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Abstract

Background:

Job-related stress and its extreme form, burnout, continue to affect almost half of all frontline healthcare workers and first responders. Current treatments are inadequate.

Objectives:

To evaluate a model of ketamine-assisted psychotherapy (KAP) delivered in a group format to address symptoms of anxiety, depression, trauma, and burnout via repeated measures of the Generalized Anxiety Disorder (GAD)-7, Patient Health Questionnaire (PHQ)-9, PTSD Checklist (PCL)-5, and Maslach Burnout Inventory (MBI).

Design:

A retrospective cohort analysis of KAP’s effect on GAD-7-item scale, PHQ-9-item scale, PTSD Checklist for DSM-5 (PCL-5), and MBI. GAD-7, PHQ-9, and PCL-5 were administered prior to the first group meeting, on the last group date, and 2 weeks after the completion of the final session. MBI was measured twice, as a pre- and post-intervention test. Mystical Experience Questionnaire (MEQ-30) was collected at each integration.

Methods:

Participants were recruited via self-referrals and professional collaborations. Participants were screened into groups of six after completing a medical evaluation to rule out contraindications. The seven-week program included three ketamine sessions and four group psychotherapy sessions. Descriptive statistics of the cohort, pre- and post-KAP measurement comparisons, regression modeling, and visualizations were prepared.

Results:

Median age was 41 years (24–60), 44% female, and 3% transgender. Participants were 97% White and 3% Hispanic. Many were receiving treatment for depression (59%), anxiety (50%), PTSD (34%), addictive disorders (37%), and other behavioral health conditions (37%). Median pre- versus post-KAP scores for GAD-7 (9.5 vs 6, p = 0.003), PHQ-9 (12 vs 5, p < 0.001), PCL-5 (27 vs 10, p < 0.001), and all three subcomponents of MBI were improved. The last value of MEQ-30 (75 vs 105, p < 0.001) was higher than the first.

Conclusion:

KAP in group settings may offer a rapid reduction in depression, anxiety, and trauma-related symptoms. Adverse events were rare. This psychedelically oriented treatment model may represent a viable intervention for epidemic job-related stress in the healthcare workplace and larger controlled studies are warranted.

Plain language summary

Ketamine-assisted group psychotherapy for symptoms of anxiety, depression, PTSD and burnout

Job-related stress and its extreme form, burnout, continues to affect almost half of all frontline healthcare workers and first responders. - We evaluated ketamine-assisted psychotherapy delivered in a group format to address anxiety, depression, trauma, and burnout via repeated measures of the GAD-7, PHQ-9, PCL-5, and Maslach Burnout Inventory. - Participants were recruited via self-referrals and professional collaborations, and screened into groups of six after completing a medical evaluation to rule out contraindications. - The seven-week program included three ketamine sessions and four group psychotherapy sessions. - Median age was 41 years (24-60), 44% female and 3% transgender. Participants were 97% white and 3% Hispanic. Many were receiving treatment for depression (59%), anxiety (50%), PTSD (34%), addictive disorders (37%), and other behavioral health conditions (37%). Median pre- vs post-KAP scores for GAD-7 (9.5 vs 6, p=0.003), PHQ-9 (12 vs 5, p<0.001), PCL-5 (27 vs 10, p<0.001) and all three subcomponents of MBI were improved. The last value of MEQ-30 (75 vs 105, p<0.001) was higher than the first.

Keywords

burnout first responders group therapy job-related stress ketamine mental health psychedelics

Introduction

Burnout among first responders and social service workers reached critical levels during and shortly after the COVID-19 pandemic, driven by increased workload and exposure to trauma. These events increased the risk of debilitating mental health issues, including anxiety, depression, and post-traumatic stress disorder (PTSD).^1,2 These conditions then have a negative effect on job performance, public health, and safety of the communities, the first responders, and healthcare workers.^3–5 Despite the need, effective interventions to alleviate burnout remain limited.

The emerging twin fields of psychedelic medicine and psychedelic-assisted psychotherapy have gained considerable attention in recent years for their potential to address a variety of intractable mental health problems.⁶ Research into the effects of naturally occurring compounds such as psilocybin and synthetic compounds such as methylenedioxymethamphetamine (MDMA) suggests promise in the treatment of mental health conditions.⁷ Additionally, psychedelic-assisted psychotherapy may have a role in alleviating burnout and social stress.^8–10 Psychedelic medicine emphasizes the innate capacity for self-growth and self-healing. As such, it begins to move away from a more medicalized view of mental illness driven by pathology and toward a strength-based model that builds upon self-healing and peer support.

More specifically, ketamine, a dissociative anesthetic, has shown promise as a treatment for treatment-resistant depression (TRD) and other psychiatric disorders. Ketamine-assisted psychotherapy (KAP) has significantly grown in popularity over the past decade among mental health practitioners employing the psychedelic framework.^11,12 This approach employs a psychoactive agent to alter consciousness while using eyeshades and headphones with music to drive introspection. Although ketamine is not considered one of the “classic” psychedelics, at medium doses it reliably produces an altered state of consciousness that can include experiences of synesthesia, euphoria, somatic release, and an altered sense of time and space.¹³

A ketamine “journey” in a therapeutic setting is, in many ways, comparable to other types of psychedelic experiences induced by other compounds.¹³ Ketamine also carries some of the same risks associated with other psychedelic medicines, such as the possibility of having a terrifying, “bad trip.” These psychological reactions generally only require interpersonal support to resolve.¹⁴ Medical complications at these dose ranges are quite rare in the medically screened, as is the risk of developing a recreational ketamine habit.¹⁵

Ketamine has a reliable and well-understood dose curve with “psychedelic” doses being typically much smaller than the doses prescribed in surgical and/or emergency settings.¹³ Researchers and treatment providers have suggested that KAP can be an effective intervention for worker burnout, providing relief from the chronic stress and emotional exhaustion experienced by the first responders and social service workers.¹⁶

We report on a grant-funded program of KAP in a group setting for the treatment of job-related stress among healthcare workers and first responders in Northern Colorado. We hypothesized that average scores on the Generalized Anxiety Disorder 7-item scale (GAD-7), Patient Health Questionnaire 9-item scale (PHQ-9), PTSD Checklist for DSM-5 (PCL-5) would decline from pretest to posttest. We also hypothesized that average scores on the Maslach Burnout Inventory (MBI) would improve from pretest to posttest as measured by a decline in scores measuring cynicism and exhaustion and an increase in the score measuring professional efficacy.¹⁷ We also anticipated that higher self-report scores on the Mystical Experience Questionnaire (MEQ-30) would correlate with improved mental health outcomes.

Methods

Population

This project is a retrospective analysis of de-identified data. Participants were recruited on an ad hoc basis as well as through a partnership with 911 Overwatch First Responder Trauma Counselors, a professional peer-support organization dedicated to providing mental health support for first responders in crisis. Six people were recruited to a group, and the groups were run sequentially over 8 months.

The data come from a sequential series of enrollments who self-identified as having experienced impairment from job-related stress or trauma. The groups were organized and facilitated by a Psychiatric Mental Health Nurse Practitioner (PMHNP), a KAP-trained clinical therapist, and a clinical master of social work (MSW) intern. Participants were screened into groups after completing a medical evaluation with the PMHNP to rule out any contraindications and to ensure that each participant was in a stable enough environment to reasonably expect completion of the entire course of treatment and follow-up. Their established medication regimens were not adjusted or restricted for the purpose of this study in any way.

Procedures

The seven-week program included three ketamine sessions and four group psychotherapy sessions. The psychotherapy sessions were designed to support participants’ integration of their ketamine experiences. The first session was dedicated to creating a safe group container via norm-setting and facilitating individual sharing and group interaction. The first session also included a portion of psychoeducation on ketamine and its effects and a discussion of intentions and intention-setting for the following week’s medicine session. The ketamine sessions were structured to allow participants to gradually increase their dose over time. In the first two ketamine sessions, the medicine was consumed sub-lingually (SL) at smaller absolute bioavailable doses as this form of administration is less dissociative and more amenable to verbal processing and group bonding. Ketamine was administered intramuscularly (IM) in the last medicine session, which was more internally focused and less amenable to group interaction. The intention was to provide participants with a deeper and more encompassing experience.

We conducted the medicine sessions in accordance with the methods and techniques of other psychedelic-assisted psychotherapy research adapted to our clinic’s process and logistics. Clients were given an opportunity to check in at the beginning of the session and were then encouraged to each share their intention for that evening’s journey. Eyeshades, pillows, blankets, and immersive music acted as the “carrier” for participants through their experience. Facilitators encouraged clients to direct their experience internally for the duration of the medicine’s effects, and then they were allowed to share anything notable at the end of the session. Verbal processing, however, was kept minimal on the day of dosing to allow participants time to remember and process their experience before sharing. The integration sessions were designed to help people make meaning from their journeys through a combination of art therapy, guided imagery to music, and psychodynamic processing. Creative activities and open-ended prompts were used to facilitate group sharing and connection-making between their journeys, their work, and their home lives.

Dosage for the first ketamine session was determined by the PMHNP and then adjusted in subsequent sessions based on participant feedback and observed effect. Due to the low bioavailability of ketamine when administered sub-lingually (SL) (25-35% bioavailability), the SL doses were significantly higher than the intra-muscular (IM) doses (90-95% bioavailability), yet typically produced a more moderate effect. The high bioavailability and rapid onset of an IM injection usually leads to a more enveloping, dissociative experience, which for those inexperienced with altered states of consciousness could be frightening or overwhelming as a first introduction to the medicine, hence the structuring of dosing as two SL sessions followed by one IM session. Each class also included a segment on healthy diet and lifestyle, followed by supportive individual coaching after the group session. We have found that a healthy diet is critical to good mental health and this work.

Measures

Our analysis used four different psychometric measures to assess changes in participants’ levels of burnout and mental health symptomatology before and after completing the 7-week course of treatment (Figure 1). These measures were the GAD-7, PHQ-9, PCL-5, and MBI, which respectively assess participants’ levels of anxiety, depression, trauma, and burnout. All of these measures have been found to be reliable and valid for use in clinical research.^18–21 The GAD-7, PHQ-9, and PCL-5 were administered prior to the first group meeting, on the last group date, and 2 weeks after the completion of the final group session to track any positive or negative tail effects. The MBI is a proprietary pay-per-use questionnaire for which our grant provided funding to collect data at two time points, pretest and posttest.

Figure 1.

Procedural flowchart.

Additionally, participants completed a MEQ-30 at each integration session (weeks 3, 5, and 7) to evaluate the depth of their psychedelic experience with ketamine. The literature on psychedelics suggests a strong, positive correlation between depth of mystical experience and clinical outcomes of psychedelic treatment for a wide variety of mental health challenges.²² Part of our analysis involved examining whether participants’ MEQ-30 scores correlated with changes in measures of burnout and mental health.

Variables

Our study included three sets of variables: independent, dependent, and moderating. The independent variable for this study was the seven-week course of group-KAP treatment. The program was designed as a standardized seven-week treatment and was delivered with as much consistency as is reasonable to expect in a dynamic, psychotherapeutic environment. The dependent variables used in this study were the psychometric measures described above. These were the GAD-7, PHQ-9, PCL-5, and MBI. We hypothesized that the average scores on each measure would decline from pretest to posttest. Lastly, our study included an analysis of the MEQ-30 as a moderating variable. We predicted that a higher MEQ score would predict lower results on the four mental health questionnaires.

Since not all patients completed all evaluations, and to mitigate potential survivor bias from only the satisfied participants continuing to later stages, we used the “last value carried forward” approach for the outcome scales of interest (MBI, GAD-7, PHQ-9, and PCL-5).

Statistical analysis

Descriptive statistics of the cohort, pre- and post-KAP measurement comparisons, regression modeling, and visualizations were prepared via DATATab (DATAtab Team, 2025. DATAtab: Online Statistics Calculator. DATAtab e.U. Graz, Austria. URL https://datatab.net). The comparisons of pre-KAP and last-value-carried-forward post-KAP scores on the GAD-7, PHQ-9, PCL-5, MBI, and MEQ-30 were performed via paired-sample Wilcoxon test. Additionally, we have created boxplots and bar charts as visualizations of pre- and post-KAP statistics for GAD-7, PHQ-9, PCL-5, MBI, and MEQ-30. We have also conducted exploratory analyses, including linear regressions and moderation tests, which are listed in the Supplemental Material only.

Results

Thirty-two participants were included, mostly comprised of first responders (police officers, firefighters, paramedics, and EMTs), with the remainder being emergency medicine providers, community mental health therapists, and school district workers. A few participants were no longer actively working in a social service field due to physical and psychological traumas sustained on the job.

Median age was 41 years (range: 24–60), 44% female and 3% transgender. The participants were 97% White and 3% Hispanic. Many were receiving medication for behavioral health conditions, depression (59%), anxiety (50%), PTSD (34%), addictive disorders (eating disorder or substance use disorder (SUD)—37%), as well as obsessive-compulsive disorder and other miscellaneous conditions (37%). Please see Table 1 (baseline characteristics) for additional detail, including intake statistics of the cohort on MBI, GAD-7, PHQ-9, and PCL-5 scales.

Table 1.

Baseline characteristics.

Characteristic	Frequency (N = 32; 100% response unless specified)	Mean (standard deviation)	Median (min–max)
Age		39 (8.4)	41 (24–60)
Sex (female)	44% (Transgender = 3%)
Race (white)	97% (3% Hispanic)
Psychiatric medications
selective serotonine/serotonine-norepinephrine reuptake inhibotors (SSRI/SNRI)	28%
Other antidepressants	22%
Stimulants	22%
Anxiolytics	16%
Mood stabilizers/miscellaneous	12%
Psychiatric diagnoses
Depression	59%
Anxiety	50%
PTSD	34%
SUD/eating disorder	37%
Miscellaneous	37%
Occupations	Emergency medical technicians (EMT)/Paramedics, firefighters, police officers, correctional officers, counselors, healthcare personnel, teachers, custodians
Adverse Childhood Experience (ACE) score	97% response rate	3 (2.3)	3 (0–8)
Maslach “pre”: Exhaustion/Cynicism/Professional Efficacy		4.1 (1.5)/3.2 ((1.4)/4.7 (0.78)	4.7 (0.8–6)/3.2 (0.4–6)/4.8 (2.7–6)
GAD-7 “pre”		10.6 (6.1)	9.5 (0–21)
PHQ-9 “pre”		12.1 (7.9)	12 (0–27)
PCL-5 “pre”		27.8 (19.5)	27 (0–84)

GAD, Generalized Anxiety Disorder; PCL, PTSD Checklist; PHQ, Patient Health Questionnaire; SUD, substance use disorder.

Mean and median pre- versus post-KAP scores for GAD-7, PHQ-9, PCL-5, and all three subcomponents of MBI showed positive outcomes. Post-KAP scores for all were significantly lower than pre-KAP scores except for a higher post-KAP MBI-Professional Efficacy, which is also a positive outcome, although this result was not statistically significant. The last value of MEQ-30 was also significantly higher than the first. Please see Table 2 (Paired-sample Wilcoxon test: GAD-7, PHQ-9, PCL-5, MBI, and MEQ-30) and Figure 2 (GAD-7, PHQ-9, PCL-5), Figure 3 (MBI and MEQ-30), and Figure 4 (GAD-7, PHQ-9, PCL-5, and MEQ-30—all time-points) for details on these outcomes.

Table 2.

Paired-sample Wilcoxon test: GAD-7, PHQ-9, PCL-5, MBI, and MEQ-30.

Outcome scale	Pre-KAP: median, mean (SD)	Post-KAP LVCF*: median, mean (SD)	p-Value
GAD-7 (32 valid pairs)	9.5, 10.6 (6.1)	6, 7.28 (5)	0.003
PHQ-9 (32 valid pairs)	12, 12.1 (7.9)	5, 6.4 (6.3)	<0.001
PCL-5 (31 valid pairs)	27, 27.8 (19.5)	10, 15.2 (12)	<0.001
MBI (32 valid pairs for all 3 measures)
Exhaustion	4.7, 4.1 (1.5)	3.8, 3.5 (1.4)	0.007
Cynicism	3.2, 3.2 (1.4)	2.6, 2.7 (1.4)	0.004
Professional Efficacy	4.8, 4.7 (0.8)	5.1, 4.9 (0.7)	0.218
MEQ-30** (32 valid pairs)	75, 77 (36.5)	105, 103 (31)	<0.001

Last Value Carried Forward.

MEQ-30 values were collected after the first and last KAP session, rather than “pre- and post-KAP.”

GAD, Generalized Anxiety Disorder; KAP, ketamine-assisted psychotherapy; MBI, Maslach Burnout Inventory; MEQ, Mystical Experience Questionnaire; PCL, PTSD Checklist; PHQ, Patient Health Questionnaire

Figure 2.

(a) GAD-7. (b) PHQ-9. (c) PCL-5.

Figure 3.

Pre- vs post-KAP scores: MBI. (a) exhaustion. (b) cynicism. (c) efficacy. (d) MEQ-30.

Figure 4.

(a) GAD-7. (b) PHQ-9. (c) PCL-5. (d) MEQ-30—all time-points

Additionally, we performed exploratory regression analyses to evaluate the influence of individual factors. Perhaps unsurprisingly, existing diagnoses of depression and anxiety, as well as pre-KAP scores on GAD-7, PHQ-9, and the exhaustion and professional efficacy of MBI, were statistically predictive of post-KAP results in GAD-7, PHQ-9, and PCL-5. Interestingly, a higher MEQ-30 last value also showed a significant predictive value for improvement in these outcome measures of interest. We thus also performed moderation analyses for MEQ-30 as a potential representative moderator of the KAP effect on the relationship between the pre- and post-KAP scores on GAD-7, PHQ-9, and PCL-5. This effect, while in the anticipated direction, did not reach statistical significance in any of the three relationships. Since these analyses were not properly powered in this dataset, they are provided for review only in the Supplemental Material.

Discussion

Our results offer cautious optimism for KAP treatment in reducing the symptoms of anxiety, depression, and PTSD among our sample participants. Our results also indicate moderate improvement among two out of the three submeasures for burnout. These data offer preliminary evidence that healthcare providers and first responders can find a rapid reduction in significant job-related mental health symptoms from a group care psychedelic-assisted model that is legal and accessible. Symptoms of anxiety, depression, and professional burnout were unfortunately common in this population, but this intervention did not target workplace and systemic issues. Thus, it was unlikely to address the complete presentation of workplace burnout, which is often driven by employer mandates, productivity demands, and workflow issues. Two of the three measures of burnout assessed by the MBI improved significantly, while professional efficacy showed only a slight improvement. Cynicism and exhaustion both improved as measured by the MBI. Professional Efficacy increased, but not significantly. This is the measure most directly related to the workplace environment.

The dosing sessions tended to be quiet and reflective. Rarely, a participant would have a significant emotional reaction. These tended to be sadness-grieving over a witnessed death or an extreme traumatic event. Sometimes, participants’ responses in a session expressed gratitude or love for friends, family, or colleagues. Rarely, participants’ responses were characterized by agitation or anger. These were routinely handled by compassionate listening and group support. Typically, big responses were initially addressed immediately following the dosing session and then, with a group process, the following week. Only twice was a call needed by the therapist in between sessions to check in on a participant. These tended to be short and supportive calls.

The measures of anxiety, depression, and trauma, as measured by GAD-7, PHQ-7, and PCL-5, respectively, all showed evidence of rapid and significant reductions. These are offered as measures of symptom load, rather than indicators of psychiatric illness. The MEQ-30 predicted improvement in these other clinical measures. This echoes prior psychedelic research in which the MEQ-30 predicted durable benefit in the treatment of depression and anxiety with psychedelic agents such as psilocybin. The intensity of the mystical experience predicted durable benefits better than the intensity of the psychedelic experience. In a related manner, the change in the MEQ-30 over the protocol reinforces the idea that ketamine can induce some mystical elements for the participant.

This work was delivered in a group format. This reduces the cost of this intervention and provides an opportunity for peer support and normalization. It also begins to develop workplace recognition that vicarious trauma and job-related stress can be serious, incapacitating, and responsive to treatment. In our experience, this was one of the most powerful elements of the intervention. A sense of community was a qualitative indicator that we did not formally measure, but exit interviews highlighted the value of this feature.

There is also a small but growing body of research on combining ketamine treatment with couples and/or group psychotherapy.^23–26 This modality leverages the normalizing and peer-support effects of group therapy in conjunction with the psychedelic effects of ketamine to produce more durable psychological benefits. Conducting KAP in a group setting also substantially reduces the cost of treatment. Group-KAP has the promise to expand access to people for whom ketamine treatment was previously prohibitively expensive. Group-KAP can also be tailored to treat specific ethnic, racial, gender, or professional groups for whom peer solidarity and support are critical to feeling safe enough to journey inward with the medicine and share experiences unique to their identity group.

Limitations

There are important limitations to our study. Firstly, since there was no control group or randomization, we cannot infer causality of the improvement in our group-KAP intervention. Secondly, our study is further limited by a small, ethnically homogeneous sample. Thirdly, our study utilized self-report measures, which are subject to response biases such as social desirability and recall bias. Participants may have underreported or overreported their symptoms and experiences, potentially skewing the results. Finally, the group was quite diverse in clinical presentation. This was not a clinical population of individuals with a specific psychiatric diagnosis, but a representative sample of highly stressed and symptomatic employees in social service workplaces. This represents both a clinical challenge in the analysis of the data collected and a practical assessment of a real-world population.

Conclusion

Our study offers an encouraging guide for delivering KAP in a group setting aimed at a reduction of job-related stress and an improvement in individual coping skills. We do not envision this model as a stand-alone strategy for addressing burnout, as no systemic workplace interventions were incorporated, although the individual positive results were rapid and clinically meaningful. This psychedelic approach emphasizes stress reduction and improved coping skills. Notable reductions in anxiety, depression, and trauma-related symptoms were found in a diverse population of healthcare and social service workers. A larger study with controls and systemic workplace involvement would better assess the value of this promising intervention. Overall, this therapeutic approach was well accepted and may represent a new model for addressing stressful workplaces that pose significant administrative and financial challenges to professional retention. Ketamine-assisted group psychotherapy may represent a useful intervention for a stressed workplace.

Supplemental Material

sj-docx-1-tpp-10.1177_20451253251383415 – Supplemental material for Treating job-related stress with psychedelic group therapy: a case series on group ketamine-assisted psychotherapy for healthcare workers and first responders

Supplemental material, sj-docx-1-tpp-10.1177_20451253251383415 for Treating job-related stress with psychedelic group therapy: a case series on group ketamine-assisted psychotherapy for healthcare workers and first responders by Luke Flynn, Martin Krsak, Mary Rondeau, Danielle McCarty, Melanie Walker, Doreen Horan, Steve Forstner and Scott Shannon in Therapeutic Advances in Psychopharmacology

Footnotes

Acknowledgements

We deeply appreciate the support from the Flourish Trust. The authors would like to share their appreciation for the staff and providers at Wholeness Center for their support and care. Most of all, we would like to acknowledge the efforts of the frontline healthcare providers and first responders of Fort Collins, Colorado for their heartfelt efforts to make our community safer.

Declarations

ORCID iD

Martin Krsak

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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