Historical study of an online hospital-affiliated burnout intervention process for researchers

Introduction

Background

Burnout is a syndrome from chronic stressors associated with work, including overwhelming exhaustion, work-related feelings of cynicism and disassociation, and futility from perceived job-related failure first recognized in 1974 (1). It is particularly associated with health researchers (2) and saw an increase resulting from the coronavirus disease 2019 (COVID-19) pandemic (3,4). Recent research on burnout undertaken as a result of the pandemic includes an extensive review of its theory and measurement (5).

On 11 March 2020, the World Health Organization (WHO) classified COVID-19 as a pandemic (6). In response to this declaration, on 16 March 2020, all academic meetings at the University of Toronto were required to move online to continue (7), similar to other institutions that moved their academic meetings online (8,9). On 5 May 2023, COVID-19 was downgraded by the WHO as no longer a public health emergency of international concern (10). In response to COVID-19 limitations, a successful hospital-affiliated weekly in-person burnout-reduction group initially became an online weekly group meeting associated with a University of Toronto hospital, developing into a one-on-one process tailored to participant time commitments for the last two years.

A recent scoping review of burnout interventions of residents identified that effective burnout interventions were longitudinal and included wellness training (11), suggesting that research on such interventions must also be longitudinal (12). The Health Narratives Research Process (HeNReP) is a longitudinal author-developed University of Toronto hospital-affiliated one-on-one intervention for those self-identifying as experiencing research burnout (13). The researcher experiencing burnout selects the intervention after becoming aware of it through Department of Psychiatry advertising or personal contact with the author—the facilitator of the intervention. The intervention has been offered one-on-one over the last two academic years and evolved from the author-developed Health Narratives Research Group (HeNReG), available free of charge in-person at the hospital from 2015–2020, moving online because of COVID-19 restrictions. From March 2020 until the end of the 2021/2022 academic year, a yearly private Facebook group was the platform for the weekly group process. There are six publications by the author regarding the positive effect of the group process on reducing burnout (14-19). The results of the one-on-one process over the last two years were unknown. Historical analysis of the relevant documents associated with the two years of the one-on-one online process determines these results.

Rationale and knowledge gap

Yet to be considered and published are the historical results of the one-on-one online process for the 2022/2023 and 2023/2024 academic years when the free intervention was a one-on-one process for the first time. Why the HeNReG became the HeNReP is it was noted in the years that it was an online group intervention during COVID-19 that participants interacted online only with the facilitator, whereas when the group met in person at the hospital in years before, all group members interacted equally with each other (19). As it seemed that online participants were more inclined to interact only with the facilitator, the group became a one-on-one process between a participant and the facilitator to accommodate this supposed preference of participants.

There was no study regarding the one-on-one interventions of the HeNReP. Determining the HeNReP outcome, this study investigates the documents associated with each one-on-one process from a historical perspective.

Objective

The aim is to determine the results of the two years of the HeNReP to inform what changes might correspond to successful burnout reduction of researchers in the future by a historical investigation of relevant documents.

Methods

The HeNReP represents a form of Gestalt (20-22) psychoanalytic narratology (23-27). Details of this intervention process created by the author are documented in previous publications (14-19). As such, providing an account of this method is not the focus of this article. The focus is historical research of the documents (28) concerning this intervention process facilitated by the author to investigate the content of the documents. The hypothesis is that doing so provides recognizable patterns in the results available from historical research of these documents.

Materials

The materials were (I) the information created by the facilitator that participants receive by email about the HeNReP before agreeing to join; (II) the postings on the private Facebook group set up for each HeNReP; (III) the online Google feedback form results with process completion; and (IV) email messages sent by the participant to the facilitator with process incompletion. As the HeNReP facilitator, the author has privileged access to all the documents representing the materials. The participants had access to the initial information sent to them by email (the same for all participants), their private Facebook group in conjunction with the facilitator, their online Google feedback form (if completing the process), and their emails sent to the facilitator if they did not complete the process (and sent such emails).

Intervention participants

All participants participating in the interventions were associated with the University of Toronto as students (undergraduate and graduate), administrators, clinicians, or faculty. The materials to be examined in the historical analysis concern the following participants (listed in their order of beginning the process). 2022/2023: psychiatrist (clinician), psychologist (graduate student), health & disease major (undergraduate student), social worker (administrator), environmental philosophy major (undergraduate student), anthropology major (undergraduate student), neurologist (graduate student). 2023/2024: educator (administrator), social worker (clinician), environmental health specialist (administrator), dentist (faculty), psychiatrist (faculty), psychologist (graduate student), narratologist (administrator). Four other clinicians (hematologist, psychiatrist, psychologist, and family and community medicine specialist) inquired about the process, but, as they did not opt to engage in it, no documents of their participation were included in any parts of the analysis.

Informed consent

The intervention began when participants engaged the facilitator over email to create a one-on-one group to decrease their research burnout based on the offering through the Department of Psychiatry, Mount Sinai Hospital in Toronto. It ended when the participant chose to leave the process or when it came to the intended end. The HeNReP was an offering for those who considered themselves burned out, not a research study. All those who demonstrated an interest (either in person or over email) in creating a one-on-one intervention with the facilitator received a document by email on the operation of the HeNReP (see Appendix 1). Part of that document included requesting the participant’s agreement with the following statement: “By joining, a participant agrees that their responses may be anonymously referenced in presentations given and/or scholarly articles written by the facilitator regarding the results”. Participants demonstrated their informed consent by sending a confirmation email to the facilitator agreeing to the terms of the document. In providing this consent, the participants agreed to the publication of any future historical analysis of their anonymous participation, such as this one. As historical research, this study did not require ethics board approval.

Analysis

Mixed methods were selected to historically evaluate the documents concerning the two years of the HeNReP, including both a quantitative and qualitative aspect to respond to the complex analysis requirements (29). The quantitative portion of the analysis involves measuring variables and investigating relationships among variables to reveal patterns in the private Facebook group postings. Although such research often involves statistical analysis (30), this quantitative study does not. As is relevant for historical research (31), each identified variable is discussed as part of a timeline, beginning with the introduction of the element and proceeding to the present, following its evolution, labeled the “lifeline approach” by previous researchers regarding this quantitative method (32). Such visual timelines have become an increasingly relevant quantitative research technique (31). The qualitative portion uses an inductive approach, representing historical research regarding the narrative feedback of those who completed the HeNReP and email comments provided if participants did not complete the process. Within social science research, historical methods provide operational time and context in shaping theoretical claims by participants (33), a relevant consideration for this historical study.

The significant aspects of the HeNReP are numbered below in the order of their appearance in the intervention.

• A researcher, self-identifying as experiencing burnout, contacts the facilitator.
• The facilitator emails the information regarding the HeNReP to the researcher.
• The researcher initiates the process by emailing their consent to participate to the facilitator.
• The facilitator sets up a private Facebook group for the online intervention.
• The facilitator provides prompts to which both the facilitator and participant respond in writing.
• The prompts follow a set process from the most objective to increasingly subjective.
• Participants initially describe themselves regarding their research related to health.
• The order of the prompts is questions beginning with when, where, who, what, how, and why.
• There are four when, where, who, and what prompts.
• There are five how prompts and six why prompts.
• For any particular prompt, both the facilitator and the participant can ask additional questions.
• Once a prompt and additional questions receive responses, the posing of the subsequent facilitator-designed prompt occurs.
• The process ends after the last why prompt no longer encourages additional questions.
• After the end of the process, a link to a Google Forms feedback form allows and encourages the participant to provide their feedback.

For a complete list of the questions asked in the 2020/2021 academic year, when the group moved online because of COVID-19, see (17). Although the questions asked of each participant and the answers provided in the one-on-one process depend on the initial description that participants give of themselves regarding their research related to health and differed each year, these questions from the 2020/2021 year are similar to the prompts individually provided for each of the HeNRePs during the 2022/2023and 2023/2024 years.

To quantitatively analyze the results of the two years of offering the HeNReP, Figure 1 presents the academic status of each researcher regarding their completion of the intervention. If the process was incomplete for any researcher, additionally displayed is their reported depression, anxiety, work overload, confusion, guilt, or shame the participant described to the facilitator in their being unable to complete the intervention. If a participant did not complete the process, providing no comment, there is no additional display.

Figure 1 The academic status of the researcher regarding their completion of the intervention (green = incomplete, red = complete). If the process was incomplete, additionally displayed is reported depression (blue), anxiety (black), work overload (yellow), confusion (grey), guilt (orange), or shame (purple). The line separating the Neurologist from the Educator divides the 2022/2023 and the 2023/2024 academic years, ordered from the participant in first contact with the facilitator to the participant in last contact.

Table 1 records the dates of the participation history of the HeNReP for each researcher, noting the participant by research concentration, the date of the first contact with the facilitator when the participant provided consent, the creation date of the private Facebook group, the making of the first and the last post by the participant in answer to a prompt, and the end date of contact with the facilitator.

Table 2 provides participant comments in their feedback forms of those who completed the process. These will be analyzed qualitatively using a historical narrative method (34). To be investigated is whether the participant was satisfied with the result of the process or whether the HeNReP was unsatisfying.

Table 3 reveals the comments that participants sent to the facilitator through email messages if they did not complete the process, providing the reason for the author’s judgments regarding the individuals’ non-completion. “Work overload” was the cumulative judgment if the participant cited work as a reason for HeNReP incompletion.

The quantitative analysis continues regarding the two figures, with Figure 2 providing the process history for each participant concerning which prompt was the last they completed or, if they finished the process, filling out the feedback form. The number of responses each participant provided during the intervention and the number of weeks the process took is arranged from the earliest to the latest-joining participant, bottom to top, in Figure 3.

Figure 2 Participants in the HeNReP process and the stage of the process they terminated participation. Participants with research areas listed in plain font started the process in the 2022/2023 academic year. Those listed in italics began the process in the 2023/2024 academic year. If listed beside the red Feedback arrow, the participant completed the process. HeNReP, Health Narratives Research Process.

Figure 3 HeNReP participants, the number of responses each provided as part of the intervention, and the number of weeks each participant was involved in the intervention arranged from the earliest to the latest participant, bottom to top. HeNReP, Health Narratives Research Process.

Results

Examining Figure 1, of the four participants who completed the process, there was no pattern to their academic relationship to the university. One was an undergraduate student, another a graduate student, a third was an administrator, and the fourth was a clinician. What is evident regarding the 2022/2023 academic year, when four participants completed the process, is that more students participated than in the 2023/2024 academic year when only one of the participants was a student. Of those who did not complete the process during the 2022/2023 academic year, all felt that they were overloaded with other commitments when they stopped the process and stated that they felt guilty about not continuing. One of these participants, the undergraduate student, was additionally depressed and anxious about not being able to complete the process. These admissions to the facilitator produced feelings of shame in the participant. The year after, the researcher administering a narratology program could not complete the program for similar reasons. The psychiatrist in 2023/2024, comparable to two of the participants in 2022/2023, left the process because of work overload and, in having to do so, felt guilt. The responses of the five other participants in 2023/2024 were unique. One left the process and provided no reason for doing so. Another left the process because of increased depression unrelated to work. The third was unable to complete the program because of difficulties understanding how to participate in the private Facebook group. One more participant also had a similar confusion problem. In addition, this researcher felt guilt about not understanding how to follow the process. The final participant, the dentist, left because of work overload.

The information provided in Table 1 is extensive as there was no previous understanding of what factors might be relevant in the completion or incompletion of the process. In examining the table, there are few clues. To a significant extent, the responses to the process were unique to the researcher, and there is no recognizable pattern. The most relevant similarity is the length of time between the first contact of the researcher with the facilitator and the private Facebook group setup. In the 2022/2023 academic year, the longest time between the first contact and the private Facebook group set up was one week. In the following year, the facilitator decided that all the private Facebook groups would be set up the first week in October (except for those who participated in a one-on-one group after this time) because, in previous years when the process was in group form, the groups always began the first week in October. One participant left the individual HeNReP almost immediately after waiting seven weeks for the beginning of the process. Yet, although the time between first contact and private Facebook group setup may be a necessary contributing factor, it is insufficient. Two participants from 2023/2024 had their groups set up almost immediately; still, they left the intervention before its completion. An additional point regarding the entries of Table 1 is the dates of the two right-most columns. The participation of most researchers in the group ended soon after their last post to the private Facebook group. However, for some, their participation extended well beyond their final post in the private Facebook group. This result was because the facilitator contacted them by email, and they responded that they planned on posting soon, although they did not. For others, the anthropology student being the best example, they wanted to continue a more open-ended discussion with the facilitator once the formal process was complete. The length of time continuing to participate in email discussions with the facilitator after the last post was in addition to completing the process.

The written responses to the feedback forms of the four researchers who completed the process are in Table 2. The consideration is whether the participant was satisfied with the result of the process or whether they believed there was some way that the HeNReP was lacking. All four of the respondents indicated their satisfaction with the process. Three had no additional comments on improving the process. One participant, the anthropology major, suggested that the HeNReP would have been more helpful if some questions were “more open-ended” so that the participant could more fully express their feelings about their research. It is relevant to mention that this participant continued with the facilitator for 42 additional weeks of email contact after the last post in the private Facebook group to engage in this desired open-ended questioning and response. In this respect, the anthropology student was not only looking to reduce research burnout (which, according to the feedback provided, completing the HeNReP had accomplished), but the additional intent was to find a mentor in the facilitator. Although the facilitator was able to provide this mentorship, it was beyond the scope of the HeNReP.

Table 3 presents the comments sent to the facilitator by email of those who did not complete the process, providing the reason for the author’s judgments of the individuals concerning process abandonment. A participant who expressed cherishing the HeNReP when the process was incomplete or that they were sorry was considered an admission of guilt in not completing the process. Depression and anxiety are either stated directly by the participant or intimated within the context of the discussion with the facilitator. The judgment of shame concerns if the participant felt inadequate about the incompletion or what led to their abandoning the process. In this regard, guilt is considered a self-evaluation of personally lacking behavior, while shame is a self-analysis of not meeting personally expected norms (35). Both terms are self-critical, although there is no consistent relationship between these self-judgments (36).

Figure 2 depicts the process undertaken in the HeNReP and how far each participant went in it during both years. It is only in Figure 2 that those potential participants who contacted the facilitator to participate but chose not to are mentioned. These four (three from 2022/2023 and one from 2023/2024) were all clinicians. Each determined that they were unable to participate because of the time commitment involved. Three felt reluctant to join a Facebook group. Of those who did participate, the four to complete the process were all from the 2022/2023 academic year. Of the rest from that year, all, except the environmental philosophy undergraduate student, were able to get far enough to experience some of the more subjective prompts with what and how questions in contrast to the 2023/2024 academic year, where all the participants responded only long enough to answer objective questions and, of these, all except the dentist responded to the “when” prompts alone. Therefore, whatever the value of the process of those who participated in 2023/2024, it was not from completing it, as the experience of moving from the objective to the subjective prompts is considered crucial to the success of the intervention (14-19). Nevertheless, as none of those who left the process incomplete provided feedback, it is unknown what value the little they participated had for them.

By Figure 3 providing a comparison of the participants, their weeks participating, and their number of responses, the difference between the completed interventions from the 2022/2023 academic year and all of those from the 2023/2024 academic year becomes evident. An investigation of Figure 3 reveals that to be successful, the number of responses by participants needed to be between 84 and 110, as it was for the four who completed the process. For those in the 2023/2024 academic year, the highest number of responses was 22—most responses were under 10. It is interesting to note that of those who completed the process, the length of time to complete the program regarding the number of responses was not equivalent. The psychiatrist completed the program in 38 weeks—the least time—but was also the participant with the highest number of postings, indicating no connection between the speed of completing the process and satisfaction with the results.

Discussion

Key findings

As exhibited in the analysis of the tables and figures regarding the historical documents, a desire to be part of an intervention program to reduce burnout in researchers is insufficient to guarantee program completion. Several reasons identified that a participant in the program may opt to leave the program incomplete. These range from the participant experiencing increased depression and anxiety—either unrelated to work or because of being unable to complete the intervention process—to self-perceived work overload or confusion over how to proceed in the online platform. Any of these may bring on guilt or shame at being unable to complete the program. The most predictable reason for abandoning the process is that it didn’t start immediately after the first interaction of the researcher with the facilitator. Waiting to start, participants lost the momentum to persist in the intervention.

Strengths and limitations

The strength of using the historical method of document analysis to determine participant satisfaction with the HeNReP is that a summary is created with all relevant information in a timeline and presented in both table and figure form to reveal the satisfaction level of participants who completed the process and the reasons for non-completion of those who did not. This historical method discloses significant aspects of the process that would have remained hidden without the analyses provided by the tables and figures. The HeNReP is a process that, when followed until the end, provides participants with the appropriate self-reflection to regain their commitment to their research while acquiring a tool with the HeNReP to help themselves if they experience burnout in the future.

The limitations of the historical method are that there is no statistical analysis, which may have provided additional insights. This lack of statistical analysis is relevant as the online process takes approximately an academic year to complete, with participants providing around 100 posts to the private Facebook group. Another limitation is that, in using Facebook as the platform for the intervention, the results are available to the facilitator and the researcher experiencing burnout only so long as the researcher maintains a Facebook account. As some of the participants gained a Facebook account only to engage in the HeNReP, if they later decide to close down their account, they—and the facilitator—lose access to the responses provided by the participant. Using Facebook is an additional problem since some researchers are reluctant to participate because they do not want to join a private Facebook group. This type of reluctance represented why, during the 2022/2023 academic year, three potential participants decided not to participate. Confusion about using the private Facebook group was also why two 2023/2024 academic year participants stopped the process. For these reasons, using the private Facebook group may need to be reconsidered when conducting a HeNReP. A possible solution is to switch to a more popular platform. Lost in doing so is the visual division of the group provided by the private Facebook group and the easy access to all postings made in the private Facebook group. The final limitation is that the size of the groups who participated each year was small, reducing the ability to recognize potential patterns in completion and non-completion of the intervention.

Comparison with similar research

Regarding hospital-affiliated burnout interventions, the HeNReP is unique. Although there are many post-COVID-19 studies of burnout interventions for healthcare clinicians (37-40), there are no other intervention programs directed to those who consider themselves burned out regarding their research. However, comparing the HeNReP and other successful hospital-affiliated one-on-one burnout interventions is possible.

One type of hospital-affiliated intervention accepts burnout as an occupational hazard of healthcare providers and approaches the problem with monthly check-ins of individuals to acknowledge and address work-life stressors (41,42). It is a method that legitimates expressions of burnout in staff and demonstrates care and concern for these healthcare providers. Through directly acting towards burnout reduction, the intervention is valuable in reducing burnout. The limitation of this method is not providing the individual experiencing burnout with a structure and strategy for helping themselves, leaving them dependent on the monthly check-ins, in contrast to the HeNReP. By encouraging reliance of the individual experiencing burnout on monthly check-ins for burnout symptom reduction, one-on-one interventions of this type do not promote personal empowerment to control burnout, resulting in identifying these one-on-one interventions as less effective than group interventions (43).

Mindfulness-based one-on-one interventions are similar to the HeNReP in that the attention is inward rather than relying on externally organized check-ins. The practices focus on directing contemplation to encourage openness and acceptance regarding present experiences in managing stress (44). To this effect, these mindfulness techniques are a form of emotion regulation (45). Emotion regulation is the pursuit of desired emotional goals regarding directing motives (46). In contrast, the method of the HeNReP does not have the regulation of emotions as its purpose. Instead, the goal of the process is to reenergize researchers in understanding why their research is significant to them, providing a foundation to sustain their research over their careers based on examining their relationship to their research, starting with what is most objective and increasingly considering more subjective aspects—something no mindfulness one-on-one intervention approaches. Reenergizing, as a psychological goal, is equated with the larger psychological aim of enlarging and sustaining rationality with affection and intuition (47)—a similar intention of the HeNReP in reducing burnout by encouraging commitment to one’s research program.

The comparisons offered concern research about the intervention itself. Although there are several recent histories of burnout in healthcare settings (48-50), there is no other historical research on the documents associated with burnout reduction—in healthcare or any other settings. This article is a first in this regard.

Explanations of findings

It is relevant to recognize that burnout interventions can have various goals. Monthly check-in interventions intend to demonstrate to the individual experiencing burnout that they are consistently cared for by their workplace (41,42). Mindfulness practices expect the burned-out individual to assume responsibility for their condition by resetting and redirecting their emotions (44). The HeNReP encourages the participant to come to know themselves and their intentions more fully. The purpose is to remember what interested them in their research to reenergize their commitment to their research program. In this way, like mindfulness practices, the individual takes control of their burnout—but in a very different manner and for a different purpose. With mindfulness, the burned-out individual can expect a stress level reduction (44). With the HeNReP, a positive result from completing the intervention, as indicated in the feedback submitted, means that the individual better understands themselves and their motivations, remembering and reaffirming what they intended when they initially decided to undertake their research.

Implications and actions needed

With the pandemic over (10), and the documents revealing that most participants do not complete the HeNReP, the question is whether this one-on-one process remains viable.

Regarding psychiatric interventions in general, the limitations concerning COVID-19 highlighted user preference for online interventions (51,52). Post-COVID-19, participants are reluctant to travel to psychiatric interventions (53), changes that are likely permanent (54). Consequently, returning to the in-person group meeting structure of the HeNReG is not advisable. Nevertheless, given documents revealed the lack of completion of the process by most who participated in the HeNReP in the two years of the program, it is evident that a change to some aspect of the intervention is required to retain success in burnout-reduction of researchers.

Based on the historical analysis of the documented results from the 2022/2023 and the 2023/2024 academic years, it is unacceptable for the process to increase any negative mental health symptoms of participants. Consequently, in offering the HeNReP again, the focus should be mitigating increased depression or anxiety and possible guilt or shame in participants if they do not complete the intervention. The suggestion is that the likelihood of the process incompletion should be part of the informed consent statement as well as an assurance that incompletion of the process should neither induce guilt nor shame. Such a change to the informed consent statement would improve the full disclosure and the validity of the participant consent (55). Yet, making this change to the informed consent information must also consider the possibility that participants may feel overwhelmed by the extent of the informed consent process (56). The result is that the facilitator of such an online intervention must construct the informed consent information deliberately and with concern for the effect of incompletion of the process on the negative mental health symptoms of the potential participant in this regard.

Also suggested is that there be as little wait time between when the participant provides informed consent and the private Facebook group set up, as this will maintain participant interest and dedication to completing the process. Currently, there is no research on the problem identified in this study of a decrease in commitment to a burnout intervention resulting from a time lag between consent provided and the start of the intervention. Future research should be directed to this issue to determine differences depending on the length of time in the delay in program start-up.

It should be considered whether it is reasonable to hold the one-on-one process over a private Facebook group or switch to another platform. Although Facebook remains the most popular platform (57), it is decreasing in popularity among younger online users who view Facebook as only relevant for mature users (58). Facebook was selected as the one-on-one meeting space because it provides a permanent record of the discussions between the participant and the facilitator, which is organized by date and prompt that is easily searchable as long as the participant retains their Facebook account. Yet, although the platform is attractive and inviting to users, there has been a migration of Facebook users to another social media platform—Instagram (59). In the future, an increasingly popular social media platform, Discord (60), may become the preferred method for a one-on-one burnout intervention. Nevertheless, the confusion of two participants in the 2023/2024 academic year regarding the private Facebook group may have been similar had Discord been the chosen platform, as poor digital literacy was the issue.

Conclusions

A historical analysis of the documents associated with a hospital-affiliated longitudinal one-on-one online burnout reduction intervention has determined that such an intervention can reenergize researchers with a career-long commitment to their research if completed. In examining the documents associated with the 2022/2023 and the 2023/2024 HeNReP, the majority of participants were unable to complete the intervention for various reasons, including increased depression and anxiety. A small number of those who could not complete the process felt guilt or shame. The suggestion is that changes be made to the informed consent document to improve the completion of the process and preempt any additional negative mental health symptoms that might result. The change would involve advising potential participants that, based on the two years of the one-on-one online intervention, there is a likelihood that the participant may not complete the process. The informed consent document should also assure the participant that there is no reason for resulting guilt or shame if terminating the process before its intended completion. Additionally, the advice to those interested in offering a similar hospital-affiliated one-on-one online process to the HeNReP is to begin the intervention as soon as the participant provides consent, possibly on another platform than Facebook—in order to increase the possibility of process completion and, as such, burnout reduction.

Acknowledgments

Thanks to the 2022/2023 and 2023/2024 Health Narratives Research Process participants for their consent to the analysis of the information from their processes as part of this historical study.

Footnote

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-87/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-87/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-87/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Participants engaged in the intervention after agreeing to the following statement as part of their informed consent: “By joining, a participant agrees that their responses may be anonymously referenced in presentations given and/or scholarly articles written by the facilitator regarding the results”. The intervention was a free offering by the author as facilitator—in association with the Department of Psychiatry of the Mount Sinai Hospital—a teaching hospital at the University of Toronto. The intervention itself was not a study. As historical research, this study did not require ethics board approval.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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