Introduction
The daily activities of psychotherapists require close cooperation with people who are in mental distress and suffer from various mental disorders. Psychotherapy is based on communication and emotional capacities that are used during therapy sessions and can cause emotional traumas to therapists and affect their professional quality of life [1]. Three main factors, including job burnout, fatigue from compassion, and secondary traumatic stress injury, can influence the quality of life of therapists.
Job burnout is an important issue among psychologists and psychotherapists that affects 20-67% of working psychotherapists [2, 3]. The level of emotional exhaustion in working psychologists was reported higher than in other health and treatment staff [4].
Fatigue from compassion is defined as frustration and exhaustion from compassion in patient care, where the caregiver feels frustrated due to observing the devastating injury and illness of patients [3]. The symptoms are presented as physical exhaustion and appear in the form of physical fatigue while other symptoms of this condition may range from symptoms similar to post-traumatic stress syndrome to nervousness and anxiety, decreased self-confidence, and physical symptoms, such as headache and dizziness [5, 6].
Secondary traumatic stress injury is defined as indirect exposure to a traumatic event [7]. The symptoms are similar to the symptoms of post-traumatic stress along with positive changes in self-understanding, interpersonal relationships with others, and philosophy of life [8].
The factors influencing professional quality of life in psychotherapists have not been well investigated and there is no consensus in this regard. Considering that similar studies have not been conducted in Iran, especially in Mashhad the second largest city in Iran, the purpose of this study was to investigate the quality of professional life of psychotherapists.

Methods
This descriptive cross-sectional study was conducted on psychologists and psychiatrists working in Mashhad City in 2022 based on convenience sampling methods. The inclusion criteria were psychologists, psychiatrists, and counselors working in Mashhad, and willingness to participate in the study. The exclusion criteria were incomplete questionnaires, the presence of a specific pattern in answering questions, and choosing two or more choices for more than five questions.
Data were collected using a questionnaire comprised of demographic information (age and gender), job information (type of employment and work approach), and Stam’s quality of professional life questionnaire (2009). The questionnaire has 30 items and three components, including satisfaction from compassion, secondary traumatic stress, and job burnout (ten items for each component). 
Participants were informed about the study through email and social media platforms. Psychotherapists who were working in Mashhad at the time of conducting the research (based on self-report) completed the questionnaires through the link sent in the invitation message. 

Results
A total of 184 participants (91, 49.5% men and 93, 50.5% women) were studied. The average age of all subjects was 37.4±7.6 years. There was no significant difference in terms of age between genders. Also, 46.7% (86 people) were contractually employed, 35.9% (66 people) were officially employed, and 17.4% (32 people) were on duty. The average working experience of the participants was 6.5±6.6 years. 
The majority of the participants (73%) were moderately satisfied with compassion, and 58.2% of participants had low job burnout, while in 46.2% of the participants, secondary incident stress was at a medium level. In addition, 59.2% of psychotherapists had very low compassion fatigue and 37% had low levels. The correlation between compassion satisfaction, job burnout, secondary stress of incidence, and fatigue from compassion to patients is shown in Table 1.



Compassion satisfaction was at a moderate level in participants who had family therapy and an existential approach. Participants with a family therapy approach did not have medium and high levels of job burnout. Moderate levels of secondary stress were frequent in all the investigated approaches. The level of fatigue from compassion with patients was mostly low and very low. There was no significant relationship between work approach and the level of satisfaction with compassion, job burnout, secondary stress of the incident, and compassion fatigue among the participants (P<0.05). Age had a direct and significant relationship with compassion satisfaction (r=0.254, p<0.001), while work experience had an indirect and significant relationship with compassion fatigue (r=0.146, p=0.048). There was no significant relationship between the level of compassion satisfaction, job burnout, incident secondary stress, and compassion fatigue and the type of employment and work in the academic field among the participants (p<0.05).

Discussion 
The results of the present study showed that the level of satisfaction of compassion in most therapists was moderate, and job burnout and secondary stress levels of the accident in most therapists were moderate to low, and fatigue of compassion level was very low in most participants, which was in contrast with the findings of a study on 240 psychotherapists in Canada [9]. Contradictory findings of these studies may indicate the impact of other social and working factors on occupational depression and the quality of life of psychotherapists. It can be stated that in the present study, psychotherapists maintained their level of job satisfaction and quality of life by reducing their emotional involvement with clients. 
This conclusion was in agreement with the findings of the present study regarding the positive and significant relationship between job burnout and secondary traumatic stress and compassion fatigue and the relationship between compassion fatigue and secondary traumatic stress.
This conclusion was in agreement with the findings of the present study regarding the positive and significant relationship between job burnout and secondary traumatic stress and compassion fatigue and the relationship between compassion fatigue and secondary traumatic stress.
The present study also showed a significant and indirect relationship between compassion satisfaction and job exhaustion, secondary stress of the accident, and fatigue from compassion among the therapists. This finding was in line with the findings of a previous study [10].
This study showed no significant relationship between gender, work approach, the type of employment, age, and work experience of psychotherapists and compassion satisfaction, job exhaustion, secondary stress, and fatigue from compassion. The findings of previous studies are controversial [9-12]. The reason for this difference might be due to the effects of gender, sample size, and differences in study instruments. It is recommended that future studies be conducted with a larger population and based on cluster sampling to impact the job and gender on the quality of life of psychotherapists.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethical Committee of the Mashhad University of Medical Sciences (Code: IR.MUMS.REC.1400.401).

Funding
This study was funded by Mashhad University of Medical Sciences.

Authors contributions
Conceptualization and methodology: Nafise Nouri Siahdasht and Ali Reza Javdani Asl; Data analysis: Saeede Hajebi Khaniki; Edit and review: Negar Asgharipour.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
 The authors would like to thank the deputy for research of Mashhad University of Medical Sciences and all psychiatrists and psychotherapists participated in the study for their support and cooperation.
 

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