Burnout Among Mental Health Professionals in India: A Qualitative Enquiry

Abstract

Background

Burnout poses a significant occupational risk to mental health professionals (MHPs), compromising the quality of care provided to clients and eroding clinicians’ overall well-being. There is a dearth of studies examining burnout in MHPs within the Indian context. The unique challenges faced by Indian MHPs necessitate localised research. Context-specific research is vital for grasping the complexities of burnout among Indian MHPs.

Purpose

The present study intends to explore three research questions: (a) How do MHPs experience burnout in Indian setting? (b) What are the factors that contribute to burnout among MHPs? (c) What are the strategies used by MHPs to cope with burnout?

Methods

To develop an insight about these research questions, the researchers used a semi-structured interview schedule and interviewed eight MHPs (five females and three males; age range: 28–50 years). After acquiring consent from each participant, the interview was audio-recorded and manually transcribed by the researchers. Data were analysed using thematic analysis based on the conceptualisation given by Braun and Clarke.

Results

Three major themes were developed: (a) experiences of burnout: being in a bind, (b) facets of burnout: candle burning from both sides and (c) protective factors of burnout: a ray of hope, along with subsequent sub-themes and minor themes.

Conclusion

The study significantly enhances the burnout literature by providing contextualised accounts of its effects on diverse MHPs in India. Through in-depth explorations, it sheds new light on burnout among Indian MHPs, sharing their personal stories and offering a rich tapestry of experiences. The data underscore the critical need for prioritising practitioner well-being.

Keywords

MHPs burnout stress qualitative Indian work culture

Introduction

It is beyond imagination that a profession that helps people deal with their mental health problems itself is in a mental health crisis. With this, the present study attempts to bring attention towards one of the most crucial and significant variables to study that has become an occupational hazard among mental health professionals (MHPs); that is, burnout. A large portion of psychological literature has studied burnout in a variety of populations mostly in the organisational setup. However, it is unfortunate that the limited number of health workers leads to the assumption that psychologists have superpowers to efficiently deal with their stress. How could you be stressed come on, you are a psychologist is a very general discourse used by people around them, which acts as a catalyst to their already existing stress. But why are psychologists stressed? Is it because of the burden of work or the exceeding number of clients they take per day? Literature suggests several factors leading to their increased stress levels, ultimately leading to the state of exhaustion and burnout.^1–4

Burnout is a psychological condition that emerges as a lasting response to chronic and persistent interpersonal stressors on the job.¹ It is defined as the ‘degree of physical and psychological fatigue and exhaustion experienced by a person’.⁵ Maslach and Goldberg proposed a very significant model of burnout and identified its three dimensions: fatigue or overwhelming exhaustion, detachment or disengagement from the job and feelings of ineffectiveness or lack of accomplishment.⁶ The over demands and stressors of the job are intimately related to fatigue, while lack of adequate resources and support impacts the feelings of disengagement.⁷ Although the experience of burnout is problematic across many professionals,¹ it can have serious repercussions on human suffering if experienced by mental health service providers.⁸ According to previous literature, psychotherapy is considered a difficult and stressful occupation, suggesting that therapists are at high risk of experiencing burnout.^{9, 10} These professionals are in continuous contact with the struggles of human beings and their trauma. This repeated exposure to people’s suffering can lead to serious negative impact on these professionals.^10–12 They are expected to provide compassion throughout their working hours, and sometimes even beyond that time frame.

As proposed by Carla Joinson,¹³ psychologists experience compassion fatigue by constantly being compassionate towards their clients. Listening continuously to people’s trauma even leads to the development of secondary traumatic stress. This second-hand experience might lead to symptoms associated with post traumatic stress disorder (PTSD), for example, hyperarousal or intrusive thoughts.¹⁴ Though these professionals are not directly exposed to the trauma, there is a vicarious traumatisation that can be experienced by them. While all MHPs are required to have a basic skill of being empathetic, this empathy itself leads to these second-hand trauma and vicarious experiences. Rauvola and colleagues¹⁵ have grouped compassion fatigue, secondary traumatic stress as well as vicarious traumatisation under empathy-based stress.

One of the very significant studies¹⁰ conducted a systematic analysis of 40 pieces of literature on burnout and found that MHPs experience an average burnout level of 55%. Burnout, although it has a very late onset, causes mental and physical impairments along with a detrimental impact on the person, which is sustained for a longer period of time, posing a common risk among MHPs.^16–18 Though burnout is different from compassion fatigue with respect to its onset and seriousness of the symptoms, Sorenson and colleagues found a positive correlation between burnout and compassion fatigue, suggesting a relationship between the two terms. This can lead to serious physical and psychological illness as well as absenteeism,¹⁹ affecting the quality of care provided by them to the clients.^20–22

Professionals in the mental health service sector experience vulnerability due to the non-reciprocity of the psychologist–client relationship. It is one-sided and participants suggest that the ‘expectations and needs of their clients are way more important than their own’.^{23, 24} This becomes one of the reasons for the depletion of MHPs. Lambie in their study posited that ‘when counsellors believe that they are responsible for a client’s behaviour and have the power to control his or her behaviour, they are at an increased susceptibility to burnout because of these unrealistic expectations’.

Synthesising previous literature, it is suggested that the mental health service sector has certain job demands, and there are three broad domains that lead to burnout among MHPs: clinical responsibilities, non-clinical tasks and work environment.²⁵ Clinical responsibilities include a large number of client loads, working with challenging clients or those demonstrating challenging behaviour such as suicidal ideations, posing risk or harm to self or others or clients with PTSD.^{26, 27} Lack of rigorous training for specific cases like trauma-informed counselling or suicidal-related counselling, as well as not using evidence-based practices, adds to their susceptibility to burnout.²⁶ Non-clinical tasks, including over-the-top paperwork as well as administrative work, contribute to burnout by enhancing emotional exhaustion and decreasing their sense of personal accomplishment.²⁸ Factors related to the work environment, such as friction or conflicts between the co-workers, also contribute to burnout among professionals.^{29, 30} Work setting and poor salary are another set of contributing factors.³¹ Especially in India, government hospitals and organisations have poor work conditions. Moreover, the pay scale for MHPs is very low. School psychologists are paid as little as ₹10,000 per month in India for more than 7 hours of work. Usually in a mental health work set-up, friction is common between a psychiatrist and a psychologist due to their differences in the treatment plan and procedure. Additionally, sick leaves become costly for the professionals. Being present at work during mental exhaustion or sickness has been shown to have negative impacts on clients, friends, families and colleagues.^{32, 33} Unfortunately, the concept of sick leave is still in its neonatal period when it comes to psychological symptoms due to stress, burnout or compassion sickness, especially in the Indian settings of work culture.

Mental health has always been one of those neglected aspects of overall health in India that needs imperative attention. With its growing urgency, the scope of the field is expanding. However, keeping in mind the population of India, the number of MHPs is highly inadequate. According to the WHO Atlas³⁴ (World Health Organization), there are only 0.3 psychiatrists, 0.05 psychologists and 0.03 social workers per 100,000 individuals in India. The government spends only about 0.06% of the total budget of the health ministry on mental health. This budget does not seem to be sufficient to address the problem as well as the growing needs for mental health services among the population.³⁵ With this limited availability of mental health human resources and care facilities across the nation, professionals working in this field are overburdened with extra responsibilities, leading to detrimental impacts on their own mental health.

There are very limited studies conducted to explore this psychological aspect of MHPs in India. A nation with varied cultural backgrounds and high population rates is presented with a mental health crisis, even among the MHPs themselves. Therefore, there is an urgent need to address the extent of burnout experienced by MHPs in the Indian work culture.

Research Questions

How do MHPs experience burnout in Indian setting?

What are the factors that contribute to burnout among MHPs?

What are the strategies used by MHPs to cope with burnout?

Method

Research Design

The study aimed to enable the emergence of burnout experiences among Indian MHPs through in-depth, one-on-one interviews. A comprehensive description of the experience of burnout among MHPs in the Indian setting was formulated using the study approach of theoretical essentialist theme analysis given by Braun and Clarke.³⁶ The adaptability of this approach and the absence of adherence to any pre-existing theoretical framework provided the researchers with a better understanding of the circumstances that precede burnout and the experiences of Indian MHPs.

During the process of data collection and examination, it has been observed that there were some impacts of the ‘social constructivist philosophy’ of Berger and Luckmann (1991).³⁷ The researchers recorded those subjective experiences of participants as well as those of others, which played a crucial role in influencing and creating their experiences at the time of the interview, which had an impact on the overall conceptualisation of the study. In order to promote inductive investigation, participants responded to a series of open-ended questions. The data revealed the responses, perceptions, emotions, interpretations and comprehensions of the participants about burnout.

Participants and Study Setting

A total of eight MHPs (five females and three males; age range: 28–50 years) participated in the study, which included three clinical psychologists, three counselling psychologists and two psychiatrists, all located in Lucknow, Uttar Pradesh, India. All the participants belonged to different mental health institutes in Lucknow. Psychiatrists had a degree of MD in Psychiatry and were MCMI-registered professionals; clinical psychologists had a degree of MPhil in Clinical Psychology and were RCI-registered practitioners and counselling psychologists had a masters in Psychology from a UGC-recognised university and were not registered under any governing body. All the participants had more than 5 years of experience in the field. Different MHPs were chosen for the purpose of including variability in the sample.

Measures Used

Demographic Schedule

In the demographic schedule, the following information was collected from each participant: age, sex, marital status, professional identity, years of, experience in the clinical setup, average patient engagement weekly, working hours and annual income. Previous research has reflected an impact of the above-mentioned factors on the burnout level of MHPs.

Interview Schedule

A semi-structured interview was created by the research team using information from the literature, clinical experience, two practice interviews and input from three clinical psychologists employed by a reputable mental health facility (who were not part of the study as participants). The participants were briefed about the study, and consent was received. The average duration for the interview was 40 to 60 minutes. To guide the interview process, here are examples of a few questions asked during the interview:

What does burnout mean to you?

According to you, what are the challenges in the profession pertaining to burnout?

Can you share cases or events in your career where you felt emotionally depleted or felt burnout in any sense?

How do you deal with burnout?

Data Collection

Recruiting Participants

The team of researchers located various mental health institutes and hospitals in Lucknow. After seeking the approachability and availability of MHPs, 12 participants were invited for the interview using a purposive sampling technique. In this first phase of contact, out of 12 participants, only 5 participants reverted. In the second phase of contact, three more participants were recruited through snowball sampling. Overall, eight participants were finally part of the research. This has to be brought to notice that due to the scarcity of psychiatric social workers and psychiatric nurses, they were not included in the study, which gives us the insight about the status of these MHPs in the field (Table 1).

Transcribing Interviews

The interviews were audio-recorded with the consent of participants. The average duration for the interview was 40 to 60 minutes. The verbatim from audio-recorded files was transcribed manually by the researchers and checked for accuracy. The audio files were heard multiple times by two of the researchers, and then the transcription was completed. This process of transcription was helpful in understanding and noting down the connotation, different perspectives, meanings, hesitations, pauses and tone of participants, making the discussion more reflexive and inclusive.

Data Analysis

The recorded data were transcribed manually by the researcher. To organise the data, it was managed through the NVivo 12 software. The data analysis procedure adhered to the thematic analysis guidelines provided by Braun and Clarke.³⁶ The procedure included six phases: (a) familiarity with the data set, (b) development of primary codes, (c) development of primary themes, (d) review of themes, (e) adequate defining and naming of the codes and (f) formulating and writing the whole report. The analysis started with the first researcher transcribing the interviews of each participant. The researchers familiarised themselves with the interview script by reading and re-reading it multiple times. In order to develop primary codes and guarantee accurate data analysis, researchers completed the coding procedures independently before comparing them. Insights for first codes were noted down. The fundamental starting codes were then created and linked to various data units. After the coding process was finished, the codes were compiled into possible themes. As the data were read again, the resulting themes were examined at different points in time. Themes were continuously reviewed during the process, and certain sub-themes were updated as well. After a thorough review, the themes and sub-themes were finalised and labelled for better understanding and clarity.

Researchers’ Reflexivity

The first author is a counselling psychologist herself and takes independent sessions. The researcher understands the complexity and crucial nature of therapeutic work. By the virtue of being a MHP herself and being in close vicinity (both professionally and personally) with other fellow MHPs, the researcher comprehends and exhibits first-hand experience of the professional demands leading to burnout. Therefore, it is utterly a matter of giving voice to Indian MHPs, which is still a budding profession in the country and is facing a lot of issues.

In order to reduce the biases of the first author, all co-authors repeatedly refined the interviews and analysis process by providing an outer perspective. To ensure a strong fit with participants’ experiences, the initial meaning-making was not rigid. The first author, who conducted the primary research, and the co-authors, who served as her research supervisors, repeatedly questioned interpretations and theme development after numerous analytical iterations.

Results

To provide answers to our three research questions, the thematic analysis has identified three major themes: (a) experiences of burnout, (b) facets of burnout and (c) protective factors of burnout: a ray of hope. Sub-themes and minor themes were also developed under these major thematic factors. Figure 1 represents all the themes, sub-themes and minor themes constructed.

Figure 1.

Description of Themes and Sub-Themes for Burnout in MHPs.

Table 1.

Demographic Details of Participants.

Participants	Sex	Age	Highest Educational Degree	Average No. of Hour in Job per Week	Client Load per Week	Work Experience	Professional Identity
1.	F	47	MPhil in Clinical Psychology	20	15–20	17 years	Clinical psychologist
2.	F	40	MPhil in Clinical Psychology	36	15–20	12 years	Clinical psychologist
3.	M	33	PhD in Clinical Psychology	48	15–20	10 years	Forensic psychologist
4.	F	50	MD in Psychiatry	48	>50	25 years	Psychiatrists
5.	M	46	MD in Psychiatry	48	>50	15 years	Psychiatrists
6.	F	33	Masters in Psychology	42	25–30	7 years	Counselling psychologists
7.	F	30	Masters in Psychology	42	25–30	9 years	Counselling psychologists
8.	M	28	Masters in Psychology	36	15–20	5 years	Counselling psychologists

Theme 1: Experiences of Burnout: Being in a Bind

The first major theme of ‘Experiences of Burnout: Being in a Bind’ illustrates the exposures and encounters of MHPs in different therapeutic settings and explores the understanding of burnout from different perspectives. The phrase ‘being in a bind’ here denotes the feeling of being trapped, restricted and overwhelmed. This provides us with an understanding of the loop of emotional entanglement and identity dilution that a MHP constantly struggles with. The constant demand of meta-observation of both clients and self-patterns makes it emotionally binding. This major theme is divided into sub-themes for a closer look at the construct in order to develop a better understanding of burnout.

Sub-theme 1.1. Case Reminiscence

Under this theme, it has been identified that MHPs have recollected the memories of their cases where they felt emotionally depleted, exhausted and overwhelmed by the demands of the job. These participants report to be emotionally drained. Their reminiscence of previous cases makes them more emotionally drained even before taking a new case, which adds up to their existing emotional baggage.

Female participants experience an extra sense of challenge with respect to how clients put them on several tests. This becomes overwhelming partly because it comes with the perplexity about the client genuinely being in distress or intending to seek mere ‘female’ interaction. According to what our female participants have responded, this gradually takes a toll on their minds and adds up to the existing client load.

[A]fter that one fine day he came to me and he told me about his story of him being sexually abused by his cousin’s sister, so he was trying to see how easy am I to crack meanwhile I told the story to my mentor … and he pointed out he’s exactly trying to test your capacities to hold the information … and it was just so overwhelming for me.… Like I didn’t know how to react to that or what to feel about it.

While talking about burnout, participants emphasised holding an explicit sense of self while constantly having an introspection about their own behavioural pattern. This is crucial for being a MHP, as one has to deal with clients who have more complex emotional and behavioural entanglements. It becomes taxing if their own complexities are not addressed and dealt with prior to taking cases. An example of one of the responses received from participants is as follows:

I was sexually abused.… And I see various cases of sexual abuse including one case where the client was himself was a sexual abuser and in the first session he came and confronted him later on … he said he had sexually abused three girls and I said you come here in a private practise, to a female therapist and introduced yourself that way.… Why do you do it? What kind of rejection were you looking from me?… So more being interpretivist than anything else … so you know to reach there you need to have a lot of things in yourself resolved.

While addressing despair of burnout, participants had a sense of helplessness budding from a sense of urgency to help the client. It is also being identified that a few participants have to almost alter their attitude while providing therapy in order to deal with the clients efficiently because their personal and professional demands are incongruent in nature. This incongruence results in depletion of emotional resources and a feeling of being trapped.

‘Ki turant iss samay isse isse bahar nikaldun … Help kar dun’. But at that point of time I am not an advisor or guide.… And there to be a person who has let the client choose their own path.… Is a struggle … It’s weird … Main wahan pe ek different personality show karti hun which I guess makes me exhausted at the end of the month.

Its just make me helpless sometimes because you cannot help after a point if the client is not ready.

Participants also shared instances of being lost and baffled at times due to the subtlety of how a client’s information can go beyond the professional periphery and enter personal realms, often unnoticed. This results in feelings of inadequacy and resentment with the pretext that being a MHP, one cannot let the emotional turmoil of clients affect them at any level.

There was a case where a student was physically abused by her own father and that broke me … Somehow … it entered me … She was very mature, understanding everyone’s perspective and I was amused by that as well … After a certain point of time I could see my transference and I resolved it … But it got to me … I don’t know how but it made me feel so angry about myself also.

Sub-theme 1.2. Deconstructing Burnout

In this sub-theme, the authors have tried to dissect and break down the meanings and comprehension of burnout from the perspectives of MHPs in the Indian setting. This theme elucidates underlying structures of mental and emotional exhaustion that help in dismantling burnout as a construct. Under this theme, it has been identified that participants have experienced burnout in terms of burden, emotional toll, blurry boundaries, sense of doubt, exceptionally critical demand from oneself to provide help to others, work-life imbalance and failure of emotional regulation. It should be noted here that the underlying assumption of a MHP to be a perfect human being without any emotional or mental discord adds up to the pressure and often results in burnout. The vast majority of participants agreed that the above-mentioned mental states lead to burnout. A few quotes are mentioned below.

Skills are difficult to learn.… In Indian society, if I say, being a MHP takes a toll on you even if the job is very satisfying and fulfilling, we don’t get to do this.… Because of the constant struggles we face.

I could also not help them until they didn’t want to. I see doctors (psychiatrists) giving unsolicited advice ‘ki aap bohot negative feel kar rahi hai … Koi baat nahi … aap thoda bhajan suna kareye.… Thoda positive talk suna kareye’. It’s unsolicited advice.… So, I knew where to have my own boundaries

During the interview, participants often noted the adverse effects of being exposed to patients’ challenging situations. However, there were some participants who mentioned that despite the difficulty, listening to their patients’ stories was an important and meaningful aspect of their work. Overall, participants conveyed that working with ‘difficult fates’ could be both rewarding and emotionally draining.

I could see the resilience of clients.… Their emotional burnout … And all these things were co-existing yet I could not do anything about it. It’s like you want to do everything for this person and you are doing it but still you are not doing anything.

Suppose ‘ek din 3-4 session ho gaye’. where things are difficult … There was a session which messed up my mind … Majorly I deal with adolescents … And to see how they are being abused.… Or to listen their stories definitely takes a toll on me

The complex and demanding issues required more resources than participants were accustomed to. This includes additional time, emotional investment and mental energy. Some participants linked these high demands to a heightened risk of burnout.

Mujhe khud lagta hai main poori nhi padti hun school ke liye … School bohot bada hai … itne bache hain … Bohot zyada overburdened hai.

As a MHP, the health of MHP is epitome unless he or she is not mentally and physically capable of tackling the cases serious issues can take place.

A significant proportion of participants quoted that burnout affects their emotional regulation process, emphasising harsh working conditions. Burnout has a detrimental effect on work-life balance. The predominant emotions seen were anger, guilt and shame because of the helplessness of being the ideal therapist or lack of resources to deal with burnout.

I said sometimes I get aggressive, sometimes I feel annoyed. If you want in terms of emotion, sometimes extremely irritated, because of the Harsh working nature over here these emotions sometimes become very tough to be controlled.

Sometimes personal and professional life imbalance is created. That is the only thing which I have faced is that I am not able to give sufficient time to myself for my priorities and my personal priorities because of the harsh working nature which changes from organization to organization.

Theme 2: Facets of Burnout: Candle Burning from Both Ends

The major theme of ‘Facets of Burnout: Candle Burning from Both Ends’ represents the sources and contributing factors of burnout in MHPs in the Indian setting. Candle burning from both ends here denotes how MHPs face challenges from the ends, that is, personal and professional ends. Here, the candle accurately represents MHPs as an entity that gives light to others by literally burning itself. The theme explores the professional and personal dynamics that act as stressors leading to burnout. Thus, the theme is divided into two sub-themes, that is, professional ethos and personal ethos. The participants have passionately and almost aggressively reported the professional and personal challenges of the field.

Sub-theme 2.1. Professional Ethos

The professional or organisational factors play an imperative role in providing the facilities and resources to MHPs in order to efficiently deal with clients. The participant emphasised that it is important to ensure a structure that supports and encourages the professionals in the field for a smooth run of mental health facilities. Their outrage against the legislature and policymakers has been evident in their comments, expressions and gestures. While talking about the professional challenges, they non-verbally indicated a high pitch in their voice with a sense of disappointment and annoyance. Participants conveyed the lack of training, collaboration and underpayment in the field as unanimously the voice of their plea.

1. Minor Theme 2.1A. Lack of Training:

So opening up a can without getting closed is much difficult to handle and sadly our training does not include that … Doing random tests … and nothing figuring out … Don’t know what to do with the data … we are left vulnerable … Our training … has left us vulnerable … that’s the sad part.

I feel there’s a gap in whatever is being taught in colleges and what we actually do in the field … Nobody is teaching the real stuff.

Oh I might cry. Because … ‘kitabon se kitni alag hai dunia. Jo bhi humne padha. Dekha’… frankly it’s a very different … when I see adolescents with self harm. Which now I see is very common after coming in the field … and frankly ‘maine isse kisi kistab me nahi padha’ and yes I know the techniques. But still the training part is so much missing.

They want freshers to behave like full-fledged counsellors. ‘Guidance hi nahi hai … MA karne ke baad counselling ke liye proper koi institution ya course nahi hai jo hume sikhaata hai ki practical world mein kaise counselling kaise karni hai’ with a rigorous training

Aur bohot buri baat hai ye … ethically bohot wrong hai par hum sab gir pad kar seekhte hain … ek do cases pe kaam karke seekhte hain.… On our own.

An apparent lack of training is visible in all these excerpts expressed with a lot of pain and helplessness. It also addresses the demand of the job, which is not fulfilled in the curriculum at colleges, ultimately leading to burnout in early-career MHPs. Lack of training institutes for counselling in particular is a grave concern. Previous literature has also suggested that professionals in the mental health sector face challenges due to a lack of training.^{3, 9, 14}

2. Minor Theme 2.1B. Perceived Worth Versus Wage Reality

MHPs, excluding psychiatrists, are facing financial crises in the field. Under this section, the participants were observed to be extremely disappointed and disheartened by the pay structure of their job. The underpayment and economic disparity have a direct effect on their low self-esteem, resulting in a feeling of lack of accomplishment, which is included as a component of burnout.^{36, 38} The payment disparity affects productivity and creativity of the participants. Participants reported financial frustration, emotional distress due to underpayment, demotivation by low payment and financial insecurity. The encounters of participants are quoted:

I tell my junior’s coming into the field but if you’re thinking of earning money this is not the field for it.

Retaining clients is very difficult, finding clients is difficult, people are not willing to pay much for therapy. Just in the top cities people are paying very experienced therapists … otherwise in a small city or a second tier city people are not willing to pay. So there’s a lot of financial issues

Many times we are underpaid, the basic thing is you take out any government project, they are giving only 20 to 25,000. People who are coming from outside how they will be working minimum TA minimum accommodation enter the inflation rates going up of course, they are underpaid.

3. Minor Theme 2.1C. Quandary Between Psychiatrists and Psychologists

Clinical and counselling psychologists, particularly those working in hospital settings, have pointed towards a professional challenge that pertains to the ideological difference between psychiatrists and psychologists in terms of the ‘talking cure’. The clinical and counselling psychologists have reported that they were seldom looked down upon by their own colleagues and sometimes even by their clients when it is about the authenticity of the nature of therapy/counselling. Psychiatrists tend to hold a prejudice against psychologists or psychotherapists. They believe that people belonging merely to a psychology background without having any medical knowledge cannot efficiently contribute to the field of psychiatry. There is a sense of disrespect or indifference towards psychological therapeutic modules as compared to psychiatry. Eventually, medicine is considered a supreme and quick fix to mental health problems. Few excerpts are as follows:

psychiatrists ka ye manna ki patient ke liye therapy bilkul jaruri nahi hai … bohot Kam aise psychiatrists hai jo therapy recommend karte hai … bohot saare psychiatrists.

Par bht saare hospitals me aisa hai ki isme therapists kya karenge … isme therapy ka kya hi role hai … ya counselling ka koi role nahi hai … just medicine khilao aur kaam ho jaeyga.

Sub-theme 2.2. Personal Ethos

The second sub-theme explores the personal facets of burnout conveying sentiments of ‘not feeling enough’, role confusion, identity crisis and stigma from clients, which ultimately opens the door for burnout. Participants have advocated that role confusion can arise due to overlapping duties with other healthcare providers, societal expectations and the ambiguous understanding of mental health roles within communities.

1. Minor Theme 2.2A. Role Confusion

Clients may have preconceived notions about mental health that cast professionals in a sceptical or even negative light, assuming that they are only for the ‘mentally unstable’ or not holding a firm belief in therapy/counselling. This stigma not only affects how clients perceive these professionals but also affects how they perceive themselves, sometimes leading to self-doubt and lower job satisfaction.

See, it’s not clear, the boundaries are not clear, our roles are also not clear nor are the courses defined that way nor is the government actually taking any steps to make it clear for us, so our boundaries are very diluted.

Even to us as to how exactly we can work, it even dilutes our own positions. So that’s why there’s so much confusion in our head, we do know where to work, we are not respected for what we work.

Also, challenges are related to the degree to which you have learnt that your own course. For example, if you have just passed from master’s degree, the student uses a word psychologist or counsellor, ‘jab ki aisa technically possible name nahin hai’. Because in a two-year master degree and if you were only doing masters. People do and fill in and learn technical skills, but if you only have masters … there’s no practical exposure, only theoretical knowledge.

This uncertainty may lead to an identity crisis for professionals who struggle to establish a clear, respected identity in a field that is still marked by stigma. In India, there is a lack of any governing bodies that train and specify roles for all MHPs. This not only creates confusion within the professionals themselves, but their credibility is being questioned by the general population as well as the clients. Apart from a psychiatrist, the second most important mental health profession is considered to be that of a clinical psychologist who is trained in a clinical setting dealing with the diagnosis of disorders and their treatment. Even the general population is not aware when to consult which MHP,.

Dekhiye jab kisi ko yeh nahi pata hai ki aap ko apne name ke ageay kya lagana hai to salary structure becomes a challenge, the pay scale, nobody will work free of cost

Lack of education/understanding ‘ki counselling the role kya hai … Ye special educator bhi kaam kar lein, ye dawa bhi de dein aur ye assessment bhi kar lein’ … It’s too much.

There is only one council that is RCI … but that gives the license to those professionals who work in a clinical setting … But for any other branch of psychology we do not have … even ‘counselling ko lekar … School counselling ko lekar humare pass koi governing body nahi hai’, in that case even a MHP does not know what kind of actual profession he or she, the same person is in working in school as personal taking marital therapy and in clinical setting same person is working, that thick and thin line should be defined.

2. Minor theme 2.2B. Stigma in Society

Under this theme, it has been identified that participants expressed frequent encounters of stigma from clients who hold misconceptions about mental health, perceiving it to be a taboo or a sign of weakness. Clients are reluctant to seek help, fearing judgement or misunderstanding, which can hinder the development of trust and a strong therapeutic relationship. This hindrance in the therapeutic relationship puts a lot of mental pressure on the participants, and they have to go extra miles to build a comfort space. This eventually adds on to their already existing stress.

It takes an emotional toll … ‘Kabhi kabi bohot rude ho jaate hai … hai ki nahi aap nahi samjh rahe hain ki itni jaldi nahi ho paeyga … Patience rakheye’

Often they present to us late … Often they do not adhere to treatment and they often resort to some sort of quackery or other form of treatment that lead to worsening of their condition, so their prognosis could have been better had they and their family members been more aware about psychiatric illnesses.

Stigma is observed among the people of the mental health profession as well. Participants have encountered scepticism or judgement from colleagues, which leads to feelings of isolation or insecurity. The sense of purposefulness and accomplishment can enhance when professionals receive validation and supervision from their own colleagues and seniors, but this negative judgement among their own mates degrades their sense of meaningfulness. As a result, the stigma surrounding the profession itself can create additional challenges in delivering effective care and maintaining professional confidence.

As MD doctors we have various options but we have chosen to be a psychiatrist. So the common perception in the profession is that if you are choosing psychiatry you are either not satisfied with your job or you might have some sort of inferiority.

It is so horrible because the students, teachers, parents and the management are against counselling in a very subdued way, ‘aise upar se toh sab bolte hai wah wah … But when it gets to them they are like nahi, it is very very sad … Agar baha chah bhi raha hai counselling ke liye to … aree tum pagal ho kya … Counselling nahi karani hai, ghar ki baat ghar mein rehni chahiye’. this is the thing we hear and this is very painful because we cannot help

The participants spoke about the struggle with unsupportive families who lack understanding of mental health issues. This lack of support can create additional stress for professionals, as they may feel torn between advocating for their clients and managing family expectations.

I faced this in my own family … I suggested that my sister should get a career assessment … My father was like, does it really make sense? So in my own family I see people are really not inclined to seek help for mental health or emotional problems … Career … It’s a struggle I feel if they do not understand how they will support me and I as a new MHP.

Agar mujhe dikh raha hai ki mere ghar walon ko hi bharosa nahi hai … to main kaise aage badhungi … Let alone what society thinks.

Theme 3: Protective Factors of Burnout: A Ray of Hope

The theme of ‘Protective Factors of Burnout: A Ray of Hope’ elucidates the shielding factors that act as a guard against burnout for MHPs. Participants describe ways that help them to get through a tough day or how they loosen up after a hectic day to bring balance between professional and personal demands. Participants mentioned two key factors that safeguard them from depleting completely, which include therapy for self and engaging in recreational activities like talking to a loved one and unwinding with music and art.

Sub-theme 3.1. Therapy for Self

This theme identifies the fact that therapy for self is one of the effective resorts that help in preventing or reducing burnout in MHPs. Participants repeatedly mentioned how, by the virtue of this profession, there is a constant struggle to keep oneself sane. Participants have reported the overload of painful, disturbing and extremely sensitive information in therapeutic settings. To hold this plethora of negative experiences, it is important that one’s own mental health has been addressed in a safe place. Participants stated therapy provides that space, helps to unwind and takes the load off. They reported about addressing their personal and professional problems in therapy. A sense of putting off the load and catharsis is expressed. Feeling of empowerment and acknowledgement was also expressed by participants. Participants verbatim are quoted below.

I go for my own therapy.… It’s the best thing … I see my biases, my transferences also.

I took therapy long back, now I connect whenever I need to … Say like … Once in three months maybe … I feel seen and heard … I feel I have switched off from my job … It has been really wonderful

Therapy is actually a game changer. It is much more than just venting … It is giving meaning to complicated things.

Therapy gives me space to vent out … It protects me from getting burned out.

Participants spoke about therapy as striking a balance between professional and personal life, as the line often gets blurry. Being a MHP, holding so much information and stories about people becomes overwhelming and draining. Taking therapy helps them to overcome this challenge and be more efficient.

I was going through a tough time in my marriage … Therapy has helped me to overcome those challenges and helped to cope with my things and as well as exposure of client’s problems.

I think I could become a therapist only because I took therapy.

Therefore, MHPs taking therapy is undeniably beneficial, but it is also coupled with challenges. One of the participants pointed towards a good concern of finding a therapist for oneself being in the profession. Almost everyone is in close vicinity or might know their colleagues; it becomes difficult to get a therapist outside one’s professional circle. Participants also reported about the stigma revolving around psychologists taking therapy. It ultimately tends to question their credibility and expertise. MHPs are assumed to have ‘superpowers’ and have no mental health concerns.

It is difficult to find a therapist for yourself as a mental health professional because every good therapist you know … Share your common groups … But with a little help you can find one.

So I don’t know why psychology, in India there is no concept of going through self therapy … But I have been helped a lot … It has given me a space to let things be and be okay with that … I know there’s a space where I will be understood.

Sub-theme 3.2: Renewal through Recreation

This theme has been formulated on the basis of participants’ responses about various activities implied by them in their daily routine in order to deal with stress and burnout. This theme majorly focuses on everything that they preach to their clients as well. In psychology, when we understand human behaviour, we start by understanding our own selves. In this process, acknowledging one’s own emotions and sitting with one’s own thoughts is the start to a healthy psychological lifestyle. A dietician suggesting a balanced diet must have a diet for himself that is balanced. Similarly, a MHP such as a psychologist must practice what they preach to their clients in order to maintain their mental health. Music, interaction with nature, art, talking to a close friend or family members, breath work and muscle relaxation have emerged to be some of the applied strategies that help in reducing stress and burnout.

Music is my very important thing … My routine definitely helps me … guardians. Parents se baat karna helps to be sane.

Walking. Music helps a lot

Scribbling. Drawing. My go to things for every time I am stuck

traveling of course traveling is one of the techniques which I have used I am using in fact for the stress Buster.

Participants have emphasised talking to their loved ones and having a good time rejuvenates them from within. Seeking community support also has an effective role. Even during providing counselling sessions to clients, sometimes community support and family involvement are suggested by the counsellor in order to provide extensive support to the client.

Having good company … venting out emotions. Talking to my colleagues is the most effective things for personal and professional things

I talk to my other colleagues. That helps.

Going Out for a coffee, these are the ways how I have reduced my personal stress levels

Simple strategies like I like Going Out hanging over the friends … talking over the phone, especially not on the chats or Instagram through social media but over the phone physically meeting people.

Participants have shared that practicing skills that they teach clients in therapy and counselling is also a way to prevent burnout. It leads to healthier relationships, enhanced support and a clear sense of self. Working on communication style and visualisation helps to deal with things better.

Integrating breath work in a day-to-day activity which can help me mostly regulate my emotions

Relaxation techniques is very beneficial.

Visualization helps in my difficult times … drawing … writing poems … Reading novels … helps me balance my mindset.

And if I disagree with someone like I have a disagreement with someone I talk to that person directly rather than indirect communication. direct communication always helps me manage my own emotions.

Discussion

‘It is okay not to be okay’. This statement is even applicable for MHPs because they are not just ‘providers’ of support and care, but sometimes they too are the ‘destitute’ and seek some nurturing and upholding. In a country like India, where mental health sensitivity is still in its infancy stage, there lies a lot of stigma when it comes to the ‘powers’ that MHPs exhibit. If a physician can fall physically ill, then why cannot a MHP experience mental illness or undergo stress? This is something that needs to be widely spread within the community so that at least professionals are not perceiving themselves to be less worthy or questioning their own ‘powers’.

The present study had made a very significant and novel attempt at providing an in-depth understanding of the experiences of burnout among MHPs, subjective understanding of contributing factors and the strategies brought up by them to cope with the job demands. The findings of the study highlight the experiences and detrimental consequences of burnout on the quality of care provided by MHPs. The findings of this study enhance understanding of the factors contributing to burnout and support MHPs in managing it. It also highlights the significant role of clients and their trauma weighing heavily on the mental health of professionals. Moreover, it cannot be denied that there are socio-economic and cultural differences due to which the factors contributing to burnout might differ in the Indian work setting, especially in the mental health sector. For this reason, the study also revealed the important factors or facets of burnout as per the subjective understanding of the Indian MHPs. MHPs have shared memories of cases that left them feeling emotionally depleted, exhausted and overwhelmed by their job demands. This finding has been in accordance with other research, which has identified awareness of psychotherapists’ susceptibility to recurrent burnout cycles.^{25, 39, 40}

Female professionals, in particular, face an additional challenge, as some clients seem to ‘test’ them, adding stress and uncertainty. These female participants often feel unsure if the client is genuinely in distress or merely seeking female interaction. It has always been difficult and challenging for women to deal with these kinds of situations, which act as a catalyst to their existing job concerns. Across diverse cultural contexts, women frequently report experiencing discomfort in professional settings due to male colleagues or customers engaging in unwanted flirtatious behaviour and overstepping personal boundaries. Similar findings have also been quoted by previous study, which mentions that interactions often lead to feelings of insecurity and undermine a safe, respectful work environment,⁴¹ especially in the field of mental health, where the job demands ‘non-judgemental and empathic interaction’.⁴²

Through the analysis of interviews, the study yielded some significant shielding factors to help fight against burnout. The intense demands of both clinical and non-clinical duties appear to contribute to burnout. This issue is compounded by the rising severity of mental health challenges and limited training. This finding confirms prior findings done by Noman et al.,⁴² where the problems of limited training and mental health challenges of MHPs were being discussed.

It paints a picture of self-care in the form of going to therapy themselves and engaging in activities that recharge them for fulfilling the duties and being able to deliver quality care. Previous literature has revealed the impact of self-care⁴³ and recreational engagements^{37, 44, 45} among MHPs. These professionals tend to acknowledge their problems and demonstrate alignment with their professed values, which eventually helps them to efficiently navigate challenges faced by them.

The study voices the importance of more structured training modules, better curriculum and legislation for Indian MHPs. It highlights the failed salary structure, undervalued contributions and ideological differences within the profession. These results harmonise with established views on MHPs working in other countries.^{37, 42, 44, 45} The facets address the pivotal role of clear and better identity, strong boundaries and awareness in society in context with mental health and MHPs. There is a lot of research available^{24,18,21,24,32} around stigma in MHPs, but this study made an attempt to elaborate on how stigma affects the role of MHPs in the field.

Conclusion

This qualitative investigation probed the burnout phenomenon among Indian MHPs in disparate care settings. This study significantly enhances the burnout literature by providing contextualised accounts of its effects on diverse MHPs in India. Through in-depth explorations, it sheds new light on burnout among Indian MHPs, sharing their personal stories and offering a rich tapestry of experiences. The data underscore the critical need for prioritising practitioner well-being. As a community, we must recognise the vital role MHPs play in the healthcare field, acknowledging that their work can have profound consequences for their own well-being. To mitigate these risks, we must prioritise preventative measures, integrating guidance on self-care and burnout prevention into training programmes. Lastly, it necessitates a paradigm shift in supporting MHPs revealing alarming rates of burnout that demand immediate attention.

Limitations

This qualitative study analysed eight interviews with MHPs but faced several limitations. The sample included professionals with varying experience levels (5–17 years), which may have influenced the findings, as less experienced professionals might struggle more with job demands, while those with over 10 years may have greater resilience. Additionally, two participants were psychiatrists, whose job roles differ significantly from psychologists, potentially affecting the analysis, as psychologists typically handle more intensive client interactions. Generalisation is also limited, as the data were collected from professionals in a non-metropolitan area of Uttar Pradesh, differing from conditions in metropolitan cities across India. Lastly, as a purely qualitative study, it lacks reliability.

Future Implications

Future studies can explore different significant variables related to MHPs, such as compassion fatigue or/and secondary traumatic stress. The sample selection can be more definite, and a specific range of factors must be considered. Moreover, applying a mixed methodology would be more beneficial to establish the reliability of the results and bring more objectivity to the study. Qualitative analyses such as phenomenological analysis or narrative analysis might bring more inputs to the deeper understanding of professionals’ lived experiences and their life stories.

Footnotes

Acknowledgements

The authors extend their gratitude to the participants from different mental health institutes and the concerned authorities for permitting the researcher to conduct this study. The authors also acknowledge the support of staff and colleagues who provided a conducive environment to carry on with this research work.

Authors Contribution

All authors contributed to the study’s conception and design.

Research conceptualisation, data sorting, analysis and duplication checks were performed by SS, SC, RS, SS and SS.

The first draft of the manuscript was written by SS, and all authors commented on previous versions of the manuscript.

All authors read and approved the final manuscript.

Statement of Ethics

The research adheres to the International Committee of Medical Journal Editors (ICMJE) and World Health Organization (WHO) guidelines for conduct, reporting, editing and publication. The current study is a part of the authors’ doctoral research study. The research has been approved by the Department of Psychology, University of Lucknow, Lucknow.

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

Informed Statement

Written informed consent was taken from professionals to participate in the study. Participants were informed of the anonymity of their identity and confidentiality of their responses and the voluntary nature of the study.

ORCID iDs

Swapnil Sinha

Ramya Srivastava

Shivali Sharma

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