organisational
structure of the public sector is a much more complex task than ad-
dressing perceived competence, which may presumably be targeted
with individual interventions. We found that 50% of the psychother-
apists reported moderate levels of burnout, while 12% reported high
levels. In other words, 62% of the psychotherapists reported mod-
erate or high levels of burnout symptoms, with significantly higher
levels of personal- and work- related burnout than client- related
burnout. Being female, having low self- perceived competence and
working in the public sector were associated with higher levels of
burnout. Other factors, such as age, work experience, formal educa-
tion or having clinical supervision, were not associated with burnout
after controlling for gender, perceived competence and work setting.
The levels of work- related burnout found in this study are similar to
levels seen in previous studies of mental health staff. In a systematic
review of burnout among psychotherapists that included 40 studies
published between 1986 and 2016, mentioned above, 50% of partic-
ipants showed moderate to high levels of stress and burnout symp-
toms (Simionato & Simpson, 2018). However, in that review, only two
studies used the CBI to measure burnout. Interestingly, in a study
by D'Souza et al. (2011), the reported CBI mean values were gener-
ally on par with the results in this study, but the pattern across the
CBI subscales was inverted compared to this study, with the lowest
scores for personal burnout and the highest scores for client- related
burnout. In a study by Di Benedetto and Swadling (2014), both the
levels and subscale pattern of the CBI were similar to the present
study. However, in contrast to this study, Di Benedetto and Swadling
found no differences in burnout between participants working in
public and private settings, but a negative association between work
experience and burnout. In another study by Wilkinson et al. (2017),
80 mental health providers (primarily psychologists and counsellors)
scored a mean total of 42.6 on the CBI, with 19% scoring above 50
points, indicating risk for burnout, which is higher than in the current
study. The subscale pattern was otherwise similar to this study, with
the highest scores on the personal burnout subscale and the low-
est on the client- related subscale of the CBI. Wilkinson et al. (2017)
also found that working with evidence- based methods and follow-
ing treatment recommendations were associated with lower levels
of burnout, which may be related to self- perceived competence, as
investigated in this study. Taken together, it seems that for psycho-
therapists that have adequate competence for their clinical work,
workplace setting and working conditions may still be important
factors in work- related stress (McCormack et al., 2018; Rupert &
Morgan, 2005). An analogue pattern was seen regarding work satis-
faction, where participants in this study reported more satisfaction
with client work than with the work environment.
TABLE 2 Mean and standard deviations for the CBI subscales
and total score (N = 327)
CBI M (SD)
Personal burnout 35.8
(17.6)
Work- related burnout 31.0
(15.7 )
Client- related burnout 27. 7
(16.2)
Total score 31.5
(14.6)
Abbreviations: CBI, Copenhagen burnout inventory.
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SPÄNN ARGÅRD et Al .
In this study, levels of work- related stress and burnout, based
on the CBI total score, were only predicted by two variables in the
final multiple regression model, namely perceived competence and
working in private practice. This finding corresponds with estab-
lished models of work- related stress that focus on the importance
of perceived control (Karasek, 1979; Rupert et al., 2012). In contra-
diction, a qualitative study of solo- practising clinical psychologists
revealed that participants felt that perceived loss of control of one's
economical safety was an important aspect of burnout (Hammond
et al., 2018). A recent meta- analysis by Lee et al. (2020), that in-
cluded 27 original studies on work- related risk factors for burnout,
showed that negative client contacts (e.g., aggressive, dangerous
and threatening behaviours from clients) was a stronger predictor of
burnout than, for example, caseload or working hours. Also, role and
work task conflicts were stronger predictors of burnout than work-
ing hours. Regarding the results of this study, an interpretation could
be that a higher degree of perceived competence lessens the impact
of negative client contacts and that therapists working in a private
practice have more control of working roles and tasks. It is also pos-
sible that it is important to differentiate between positive and neg-
ative client contacts when exploring sources of work- related stress.
A psychotherapist who perceives that they have the competence
to help patients is likely to feel less anxiety, more work satisfaction
and reduced stress. In their thematic study, Hammond et al. (2018)
found that knowledge of their profession and years of experience
working with clients were protective factors against burnout for
psychotherapists. Psychotherapy is not always a rewarding experi-
ence for therapists, and most have experiences of failed treatments
and patients they were unable to help (Honda, 2014). These expe-
riences can lead to frustration and feelings of inadequacy that may
in turn lead to stress and fatigue. It is noteworthy that, in this study,
we did not measure actual competence but only self- perceived com-
petence, and whether this is an accurate measure of competence
is questionable. However, the feeling that one has control may be
a highly important factor in the development of stress. This is sup-
ported by the fact that psychotherapists that work in private prac-
tice have a higher level of control over their working conditions than
therapists that work in public healthcare practices (Steel et al., 2015;
Vredenburgh et al., 1999). As reported above, burnout associated
with general work experiences was significantly higher than burn-
out associated with client- related work. Accordingly, working condi-
tions, rather than clinical challenges, may be more important in this
regard. However, it is also possible that the clinical contexts are dif-
ferent between private and public practices, as a larger proportion
of challenging patients tend to be found in public practice, and this
was not investigated and controlled for in this study.
Previous research has suggested that gender differences in
burnout are best explained by the fact that male and female psy-
chotherapists tend to work in different clinical settings. This was
not supported in the current study, in which gender and work set-
ting were independent risk factors for burnout. The results of the
present study showed that gender was not a significant predictor
for client- related stress, but was a predictor of personal and work-
related burnout, with women reporting higher burnout than men,
which is in line with previous research (Yang & Hayes, 2020). In a
number of studies, it has been found that women have higher levels
of burnout, especially in relation to the aspect of burnout defined as
exhaustion (Johnson et al., 2020; Simionato & Simpson, 2018). For
example, in the study by D'Souza et al. (2011), only 8% of 87 clinical
psychologists reported a CBI score above 50. The gender pattern
was nevertheless similar to the present study, where the results
showed that women were reporting significantly higher levels than
men on the CBI personal and work- related subscales, but not on the
client- related subscale. Furthermore, age was negatively correlated
with each of the CBI subscales. Taken together, this suggests that
the elevated levels of personal burnout may be at least partly ex-
plained by factors such as different responsibilities in the workplace,
family situation, social obligations or economic strains, which tend
to be larger burdens for women than men (Cerrato & Cifre, 2018;
SCB, 2018:44).
Regarding person- specific risk factors, previous research has
shown that less work experience, lower age and less education
can predict higher levels of burnout and work- related stress (Lim
et al., 2010; McCormack et al., 2018; Simionato & Simpson, 2018).
BSE βt p
Bivariate regression analyses
Age −0 .19 0.08 −0.14 −2. 57 .011
Advanced training in psychotherapy −4.77 1.60 −0.16 −2.97 .003
Years of working experience −0.35 0.09 −0.19 −3.57 .001
Perceived competence −0.22 0.05 −0.23 −4.19 .001
Private practice −7. 28 1.76 −0.22 −4.13 .001
Multiple regression analysis
Age 0.03 0.10 0.02 0.30 .76
Advanced training in psychotherapy −0.35 1.97 −0.01 −0.17 .86
Years of working experience −0.20 0.14 −0.11 −1 .42 .16
Perceived competence −0.15 0.06 −0.16 −2.78 .006
Private practice −5.02 −1 .9 3 −0.15 −2.59 .010
TABLE 3 Bivariate and multiple
regression analyses of predictors for
burnout and fatigue (CBI total score)
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7
SPÄNNARGÅR D et Al.
These results were, to some extent, confirmed in the present study,
in which age, work experience and advanced training in psychother-
apy were predictors of protection against burnout. However, when
analysed together with perceived competence, the effects vanished,
suggesting that perceived competence is the essential factor com-
monly associated with all these variables (Yang & Hayes, 2020). This
finding confirms previous research which has found that feelings of
inadequacy are a risk factor for work- related stress among mental
health workers (Eliacin et al., 2018). Furthermore, in the study by
D'Souza et al., 2011, it was found that perfectionism was related
both directly and indirectly to burnout in a sample of clinical psy-
chologists. It is likely that some personality traits are associated with
burnout across professions and not only among psychologists. Since
the current study focused on the work situation for psychothera-
pists, personality traits were not investigated, but this may be im-
portant to explore further in future research.
Several previous studies have shown that organisational factors
in the workplace, such as case- or workload, can have an impact on
burnout. For example, in their review of burnout among psycholo-
gists, McCormack et al. (2018) found that the most consistent risk
factor for burnout was workload, especially in combination with low
levels of control and low levels of perceived self- sufficiency. In the
current study, workload as measured in McCormack's study was not
assessed, but the percentage of working time spent on client work
was not associated with burnout.
Regarding protective factors, a majority (n = 243, 74%) of psy-
chotherapists in this study participated in clinical supervision, which
typically was conducted once a month in a small group. In contrast
to some previous studies, levels of work- related burnout and fa-
tigue were not different between those who received supervision
and those who did not, and there may be several reasons for this
(Westwood et al., 2017). To start with, clinical supervision may sim-
ply not affect work- related stress. If clinical supervision would have
a burnout- reducing effect, it would theoretically be found on the
client- related burnout scale, but there were no significant differ-
ences on this scale between those who had supervision and those
who did not. However, other reasons may be more plausible. For
example, there may be a subgroup of therapists who may benefit
from supervision regarding reduced burnout, but this group was too
small to have an impact when analysing the larger group of thera-
pists. Along similar lines, the therapists who do not receive supervi-
sion may have less need for supervision for stress- related reasons. In
other words, whether or not a therapist participates in supervision
may not be random but dependent, among other things, on elevated
levels of stress. Furthermore, this study did not investigate the con-
tent of supervision, which most likely has a significant impact on
whether the supervision has a reducing effect on burnout. There is
no indication from our results that supervision had a significant im-
pact on therapists’ work- related burnout and fatigue at a group level.
However, this does not mean that supervision tailored for managing
work- related stress may not be beneficial for therapists with such
symptoms. A recent study examined the quality of supervision in
relation to burnout among psychotherapists (Johnson et al., 2020)
and found that the quality of the supervision relationship had a small
but significant impact on ‘disengagement’ but not on the ‘exhaus-
tion’ aspect of burnout (Johnson et al., 2020). Even though the re-
sults of this study did not reveal any predictive effect of supervision
on burnout, in a recent study, we found that reduced work- related
stress and burnout was a supervision goal for a majority (59%) of
psychotherapists (Spännargård et al., this issue). This indicates an
existing need to address burnout in supervision, and defining which
aspects of supervision may have an effect is an important question
for future research.
This study was a cross- sectional survey study that collected
data from self- selected participants and the results may therefore
be biased. However, the background data indicate that the sample
is at least moderately representative of the psychotherapist pop-
ulation. The research questions focused on risk factors associated
with background variables of psychotherapists and their work-
places. However, data on some potentially important variables
that have been studied in previous research were not collected.
These include workload, professional position and role conflicts.
Thus, future studies may benefit from a more comprehensive data
collection of risk factors. However, in contrast to some previous
studies, this study investigated risk factors in multivariate analy-
ses that made it possible to clarify the relative importance of dif-
ferent risk factors.
In conclusion, the levels of burnout in this group of psychother-
apists were high and similar to levels seen in previous studies on
this population. Only two factors were significant predictors for all
three aspects of burnout measured with the CBI: perceived compe-
tence and working in private practice. High perceived competence
as a protective factor against burnout is in line with previous find-
ings, but this study further clarifies that this perception of compe-
tence is more important than work experience, education or age.
The specific factors that contribute to a sense of competence in
relation to clinical work were not explored in this study, but this is
an important topic for future research (Yang & Hayes, 2020). That
working in private practice is a protective factor against burnout is
also in line with previous research, even though result s by Hammond
et al. (2018) indicate that many risk factors for burnout are present
even for solo- practising psychologists. It is suggested that perceived
control at different levels of the work environment is important for
reducing stress for psychotherapists. Changes in how psychiatric
treatment is delivered, with a higher degree of private practitioners
working under similar circumstances as practitioners in the public
health system, is at hand in many countries. Workload, and other as-
pects of the working situation, can be hard to control, even for those
working in private practice. Being female was a significant predictor
of personal and work- related burnout, and this may at least partly
be explained by the specific burdens women in the workforce face,
including workplace related gender inequalities. Future studies are
needed to explore other risk factors for burnout such as personality
traits, meta- cognitive beliefs about stress and how to best address
work- related stress and tailor interventions to psychotherapists for
optimal outcomes on burnout.
8
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SPÄNN ARGÅRD et Al .
ORCID
Åsa Spännargård https://orcid.org/0000-0002-9765-1269
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AUTHOR BIOGRAPHIES
Åsa Spännargård is a licensed psychologist and psychothera-
pist at the Centre for Psychotherapy, Education & Research,
Department of Clinical Neuroscience, Karolinska Institute &
Stockholm Health Care Services in Stockholm, Sweden. In teach-
ing, she focuses on training in cognitive behaviour therapy, di-
alectical behaviour therapy and clinical supervision and she is
responsible for courses in clinical supervision at basic and ad-
vanced levels. During her career, she has worked in different
clinical contexts where she has been involved in several projects
of implementation of evidence- based psychotherapy in the pub-
lic health system. She has also been involved in research proj-
ects concerning clinical supervision and has an interest in how
psychotherapists can maintain a sustainable working situation
throughout their carrier.
Simon Fagernäs is a licensed psychologist and PhD student at the
Centre for Psychotherapy, Education & Research, Department of
Clinical Neuroscience, Karolinska Institute & Stockholm Health
Care Services in Stockholm, Sweden. He spends half his time
working with evidence- based treatments for patients with dif-
ferent psychiatric diagnoses and the other half on research. In
his research, he is involved in several projects concerning clinical
supervision, cognitive behaviour therapy and evidence- based
clinical psychology. His thesis is about clinical supervision with
the goal of developing evidence- based methods for developing
psychotherapist competence.
Sven Alfonsson is a researcher and teacher at the Centre for
Psychotherapy, Education & Research, Department of Clinical
Neuroscience, Karolinska Institute & Stockholm Health Care
Services in Stockholm, Sweden. He has a PhD in Psychology,
a PhD in Medicine, and is a licensed psychologist and psycho-
therapist. In his research and teaching, he focuses on training
in cognitive behaviour therapy and clinical supervision. In his
research, he has an interest in how to integrate and evaluate
evidence- based psychological treatments and psychother-
apy in psychiatric care. He has published around 30 scientific
articles, of which about half he was the first author, in peer-
reviewed journals.
How to cite this article: Spännargård, Å., Fagernäs, S., &
Alfonsson, S. (2022). Self- perceived clinical competence,
gender and workplace setting predict burnout among
psychotherapists. Counselling and Psychotherapy Research, 00,
1– 9. https://doi.org/10.1002/capr.12532
