Innov Clin Neurosci. 2025;22(7–9):24–27.

by Muqadas Fatima, MS, and Uzma Ilyas, PhD

Ms. Fatima is serving as Lecturer at National University of Modern Languages (NUML) in Lahore, Pakistan. Dr. Ilyas is Senior Lecturer at Forman Christian College University in Lahore, Pakistan.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

In the realm of psychology and healthcare, mental health professionals represent a diverse group of individuals who have undergone specialized training and qualifications. Their main responsibilities pertain to the assessment, diagnosis, treatment, and support of individuals who are dealing with mental and emotional health challenges.¹ Psychiatrists, social workers, clinical psychologists, counselors, and couples and family therapists are among the numerous roles classified under this category of professions. They apply well-established therapeutic methods, interventions, and strategies to improve the overall psychological wellbeing and health of the individuals they serve while upholding the ethical code of conduct and making ethical decisions.²

Ethics can be defined as the set of rules that guide actions and behavior and direct the decision or behavior of an individual or community in a given situation. It revolves around making decisions and determining the basic standard of conduct required from mental health professionals.³ Ethics serve as a helpful instrument to assess various choices and strategies when confronted with ethical dilemmas in psychotherapy.⁴

Burnout is defined as a psychological condition characterized by persistent exhaustion, skepticism, and a sense of incompetence. It emerges as a reaction to prolonged exposure to workplace stressors.⁵ The symptoms of burnout include depersonalization, decreased sense of personal accomplishment, and feeling emotionally exhausted.⁶

Healthcare workers, especially mental health professionals, might endure chronic, undetected pressures that result in psychological, interpersonal, and organizational problems if they lack a way to assess ethical dilemma, which can further lead to fatigue or burnout.⁷ Workplace stress and burnout are more common among mental health professionals when compared to other healthcare providers and the general working population and can negatively impact their wellbeing and the quality of mental health services they provide.^8,9 A study on mental health professionals revealed that practicing psychologists are more vulnerable to develop burnout compared to other professionals.¹⁰

Pakistan faces a significant challenge in mental health field because there are only about 400 trained psychiatrists in the country.¹¹ There is a pervasive stigma surrounding mental illnesses, and they are often associated with supernatural or paranormal causes.^12,13 Pakistan is facing many infrastructural issues in the mental health sector as well. During recent events, such as the 2022 flooding and the COVID-19 pandemic, the prevalence of mental health illnesses drastically increased. However, government-provided mental health facilities did not experience a corresponding increase in resources. This imbalance between supply and demand placed additional pressure on the already fragile mental health system, resulting in burnout among mental health professionals.Western societies are witnessing an increase in the prevalence and severity of burnout, while in Pakistan, the research addressing the experiences of mental health professionals who have encountered burnout remains scarce.¹⁵ Additionally, there is a distinct gap in Pakistani research regarding the relationship between ethical awareness and burnout. Consequently, the current study was designed to evaluate the relationship between levels of ethical awareness and burnout experienced by mental health professionals in Pakistan.

Subjects and Methods

A quantitative, correlational research study was conducted between February to July 2023 at the University of Central Punjab in Lahore, Pakistan. Permission was sought from the university’s institutional review board before starting the research. Using a purposive nonprobability sampling approach, data was collected from 319 mental health professionals with at least two years of experience and working in public and/or private institutions in Lahore. Trainee mental health professionals and professionals with fewer than two years of experience were excluded. The sample size was calculated using rule of thumb (1:5); for every one item, five participants were selected.¹⁶ Data were collected through an online survey and in person, when possible. Permission was received from institutions from where data were collected. Written informed consent was taken from participants prior to data collection.

To measure the ethical awareness and burnout levels in mental health professionals, the Santa Clara Ethics scale and Counselor’s Burnout Inventory (CBI) were used, respectively. The CBI is a self-report questionnaire containing 20 items, specifically designed for evaluating burnout levels among counselors. This inventory encompasses five distinct subscales, which are exhaustion, negative work environment, devaluing clients, incompetence, and deterioration in personal life. Scoring on the CBI ranges from 20 to 100. Respondents use a five-point Likert scale to rate their responses, where a rating of 1 corresponds to “never true” and 5 to “always true.” Notably, the CBI has demonstrated strong reliability, with an overall score of 0.88, and the internal reliability of its subscales falls within the range of 0.80 to 0.84.¹⁷ The Santa Clara Ethics Scale was used to assess ethical awareness among mental health professionals. This particular scale consists of 10 items and uses a four-point Likert scale for participants’ responses; a rating of 1 denotes ”strongly disagree” and 4 denotes ”strongly agree.” The internal consistency of the scale, as gauged by Cronbach’s alpha, was established at 0.83.¹⁸

Demographic information, encompassing age, sex, institution of affiliation, highest educational achievement, and any completed coursework in ethics, was acquired through self-reported responses. The data underwent statistical analysis using SPSS version 23. While categorical data were represented using frequencies and percentages, continuous variables were summarized using mean values and standard deviations (SD).

To explore the potential relationship between ethical awareness and burnout levels in mental health professionals, Pearson product moment correlation analysis was employed. Institution-based differences in exhaustion level was assessed using t-tests. To indicate statistical significance, a significance level of p-value less than 0.05 was applied.

Results

Out of 319 participants, 286 (89.6%) were identified as female and 33 (10.4%) as male. The mean±SD levels of ethical awareness and burnout were 31.4±4.46 and 48.4±13.91, respectively (Table 1). The Santa Clara Ethics Scale and CBI demonstrated good-to-excellent reliability, with values of 0.84 and 0.89, respectively. The study revealed a significant positive correlation between ethical awareness and age. Simultaneously, age showed a significant negative correlation with exhaustion, incompetence, negative work environment, devaluing clients, deterioration in personal life, and overall burnout. This indicates that as age increases, levels of these burnout-related factors tend to decrease. In other words, older individuals in the sample reported experiencing less burnout and its associated components, compared to their younger counterparts. Ethical awareness showed significant negative associations with incompetence, negative work environment, devaluing clients, deterioration in personal life, and overall burnout. Additionally, significant positive correlations were found among exhaustion, incompetence, negative work environment, devaluing clients, deterioration in personal life, and overall burnout (Table 2). The results of independent sample t-test revealed that mental health professionals working in the public sector exhibited a significantly higher level of exhaustion than professionals working in the private sector at (p=0.013, t (317)=2.50; Table 3). The effect size, measured by Cohen’s d, was 0.27, indicating a small effect.

Discussion

The findings of the present study indicate a significant difference in the sex distribution of mental health professionals in Pakistan, with a majority being female. Previous studies have also demonstrated that there are more women employed in the mental health sector.¹⁹ It is crucial to look at potential sex differences in burnout and ethical awareness, given the larger presence of women among research participants.

The study examined the relationships among age, ethical awareness, burnout, and dimensions of burnout within a sample of 319 participants. The findings emphasize the importance of considering these factors collectively in the context of mental health professionals. The negative correlation between age and burnout is consistent with previous research findings.²⁰ Furthermore, the negative correlation between age and burnout dimensions, including exhaustion, incompetence, negative work environment, devaluing clients, and deterioration in personal life, emphasize the potential protective effect of experience and maturity in mitigating burnout risk factors. Previous research suggested that employees with more seniority tended to experience lower levels of burnout compared to their younger colleagues.²¹ Mental health professionals under the age of 40 years have reported higher stress levels and were more likely than their older colleagues to experience burnout. ²²

The positive correlation between ethical awareness and age suggests that older professionals might possess higher levels of ethical awareness due to their professional experience.²³ The present study emphasizes the significance of nurturing ethical awareness throughout the career trajectory of mental health professionals. The positive associations among incompetence, negative work environment, devaluing clients, deterioration in personal life, and overall burnout indicate that these factors might lead to increased burnout in mental health professionals.^17,24

The negative correlation among ethical awareness, overall burnout, and dimensions of burnout highlights the likelihood for ethical awareness to function as a protective factor against burnout. Mental health professionals who exhibited higher ethical awareness might have had coping mechanisms that strengthened their ability to face professional challenges, ultimately contributing to increased resilience.^7,25–29

Mental health professionals working in a public setting reported a higher level of exhaustion compared to the professionals working in a private setting, which aligns with existing literature highlighting the impact of systemic factors on burnout.^4,8 The current finding underscores the need to examine workplace conditions, available resources, and systemic support structures that might contribute to higher burnout rates in public sector settings.In Pakistan, mental health professionals employed in public hospitals often face insufficient resources and infrastructural challenges. They are required to manage an excessive number of patients due to limited facilities and mental health resources, all of which may increase their risk of exhaustion.^30,31

The significant differences in exhaustion levels between mental health professionals in the public and private sectors raise important considerations for organizational and systemic interventions, suggesting that public mental health professionals might require additional support and resources to manage their workload and stress levels effectively.^4,24 Understanding the unique stressors and challenges faced by mental health professionals in different sectors is crucial for developing targeted strategies to address burnout and promote wellbeing.^25–27

Limitations. The current study has several limitations. Self-reported measures were used for data collection, and such measures are vulnerable to biases. In the current study, the professionals might have over- or underestimated their level of ethical awareness or burnout. The study used a cross-sectional design, and future longitudinal studies should be conducted to understand the interplay between ethical awareness and burnout.

Conclusion

The findings of the present study emphasize the importance of addressing burnout in mental health professionals, particularly among female individuals who make up the majority of the Pakistani workforce in this field. These findings offer valuable insights for crafting targeted interventions, including ethical training programs and support systems, especially tailored for early-career mental health professionals. Implementing measures such as scheduled breaks, duty rotations, flexible work schedules, and paid leave is essential for promoting the overall wellbeing of mental health professionals. These factors play a significant role in fostering a sustainable work environment, mitigating burnout or fatigue, and ultimately enhancing the effectiveness and quality of services provided by mental health professionals. This study advocates for a holistic approach to address burnout, encompassing various facets of professional life to ensure a healthier and more resilient mental health workforce.

Acknowledgements

We would like to acknowledge the scales’ authors for granting us permission to use the scales and all the research participants for their valuable contribution in the present study.

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