Changes in Occupational Burnout Measures for Emergency Medical Workers

The Importance of Mental Health Support for Emergency Medical Service Workers

The essential nature of the care and treatment carried out by emergency medical service workers (EMSW) is indisputable as they “address the needs of patients with acute illness and injury” (Mitchell et al., 2022, p. 1). However, in the effort of fulfilling their role, their level of exposure to critical incidents, defined as “potentially traumatizing events that may cause psychological distress” (Loef et al., 2021, p. 2), has been reported to be between 80 and 100% (Donnelly & Siebert, 2009), significantly impacting their mental health and wellbeing (Gallagher & McGilloway, 2008).

The regular exposure to distressing situations, accident scenes, death, trauma, and violence, puts the population of emergency responders at a higher risk of suffering from more mental health problems, compared to the general population (Sharp et al., 2020). Furthermore, workplace culture and organizational stressors such as inadequate support, excessive and unpredictable workloads, shift work, decreasing numbers of staff, productivity and effectiveness demands, and increasing social accountability, have been shown to play a strong interactional effect with critical incidents, in detriment of their mental and physical health and well-being (Lawn et al., 2020).

This negative feedback loop is at the source of symptoms of post-traumatic stress disorder (PTSD), burnout, depression, and exhaustion (Stevelink et al., 2020), but also of high-risk coping strategies, with studies referring to alcohol and drug use rates as high as 40% within EMSWs (Donnelly & Siebert, 2009). Of particular importance is the concept of ‘occupational burnout’ (OB), defined as “exhaustion due to prolonged exposure to work-related problems” (Guseva Canu et al., 2021, p. 95). Concerning rates of exhaustion due to prolonged exposure to work-related problems, at around 60% in samples of clinicians and EMSWs, include symptoms of fatigue, emotional and physical exhaustion, cynicism, and irritability, often directed towards the patients, and reduced feelings of personal accomplishment (Kaplan et al., 2023; Petrino et al., 2022).

The development of OB due to external factors has a clear impact at the organizational level, leading to absenteeism, misjudgments and errors, and higher job turnover rates (Johnson et al., 2018; Morse et al., 2012; Suner-Soler et al., 2013), all leading to overall reduced capability and a concerning worsening of the quality of patient care, according to a recent meta-analysis (Garcia et al., 2019a, 2019b). Another well-known consequence that can compromise the quality of patient care is ‘compassion fatigue’ (Cocker & Joss, 2016), “the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering” (Bellolio et al., 2014, p. 629), a particular type of stress to which EMSWs are susceptible.

Despite the high prevalence of intense levels of OB and associated psychological challenges, it is believed that less than 40% of EMSW seek help, even when mental health services are available, with barriers thought to be a lack of perceived need for treatment, fears regarding confidentiality, negative career impact, work overload, but also a widespread distrust and generalized pessimism for mainstream methods that require commitment, consistency and considerable periods of time to become effective, which can potentially lead to worsening post-trauma psychopathology (Haughen et al., 2017; Jones et al., 2020).

The high frequency of OB and the high prevalence of common mental disorders among EMSWs, points to the need for further studies to better understand the actual picture and design innovative strategies to intervene on a series of well-recognized OB predictors (Shoman et al., 2021), and at the end of the line, assure high quality patient care. With the recent resurgence of psychedelics as a ‘re-emerging therapeutic paradigm’ (Tupper, 2015), showing promising results in clinical research (Elsey, 2017; Sessa, 2012), by successfully addressing symptoms of psychological distress in a short period of time, it is feasible to consider psychedelic therapy as a favorable option to address the mental health challenges that EMSW face.

The Potential of Psychedelic Therapy for EMSWs

From a clinical perspective, there are now numerous studies demonstrating that, where conventional psychiatric medications need to be administered over long periods of time without being sufficient for most patients (Insel, 2009), single supported therapeutic doses of psychedelic substances have been shown to drastically reduce symptoms of mental health conditions, including: ayahuasca for addiction (e.g., Fábregas et al., 2010; Loizaga-Velder & Verres, 2014); MDMA for PTSD (e.g., Chabrol, 2013; Feduccia et al., 2018; Gorman et al., 2020; Mithoefer et al., 2018, 2019) and social anxiety (e.g., Grob et al., 2013); psylocibin for depression, anxiety and obsessive compulsive disorder (e.g., Carhart-Harris et al., 2017; Goodwin et al., 2022; Griffiths et al., 2016; Grob et al., 2011; Gukasyan et al., 2022; van Rotz et al., 2023), and for alcohol and tobacco addiction (e.g., Bogenschutz et al., 2015; Johnson et al., 2014, 2017); LSD for anxiety caused by life-threatening diseases (e.g., Gasser et al., 2015) and ketamine for mood disorders (e.g., Newport et al., 2015; Sanacora et al., 2017).

As a result, psychedelic assisted psychotherapy has been considered as a “potential breakthrough treatment for several types of mental illnesses” (Belouin & Henningfield, 2018, p. 7), with psilocybin and MDMA “having already received Food and Drug Administration ‘breakthrough therapy’ designation for the treatment of resistant major depression disorder and PTSD, respectively” (Bird et al., 2021, p. 229). Currently, there has been a lack of psychedelic research with EMSW, although in 2022, a pandemic-era open-label uncontrolled study was conducted with front-line workers using microdose ketamine, that showed promise in combating anxiety, stress, and burnout (Atoian et al., 2022), in comparison to conventionally offered treatment options (Hutten et al., 2019).

However, little research has been conducted into how psychedelics can affect the workforce (Korman, 2024), although psychedelic use has been shown to not lead to motivationally-based workplace absenteeism generally (Korman, 2023b), although overtime was found to be reduced following the use of psilocybin (Korman, 2023a), but as a probable benefit to employee well-being. Additionally, studies with higher, therapeutic doses of psychedelics have been demonstrated to be effective in treating army veterans and first responders for severe mental health challenges, showing significant decreases in PTSD symptomatology severity after the application of active doses of MDMA with adjunctive psychotherapy (Mithoefer et al., 2018), and immediate and long-term symptom reductions in trauma symptoms with psilocybin (Smith et al., 2022).

Psilocybin’s favorable safety profile (Lowe et al., 2021) and its increasing popularity as a viable treatment option for immediate and long-term improvements in psychiatric symptomatology (Danforth et al., 2018; Wolfson et al., 2020), has caused an increase in its use, even outside research settings (Cameron et al., 2020; Yockey & King, 2021). These results not only encouraged the creation of the ‘Heroic Hearts Project’, a charity working with researchers to improve veterans’ access to psychedelic programs (Gould, 2019), but the publication of a special edition of the ‘Journal of Military, Veteran and Family Health’ (Shore, 2023) supporting the therapeutic use of psychedelics in military and veteran populations. Eventually, such interventions could be applicable, mutatis mutandis, to first responders, including ambulance workers, as military and emergency services share similar rates of negative health impacts (Doody et al., 2021).

A Naturalistic Study Exploring Psilocybin Therapy for EMSWs

The conceptualisation for the present study and how the participants were recruited came about after indicating that they were planning a therapeutic dose of psilocybin in a near future, in their responses to an anonymous online multiple-choice questionnaire named “Psychedelics Awareness and Attitudes Within Emergency and Primary Care Settings” created with the aim of collecting data about psychedelic substances knowledge, attitudes, and uses within the EMSW population. The survey gathered 113 complete responses from 113 participants, with 37.2% answering yes to the question ‘Have you ever consumed any psychedelic substance?’; 54.5% considering such experiences as potentially life-changing, 57.5% supporting therapeutic applications, and 21.2% supporting recreational uses. Additional results showed that EMSWs, even if they did not have any personal experience with psychedelics, considered the need for further specialized training in supporting psychedelic crisis important (95.6%), and would be prepared to further their knowledge as extracurricular learning in their own time (91.1%) considering the lack of practical guidance available for health care professionals.

The present naturalistic mix-method, study represents an effort to add to the existing knowledge regarding the use of psychedelics to address mental health challenges outside a clinical setting, by using a set of pre-approved instruments to measure aspects of occupational burnout like symptoms of PTSD, compassion satisfaction and fatigue, and work-related stress in a sample of EMSWs. The participants, in an attempt to find relief to severe mental health challenges and encouraged by favorable examples from veterans who used psychedelics successfully, decided to use a single self-administered dose of psilocybin mushrooms, in a natural, nonclinical, and noncontrolled setting. A secondary goal was to observe if any possible changes were related to the quality of the experience, namely phenomenology, and possible psychological insights and emotional breakthroughs, using psychometric tools and follow-up interviews.

Study Design and Methodology

A naturalistic mixed methods field study was conducted, with longitudinal psychometric measures and follow up qualitative interviews, in an intentional sample of five self-selected participants from a pool of 113 EMSWs. All data was collected through two follow-up interviews and psychometric measures, for which the volunteers were given instructions and provided with the respective materials, at a baseline point before the planned day for the experience, one day after, and approximately two weeks and two months later:

The five participants of the intentional sample of this study were selected from a group of EMSWs, either paramedics or ambulance technicians working in the United Kingdom (UK) as UK nationals, with ages ranging from 32 to 46 years old, three man and two women, with a mean age of 38.6, and years of EMSW experience ranging from 2 to 15, with a mean of 7.4. All participants were recruited after indicating that they were planning a therapeutic dose of psilocybin in the near future in their responses to an anonymous online multiple-choice questionnaire described in the introduction section.

Six (6) respondents declared they were microdosing with psilocybin, after gaining knowledge regarding positive outcomes in war veterans suffering from PTSD. They also declared they planned to take a therapeutic dose of psilocybin on their own, with the support of a sitter they sought out and found on their own, in a non-controlled, naturalistic setting, and expressed their interest in participating in a naturalistic study when they would do this. They predominantly hoped that a higher dose of the same substance they had already found beneficial, would help them to manage mental health challenges and workplace stress-related symptoms (see Supplementary Material 1).

All participants reported suffering from undiagnosed psychiatric conditions coming from a combination of unresolved traumatic life situations and organizational stressors, which constituted the main reason why they started microdosing. As the decision to take the substance was not influenced by the researchers, there were no applicable exclusion criteria. The participants filled in an informed consent form and were guaranteed anonymity and full confidentiality during the procedure, as well as the possibility of withdrawing at any time, and given suitable suggestions for support organizations, should they need them. Participants were not compensated for their participation.

There were initially six participants but one participant dropped out before completing the follow up measures and interviews without providing reasons for withdrawing, leaving a total of five. During the two months following their therapeutic dose all participants refrained from consuming psilocybin at any dose, and four out of the five returned to their usual EMSW work directly following their therapeutic dose. The other participant, who had been off work on long term sick leave due to stress prior to participating, returned to work within two months, citing the psilocybin as “a game-changer”.

Psychometric Measures and Follow-up Interviews

Four instruments were used to assess common OB predictors within the EMSW population:

IES-R- Impact of Event Scale-Revised (Weiss & Marmar, 1997)
SPRINT-Short Post-Traumatic Stress Disorder Rating Interview (Connor & Davidson, 2001)
PROQOL-Professional Quality of Life Scale (Stamm, 2009)
EMS-CSQ-The Emergency Medical Services Chronic Stress Questionnaire (Donnelly et al., 2014)

Two other instruments were used to assess psychological and emotional features of the psychedelic experience that might be associated with changes in the impact of events, psychological well-being and stress related indicators:

EBI-the Emotional Breakthrough Inventory (Roseman et al., 2019)
PIQ-the Psychological Insight Questionnaire (Davis et al., 2021)

Two follow-up interviews were facilitated, where participants were retrospectively inquired about the phenomenological contents and overall subjective impact of the experience, if and how it addressed initial intentions and possible challenges or negative consequences.

For more information regarding the instruments, see Supplementary Material 2.

To ensure legality and to comply with ethical boundaries, throughout the entire project, the participants were not encouraged to engage in any illegal activity nor were supplied, sold, dealt, or shared any controlled psychoactive substance for their experience, being fully responsible for the substances they possessed and used. The study conformed to and complied with the ethical guidelines of the British Psychological Society.

Study Results and Implications

The Table 1 below presents post-treatment ratings of relevant OB measures at approximately 2-weeks and 2-months, compared against those collected at baseline (before the session). For detailed individual results and follow-up interview summaries, see Supplementary Materials 3 and 4.

The present non-interventional study, conducted with in an intentional sample of five EMSWs showed that, two weeks after the self-administration of a single, therapeutic dose of psilocybin mushrooms, a visible improvement occurred in all selected measures of OB, that was mostly sustained at two months, except for the organizational stressor’s subscale, which showed a decrease at two weeks, but then a slight increase to that at two months.

All volunteers showed less intense levels of reactivity to specific events and occupational stressors, less intense PTSD symptomatology, lower levels of job burnout and secondary traumatic stress and higher levels of compassion satisfaction, fulfilling enough criteria to demonstrate some level of efficacy in the self-administrated treatment condition. The perceived successful outcome was mostly (4/5) attributed by the participants to emotional breakthroughs and psychological insights that occurred within the session.

However, it should be mentioned that an improvement in the intensity of disturbing psychological symptoms had been already noticed after they started microdosing (Fadiman, 2011) with psilocybin for a period between 4 weeks and 6 months prior to the full dose, even inconsistently, with this being the main reason why they decided to experiment with a higher dose. Their perceptions were consonant with studies accounting for perceived positive effects of microdosing in psychological functioning (e.g., Anderson et al., 2019; Atoian et al., 2022, Hutten et al., 2019; Johnstad, 2018; Prochazkova et al., 2018; Rootman et al., 2021; 2022), and might be responsible for any perceived improvements regarding the intensity of pre