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Work-Stress Burnout in Emergency Medical Technicians and the Use of Early Recollections.

Numerous studies have indicated the high work-stress burnout and attrition rate of emergency medical technicians. Of these studies, none have attempted to use projective techniques to predict work-stress burnout. Eight central themes of early recollections have been reported: getter, controller, driver, pleaser, martyr/victim, "aginner," feeling avoider, and excitement seeker. This article discusses those early memories that are more representative of emergency medical technicians who may be susceptible to burnout, as well as other memories that may indicate an individual's resistance to burnout, and proposes research to substantiate the effectiveness of early recollections in predicting burnout in emergency medical technicians.

Maslach and Jackson (1981) have described burnout as consisting of three components. The first component involves increased feelings of emotional exhaustion. Individuals in the helping professions are particularly susceptible to burnout and emotional exhaustion. They may develop negative, cynical attitudes and feelings toward their patients. As their emotional resources are depleted, they are no longer able to be as supportive as they need to in order to be effective. This emotional exhaustion occurs as a result of excessive psychological and emotional demands made on them as they attempt to provide therapeutic services to patients (Jackson, Schwab, & Schuler, 1986). The second component of burnout involves the tendency to deindividuate and depersonalize patients (Jackson et al., 1986; Maslach, 1976). Depersonalization is used to minimize the intense emotional arousal that could affect the performance of the helping professional in crisis situations. A third component of burnout is the tendency for helping professionals to evaluate themselves negatively when assessing their work with patients (Maslach & Jackson, 1981).

Paramedics and emergency medical technicians (EMTs) are very susceptible to burnout. EMTs face daily exposure to human tragedy and chronic stressors such as dealing with injury, mutilation, and death. EMTs do not work in well-equipped hospitals. They must make do in their immediate environment and, in some instances, in the presence of physical danger. Their job performance is often scrutinized by bystanders and the traumatized relatives of their patients (Cydulka et al., 1989). Emergency medical services provided outside the hospital emergency room setting are often delivered in a hostile world where darkness, adverse weather conditions, difficult terrain, and unpredictable dangers magnify the pressure (Linton, Kommor, & Webb, 1993; Miller, 1995). Added to these environmental stressors is the constant pressure for EMTs to perform competently. Paramedics often perceive that the public takes advantage of them by calling them to perform routine nonemergency services (Cydulka et al., 1989; Mitchell, 1984). Decreases in overall work performance have also been reported, including inaccurate diagnosis, deficiencies in relational skills, and a tendency to trivialize the complaints of patients (Hammer, Mathews, Lyons, & Johnson, 1986). When faced constantly with such precarious situations, EMTs over time and experience develop a "thick skinned" approach to providing treatment to their patients. C. E. Palmer (1983) has stated that, in an effort to protect themselves, EMTs develop numerous coping skills to assist them in dealing with the more gruesome aspects of death and dying. These include the following: educational desensitization, humor, language alternation, scientific fragmentation, escape into work, and rationalization (C. E. Palmer, 1983). These coping mechanisms allow paramedics to continue to concentrate on treating patients whose lives they can save.

EFFECTS OF BURNOUT

Increased levels of stress and burnout can result in high job-turnover rates, increased absenteeism, and low morale (Maslach, 1976; Maslach & Jackson, 1981; Maslach & Pines, 1978). McHenry (1989) reported a growing awareness among both emergency medical services (EMS) leaders and public officials that the shortage of EMS personnel was nearing a crisis. Paramedics are reported to have the highest mean burnout score observed among health professionals (Grigsby & McKnew, 1988). The average length of the professional paramedic career has been reported to be less than 4 years (Beaton & Murphy, 1993; Graham, 1981; Mitchell, 1984).

It is important to understand the high stress level that EMTs face daily. An accumulation of stress can lead to burnout, resulting in the deterioration of the quality of care provided (Boudreaux, Jones, Mandry, & Brantley, 1996). Paramedics have identified the following stressors as being the most stressful: death (especially of children), injured or battered children, gory sights and sounds, unnecessary calls, drug abuse patients, fires In high-rises with threat to human life, mass casualties, and threats to their own health and life (Mitchell, 1984). Previous research regarding occupational stress and EMTs has indicated that administrative and operational characteristics of EMS organizations are important determinants of EMT occupational stress (Allison, Whitley, Revicki, & Landis, 1987; Beaton & Murphy, 1993; Graham, 1981; Mitchell, 1984). The stress that EMTs undergo is not only limited to what they experience in the field but is also compounded by the regular monotonous routine of paperwork, lack of administrative support, low wages, long hours, irregular shifts, and cynical attitudes of hospital personnel and law enforcement officials (Boudreaux, Mandry, & Brantley, 1998; Grigsby & McKnew, 1988; Spitzer & Neely, 1992). Without any systematic training or education on how to deal with potential conflict with hospital personnel or police officers, EMTs use defensive mechanisms consistent with their personalities (Graham, 1981). One oft he frustrations that EMTs face daily is their position at the bottom of the medical hierarchy. The most experienced professional EMT is required to request permission to perform the simplest of procedures from someone with far less experience in the delivery of emergency medical services outside a hospital emergency room (Hawks & Hammond, 1990). Although EMS agencies are aware of the high level of attrition among their EMT employees, they continue to pay only minimum wage and often require overtime work (Graham, 1981; Hawks & Hammond, 1990). Both practices contribute to the problem of increased work-stress burnout in EMTs.

POST-TRAUMATIC STRESS DISORDER

The characteristic symptoms of Post-Traumatic Stress Disorder (PTSD) include (a) reexperiencing a traumatic event; (b) avoidance of stimuli associated with the trauma and numbing of responsiveness to the external world; and (c) other autonomic, dysphoric, or cognitive reactions indicative of increased arousal. These symptoms can result from participating in or witnessing a psychologically distressing event such as seeing someone seriously injured or killed (American Psychiatric Association, 1994).

Symptoms that are indicative of distress that could lead to PTSD in EMTs include (a) persistent fatigue, increased negativity, increased cynicism, and diminished job motivation; (b) increasingly hair-trigger emotions such as anger, frustration, and Irritability; (c) chronic but minor health problems; (d) headaches or backaches unrelated to injury; (e) tightness in major muscle groups; (f) clenched jaw or fists; (g) sleep irregularities; (h) inability to feel refreshed, regardless of how much sleep; (i) feeling chronically overwhelmed or relentlessly pressured or both; (j) diminished motivation for things you once found interesting; (k) overindulging consistently flood, caffeine, nicotine, drugs, and/or alcohol); (l) crying easily; (m) feelings of hopelessness or helplessness; (n) diminished ability to concentrate; (o) sensing that routines have turned Into ruts; and (p) sense of isolation or withdrawal from the world (Dernocoeur, 1989). More severe symptoms include (a) outright substance abuse, (b) clinical distress, (c) feelings of persecution, (d) feelings of paranoia, and (e) suicidal feelings (Dernocoeur, 1989).

EMTs are constantly at risk for developing symptoms of PTSD because of their exposure to traumatic stressors, such as natural disasters, car accidents, and fires. Research on the effects of disasters has usually focused on the Immediate victim of the disaster (Fullerton, McCarroll, Ursano, & Wright, 1992). Rescue workers are also exposed to both the stress of the event itself and the stress of their role as a help provider (Raphael, 1986). EMTs have higher levels of exposure than civilian victims to the experiences that are implicated in the development of PTSD and other posttrauma psychological difficulties (Weiss, Marmar, Metzler, & Ronfeldt, 1995).

Of greatest concern in the development of PTSD is the powerful stress response that occurs after a critical incident, which has the potential to overwhelm the EMT (Linton et al., 1993). Critical incidents that overwhelm EMTs Include major disasters, the death of a fellow EMT in the line of duty, the Injury of a fellow EMT while trying to provide emergency services, the suicide of a fellow worker, familiarity with treatment victims, and contact with dead or severely injured children (Linton et al., 1993). PTSD can lead to implications for both the mental health of paramedics and for the care that they provide to their patients (Grevin, 1996).

Many times those who assist In providing emergency services may be affected by the catastrophic disaster themselves (Raphael, Singh, Bradbury, & Lambert, 1983-1984). Impairment of professional performance in crisis situations not only endangers the patient but it can also affect fellow workers, family members, and ultimately the entire community.

LIFESTYLE

The lifestyle or personality is a cognitive blueprint of a person's unique and individually created convictions, goals, and personal beliefs (Adler, 1982). Shulman and Mosak (1988) described the development of the lifestyle by a simple trial and error process. Children try to organize their world in an attempt to cope with it. They develop conclusions regarding their subjective experiences, which may through time become reinforced, altered, or discarded. Eventually, these conclusions become rules or convictions that permit the child to relate to the world in a less chaotic way. The development of a lifestyle is highly influenced by the family system. The sheer repetition of family transactions that are enacted thousands of times in daffy family life has a powerful long-term effect on individuals (Teyber, 1997). These developing convictions may be true, partially true, or false. False convictions are called "basic mistakes." "Basic mistakes" give individuals a distorted approach to life. Children view these subjective experiences "as if" they were objective realities because their judgment and logical processes are not yet fully developed. Through these convictions, children develop a lifestyle that will aid them in coping with the world. Adler (1956) stated that as long as a person is in a favorable situation, it is difficult to see his or her style of life clearly. However, in new situations in which he or she is confronted with difficulties, the style of life appears clearly and distinctly.

EARLY RECOLLECTIONS

Early recollections were thought by Adler to be of special significance because they showed the origin of the lifestyle in a simple manner (Adler, 1958, 1998; Shulman & Mosak, 1988). Early recollections are those single incidents from childhood that the individual is able to reconstitute in present experience as mental pictures or as focused sensory memories. They are understood dynamically; the act of recollecting and remembering is a present activity, the historical accuracy of which is irrelevant (Adler, 1956; Shulman & Mosak, 1988). Over time memories evolve from fact to alterations of perceived events. In looking at early memories, it is expected that those that are to be collected will not be recordings of actual events but those events that the individual perceives to have occurred in the past (Shulman & Mosak, 1988). All memories contain omissions and distortions; the individual colors and distorts, emphasizes and omits, exaggerates and minimizes in accordance with his or her inner needs (Mosak, 1958).

Adler's theory of individual psychology provides a holistic and systemic framework from which to investigate the interplay between personality and stress-coping resources (Kern, Gfroerer, Summers, Curlette, & Matheny, 1996). Fleishman (1984) found significant relationships between personality characteristics and coping patterns. This led to the assumption that one's personality type may dictate one's coping mechanisms. Adler (1937) asserted that early recollections revealed important aspects of the individual's personality, their perceptions of the world, and a way of dealing with their perceptions of the world. It is believed that early memories are retained because of a selective factor in memory and that this selective factor is not repression but rather consistency with the individual's attitudinal frame of reference (Mosak, 1958). Memory is highly selective. Early recollections are selected from a vast number of experiences because they contain adaptively useful information (Adler, 1969; Shulman & Mosak, 1988). Early recollections mirror presently held convictions, evaluations, attitudes, and biases (Dreikurs, 1973).

PREVIOUS STUDIES ON BURNOUT AND PERSONALITY

McFarlane (1989) studied predisposing, precipitating, and perpetuating factors of PTSD with firefighters. Neuroticism and a past history of treatment for a psychological disorder were found to be better predictors of posttraumatic morbidity than the degree of exposure to the disaster or the losses sustained.

Piedmont (1993) found that personality plays an important role in the experience of job-related distress. Those individuals who are anxious, depressed, and unable to deal with stressors are the same individuals who experience emotional exhaustion and depersonalization both at work and in their lives away from work.

Grevin (1996) found that individuals who choose to become paramedics might tend to share characteristics predisposing them to particular types of stress reactions. This study suggested that personality traits might be more of a factor in the development of PTSD in paramedics than the inherent stressors of being a paramedic.

R. G. Palmer and Spaid (1996) found that certain personality characteristics were associated with burnout. EMTs who were authoritarian and bored tended to experience burnout more often.

PREVIOUS STUDIES ON EARLY RECOLLECTIONS AND PERSONALITY

Early recollections have been used to assist diagnosis and treatment (Olson, 1979). This technique has been used for assistance in diagnosing depression (Allers, White, & Hornbuckle, 1992), schizophrenia (Friedman & Schiffman, 1962; Hafner, Corotto, & Fakouri, 1980), paranoia (Hafner, Fakouri, Ollendick, & Corotto, 1986), PTSD with Vietnam veterans (Hyer, Woods, & Boudewyns, 1989), eating disorders (Williams & Manaster, 1990), alcoholics (Chaplin & Orlofsky, 1991), and identifying personality problems (Sweeney, 1981). Early recollections have also been used to monitor progress in psychotherapy (Kadis, 1958; Papanek, 1972; Saville & Eckstein, 1987).

Mosak (1968) proposed that the symptoms of an Individual's neurosis were Interrelated through central themes. Those central themes Included getters, controllers, drivers, pleasers, martyrs/victims, "aginners," feeling avoiders, and excitement seekers.

Caruso and Spirrison (1994) found evidence of a relationship between early recollections and personality functioning and coping abilities. They found that the amount of activity within an early memory was predictive of an individual's emotional stability. Caruso and Spirrison also found that nonpathological personality traits had significant relationships with early recollections.

Kern et al. (1996) examined the relationship between personality styles and coping resources. They found that perceptions of early childhood experiences were related to the ability to cope with stress.

THEMES OF STRIVING WITH AND WITHOUT SOCIAL INTEREST

Just as the lifestyle of individuals remains constant, regardless of their varying behavior, a particular theme for an early recollection can manifest itself In many different forms. Each individual strives toward a goal of significance and security. This is called the "fictional goal" (Adler, 1956). Manaster and Corsini (1982) stated that Adlerians generally equate social interest with positive mental health. Social Interest is viewed as a sense of belongingness with mankind, a willingness to contribute to others for the greater purpose of mankind. Persons without social Interest are viewed as psychologically unhealthy.

Adlerians do not consider human beings as types because every person has an individual style of life (Adler, 1956). The types described by Adler, and later by Mosak (1979), are used as conceptual devices to make the similarities of individuals more understandable (Adler, 1956). Adler was able to characterize Individual lifestyles through central themes: the ruling type, the getting type, the avoiding type, and the socially useful type (Adler, 1956). Mosak (1979) developed a more extensive set of central themes that included getters, controllers, drivers, pleasers, martyrs, victims, "aginners," feeling avoiders, and excitement seekers (Mosak, 1958, 1968).

According to Mosak (1968), getters exploit and manipulate life and others by actively or passively putting others in their service. Getters tend to view life as unfair for denying them that which they believe they are entitled to. Getters are characterized as individuals who exploit, manipulate, intimidate, and charm. Getters can be coy or throw temper tantrums to get what they want. They are insatiable in their getting. Getters who exhibit social interest appear as individuals who act as harvesters, procuring and acquiring to help others get their fair share (Kopp, 1986).

Controllers can be described as either people who wish to control life or individuals who wish to ensure that life will not control them. They generally dislike surprises, control their spontaneity, and hide feelings because all of these may lessen their control. As a substitute, controllers favor intellectualization, rightness, orderliness, and neatness. With their god-like striving for perfection, controllers are apt to depreciate others (Mosak, 1968). Controllers with social interest appear as individuals who work as organizers; they are orderly, efficient, punctual, and systematic (Kopp, 1986).

Drivers are active, aggressive, forceful individuals who always want to be first, be on top, be better than others, or be the center (Mosak, 1968). Drivers have to win, and, when they do not, they claim they were cheated. Drivers must have their own way, and power is important in all of their relationships, although they also feel that they would like to please everyone. The drivers' overconscientiousness and dedication to goals rarely permit them to rest. Drivers act as if they want to have "it" (whatever it may be) completed on the day they die. Underneath, drivers nurse a fear that they are "nothing," and their overt, overambitious behavior is counterphobic. Drivers with social interest are achievers, helping the world and others by being productive (Kopp, 1986).

Pleasers are people who need to be liked and feel required to please everyone all the time. These individuals are particularly sensitive to criticism, feeling crushed when they do not receive universal and constant approval. They train themselves to read other people carefully to discover what might please them and to shift from position to position in an attempt to please. They see the evaluations of others as the yardsticks of their worth (Mosak, 1968).

Victims innocently or actively pursue the vocation of"disaster chasers" (Mosak, 1968). Associated characteristics may be feelings of nobility, self-pity, resignation, or proneness to accident. Secondarily, victims may seek the sympathy or pity of others. Martyrs are in some respects similar to victims. Martyrs also suffer, but whereas the victim merely dies, martyrs die for a cause or for principle (Mosak, 1968). The martyr's goal is the attainment of nobility, and their vocation is that of "injustice collector." Some martyrs advertise their suffering to an unconcerned audience, thus accusing them of further injustice; others enhance their nobility by silently enduring and suffering. Victim/martyrs with social interest are individuals who act as advocates, striving to correct injustice and oppression in the world (Kopp, 1986).

"Aginners" oppose everything and know only what they are against (Mosak, 1968). "Aginners" choose not to stand for anything. They may be actively against or behave passively, circumventing the demands of others. "Aginners" are extreme pessimists. "Aginners" with social interest are individuals who create unique, serf-initiated, independent solutions to problems (Kopp, 1986).

Feeling avoiders believe that reason can solve all problems; they can talk a good game (Mosak, 1968). Feeling avoiders fear their own spontaneity, lest they move in a way that was not preplanned. They lack social presence and feel comfortable only in those situations in which intellectual expression is prized.

Excitement seekers despise routine and repetitive activities, seeking novel experiences and reveling in commotion (Mosak, 1968). When life becomes dull, excitement seekers stimulate or provoke it to create excitement. They require the presence of other people and often place themselves in league with others on whom they can rely to assist them in search for excitement.

EARLY RECOLLECTION THEMES AND EMT BURNOUT

Early recollection themes may be useful in predicting EMT burnout. The lifestyle typologies of Mosak (1958, 1968) provide a useful framework for discussing the dynamics of EMTs because these dynamics relate to stress and burnout. EMTs who exhibit the following early recollection themes may be susceptible to burnout: controllers, pleasers, martyrs/victims, "aginners," and feeling avoiders.

Controllers may be susceptible to burnout because the sole nature of an EMTs occupation can be described as one of no control. EMTs are not able to control the surroundings of their Immediate work environment. Pleasers may be susceptible to burnout because an EMT cannot save everyone. The EMT who needs to be good may experience guilt as a result of being unable to save patients, which may in turn affect job performance. Martyrs/victims may also be susceptible to burnout. EMTs cannot effectively help others if they are caught up in their own struggle of personal justification. "Aginners" may be susceptible to burnout. Their tendency to be oppositional could compromise the health and well-being of their patients. The rebellious nature of the "aginners" may make it difficult for them to work collaboratively with other health care professionals. Feeling avoiders may also be susceptible to burnout. Their lack of affective awareness and tendency to internalize feelings may make it difficult for them to recognize the symptoms of burnout in themselves.

There are also early recollection themes that may make EMTs resistant to burnout. These themes include the following: getters, drivers, and excitement seekers.

Getters may be resistant to burnout. They are more concerned about what they can get out of a job (i.e., paycheck, hero status) and are less likely to be emotionally involved in their work. Drivers may be resistant to burnout. Drivers are dedicated workers who are actively ambitious. Their goals help them focus on the overall objective realities of their jobs. Excitement seekers may be resistant to burnout. The work of an EMT is one that is marked by the unknown. Each call to which an EMT responds is different and potentially exciting.

DISCUSSION

Mosak (1977) maintained that early recollections constitute a quick device for uncovering an individual's unconscious attitudes. It is possible that early recollections might be used for rapid screening of EMTs. It is unlikely that a potential EMT would want to endorse items on a burnout inventory that would identify him or her as either burned out or susceptible to burnout. Early recollections would provide a projective assessment that would make it more difficult for individuals to "fake good."

The use of early recollections to rapidly screen workers or potential workers for burnout or to identify those who might be susceptible to burnout could be extended to other high-stress occupations other than emergency medical technicians. These high-stress occupations might include the following: firefighters, police officers, physicians or nurses who work in hospital emergency rooms, and air traffic controllers.

One of the difficulties of using early recollections to screen EMTs is that this Adlerian approach does not lend itself readily to empirical investigation. What might be helpful is a study that would investigate the relationship between early recollections and a scale that measures burnout. This might be the first step in identifying if there is any empirical support for using early recollections to screen EMTs for burnout.

Although it seems that it may be difficult to train employment/ career counseling practitioners to use early recollections, Mosak (1977) has developed criteria for interpreting early recollections in terms of these eight central themes. If EMS organizations could identify EMTs who are likely to burn out, they could save their organizations significant amounts of money in the areas of training, personnel management, sick leave, employee replacement costs, substitutes to cover shifts, absenteeism, and employee medical costs (Hawks & Hammond, 1990).

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Susan M. Vettor is a doctoral candidate in counseling psychology in the Department of Education and Counseling Psychology at Andrews University in Berrien Springs, Michigan, and is currently an intern at the Pilgrim Psychiatric Center in Brentwood, New York. Frederick A. Kosinski Jr. is a professor of counseling psychology in the Department of Education and Counseling Psychology at Andrews University in Berrien Springs, Michigan. Correspondence regarding this article should be sent to Susan M. Vettor, 120 Bell Harbour Place, Woodbridge, Ontario, Canada L4L 6W7 (e-mail: leggomyego@netscape.net).
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Author:VETTOR, SUSAN M.; KOSINSKI, FREDERICK A. JR.
Publication:Journal of Employment Counseling
Date:Dec 1, 2000
Words:5125
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