key: cord-0881011-2o5wup3r
authors: Joshi, Gunjan; Sharma, Ginni
title: Burnout: A risk factor amongst mental health professionals during COVID-19: With the on-going pandemic, a crisis is headed for India’s mental healthcare system
date: 2020-07-08
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102300
sha: 853ac655bc4ed76f9bf71df866a760bb7a4bc673
doc_id: 881011
cord_uid: 2o5wup3r

nan

With the on-going pandemic, a crisis is headed for India's mental healthcare system. Originating from China, the 2019 novel coronavirus was named as COVID-19 on 11 th February and was declared as a pandemic on 11 th march (WHO, 2020) . To deal with this pandemic, India is practising strict measures of social distancing, quarantine and lockdown.

Although these measures are in the benefit of the community at large, the psychological effects of lockdown cannot be ignored. Social distancing, isolation, fear of infection, marital conflicts, and loss of income are causing immense distress and impacting the already strained healthcare system thereby taking a toll on mental health of people. Indian psychiatric society found 20% rise in mental health cases during the coronavirus outbreak through a recent survey in which it is reported that at least one out of five Indians are suffering from some form of mental illness (Loiwal, 2020) . The surge is even more alarming since the imposition of nation-wide lockdown as there was 50% increase in the reported mental health cases during the initial 2 weeks of lockdown.

With the given scenario, the role of mental health professional becomes crucial in providing relief, support and psychological first aid to people who are unable to cope up with the ongoing situation with the aim to improve their quality of life and wellbeing (APA, 2014) .

Mental health practioners are now witnessing a heightened level of work-pressure as they are providing tele-counselling and therapy to an increasing number of people each day. A team J o u r n a l P r e -p r o o f of 200 therapists are now working at their maximum capacity at 'My Fit Brain', an online portal for providing therapy and counselling to people. NIMHANS reported 2,500 calls with 9 active lines, which are answered by doctors and non-doctors trained in mental health. These people are increasingly worried and fearful of contracting the infection (Agrawal & Yadavar, 2020) .

Not only has there been a rise in corona anxiety, stress and health anxiety amongst people, but practioners are also dealing with diverse and significant issues. Lockdown has worsened the family dynamics resulting in significant rise in marital conflicts and reported domestic violence by women. 'I-call' a helpline operated by Tata Institute of Social Sciences is receiving increasing number of calls about relationship conflict and domestic violence.

Companies like Microsoft, P&G and Deloitte are contacting mental health professionals with the aim to help their employees working from home to deal with the on-going stress of extended lockdown (Dave, 2020) .

Although tele-counselling and online therapy can be cathartic for the patients who are unloading their negative feelings however considering the nature of work and the increasing work-load during the pandemic, the experience for practioners' can be emotionally demanding which left unaddressed may be a risk factor for developing problems with their professional competence (Elman & Forrest, 2007) . With a population of 1.3 billion people, India presently has less than 4,000 mental health professionals which are much less than the actual numbers required in the country (Birla, 2019) . With limited practioners and increase in workload, mental health practioners are at risk of experiencing burnout. While Covid-19 presents health crises, the deleterious economic impact that the country will experience due to present and future anticipated lockdown may increase the risk of post covid stress and led to culmination of second wave of mental health crises thereby contributing to increased risk of burnout amongst mental health professionals (Tandon,2020) .

Burnout is conceptualized as a syndrome resulting from long term chronic stress (Maslach, 2003) . This may manifest primarily as emotional fatigue, overload or exhaustion, depersonalization, poor view of ones self-competence and has traditionally been considered work-related mental-health impairment (Awa et al., 2010) . Burnout can directly impact the quality of work thereby negatively affecting the standard of care provided to the patients (Rupert et al., 2015) . This article describes the stressors amongst mental health practioners which put them at risk of burnout during COVID-19.

With the on-going pandemic and its associated anxiety, practioners may experience emotional contagion (Hatfield et al, 1993) . Through EC the negative feelings and emotions of one person can directly trigger similar emotions in the in other person. As mental health practioners are dealing with increasing number of tele-counselling to address corona anxiety, the venting of negative emotions by the patient can cause mental health practioners to experience similar feelings. These feelings will directly influence perceived stress amongst practioners thereby making them vulnerable to emotional exhaustion. This is in line with past literature where perception of stress amongst practioners is significantly related to burnout wherein therapist experiencing higher stress report greater level of emotional exhaustion and depersonalization (Pimble, 2016) . During current pandemic, mental health professionals experiencing emotional contagion may perceive higher stress which over longing period can cause burnout.

Staying balanced, objective and centered and as an active therapist becomes a challenge.

With the on-going pandemic and people going through difficult times, the practioner may shut their therapeutic stance and through the process of empathetic engagement end up getting over-involved with the patients. This may manifest as compassion fatigue (Figley, 1995) which is a form of constant worry about patient and is defined as a normal reaction when working with a highly stressed patients. However cumulative compassion fatigue may result in a state of exhaustion and the reduced capacity of the practioner to help the patient after being exposed to their distress (Huggard, 2013) .

Practioners addressing people facing marital conflicts, domestic violence and child abuse during this pandemic are at risk of experiencing secondary traumatic stress which is defined as the stress caused due to helping people who have been suffering or those who have been subjected to active traumatic experiences. Listening to victims disturbing narrative of the traumatic event may cause similar experiences within the therapist. Symptoms of STS are identical to those of PTSD (intrusive unpleasant memory of traumatic content, hyper arousal and avoidance of negative emotions) along with depressive and anxiety symptoms. (Cieslak et.al,2014) . According to past literature therapists working with populations subjected to trauma are highly prone to develop secondary traumatic stress (Bride, 2007) . There also J o u r n a l P r e -p r o o f exists a strong positive correlation between STS and burnout amongst mental health practioners who are indirectly exposed to patient which traumatic experiences during therapy sessions and counselling (Cieslak et.al; 2014) .

If a therapist is not confident and feels less effective, with time this distress can lead to a state of burnout (Theriault & Gazzola, 2006) . With the imposed lockdown and restricted mobility during coronavirus pandemic, it becomes a challenge for mental health practioners to provide psychological aid to their patients. Through tele-counselling and in the absence of face-toface interaction the practioners may not be able to deliver sessions as planned (due poor network or difficulty forming rapport) leading to helplessness and perceived therapeutic inefficiency. This may lead to distress and eventually be manifested as burnout. This is in line with the past literature where therapeutic effectiveness was negatively related with emotional exhaustion, depersonalization and sense of personal accomplishment (Pimble, 2016) .

During the pandemic, mental health professional are offering help to different populations including those with pre-existing mental illness and those facing serious mental illness.

Working with this population can be challenging for the practioner as these patients have greater vulnerability of relapse considering presence of stressful psychosocial factor amid COVID-19. Because they are highly vulnerable, and the present episode stemming from relapse due to 'corona anxiety', short duration therapy may not yield effective results.

In order to alleviate their distress, therapy will typically be on longer duration, more sessions and it may take much more time to see improvement (Acker, 1999) . Dealing with these patients, will require increasing time and mental resources of the practioner. They may also end up experiencing feelings of inadequacy as a result of not seeing any significant improvement in patient's symptoms and maladaptive behaviours.

Job demand resource model (Demerouti & Sanz, 2014) 

With the on-going pandemic, India is witnessing a significant rise in reported mental health cases, with an increasing number of people seeking telecounseling and online psychotherapy.

The number and proportion of mental health professionals in India is substantially low as compared to the rising demand of these service givers. Given the limited resources and considering the situation amid covid-19, the surge in mental health services has augmented the risk for personal and professional burnout among practitioners. Emotional contagion, perceived stress, compassion fatigue, secondary traumatic stress, poor therapeutic effectiveness, and longer duration of therapy are the contributing factors which increase the risk of burnout amongst mental health practioners. Additionally, uncertainty and unpredictability of the pandemic has increased the likelihood for people as well as the professionals to experience post Covid stress along with secondary mental health issues. It therefore becomes of paramount importance for health care providers to address their own psychological health so as to avoid deleterious aftershocks of this pandemic.

It was never published anywhere.

Conflict of interest-Nil

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