Evaluating an Integrated Trauma Treatment Program (ITTP) for Paramedic First Responders with Post Traumatic Stress Disorder (PTSD)

ITTP is an intensive outpatient treatment program for post-traumatic stress in paramedic first responders that integrates four different treatments. Each of the 9 treatment days across three weeks (3 days per week, 8 hours per day, with lunch and morning break included) are held in person at the clinic at the Turner Clinics, Monash University and run by trained psychologists. Each day includes: i) individual EMDR; ii) individual Virtual Reality delivered exposure therapy; iii) group trauma-focussed psychoeducation; and iv) somatic-based therapy to support arousal regulation. i) EMDR EMDR is a psychotherapy treatment designed to alleviate the distress associated with traumatic memories or images. An initial assessment is conducted by a psychologist trained in EMDR to map a personalised treatment plan for each participant, with a list of the most disturbing memories to process during the ITTP delivery (highest disturbance processed first). This plan will take approximately 30 minutes. Treatment is delivered individually in nine 90-minute sessions using a structured 8-phased protocol. The psychologist supports individuals to recall the relevant distressing memory whist simultaneously focussing on an external stimulus (thereby taxing their working memory). External stimuli may involve the participant making directed eye movements, listening to audio content, responding to questions, or engaging in complex tapping patterns. EMDR 2.0 techniques may be included to intensify the level of taxation (e.g., faster eye movements, multiple distraction activities at once). Regular breaks are included to pause and reflect on the experience. The goal is a reduction in distress associated with the memory and increased access to more adaptive informed (e.g., positive self-views) to support memory resolution. Each session will typically involve the following steps: Review and Preparation – The psychologist will briefly review the participant’s current wellbeing, assess readiness for memory processing, and reinforce coping and emotional regulation strategies where required. Subsequent sessions will review previously processed memories. Target Identification – A specific traumatic memory, distressing image, trigger, or related experience will be identified as the focus of the session. Assessment – The participant will identify key aspects of the target memory, including associated thoughts, emotions, physical sensations, and the current level of distress associated with the memory. Memory Processing – The participant will be asked to bring the memory to mind while simultaneously engaging in structured dual-attention tasks designed to support memory processing. EMDR 2.0 procedures may be incorporated, including enhanced working memory taxation strategies intended to increase processing efficiency. Ongoing Reassessment – Throughout the processing phase, the psychologist will regularly assess changes in distress, thoughts, emotions, and physical sensations, and will guide the participant through additional processing as required. Installation of Adaptive Beliefs – As distress reduces, attention may shift toward strengthening more adaptive and helpful beliefs associated with the memory. Body Scan – The participant will be invited to notice any remaining physical discomfort or activation associated with the memory, with additional processing undertaken if required. Closure and Session Debrief – The session will conclude with a review of the participant’s current emotional state, use of grounding or regulation strategies if needed, discussion of any between-session experiences that may occur and planning for the remainder of the treatment day. Physical materials that may be used for this component include EMDR hand-held buzzers and a light bar. We may add materials to tax working memory according to EMDR 2.0 such as music or olfactory prompts including essential oils. ii) AI-Enhanced Virtual Reality Exposure Therapy This exposure treatment will include a combination of pre-developed Virtual Reality (VR) content and AI-generated VR scenes utilising a software program that permits personalised scenes to be developed. A library of common occupation triggers (e.g., ambulance vehicle, paramedic uniform) will be available to utilise, based on clinical appropriateness for each participant. The AI-powered software will allow clinicians and participants to generate scenes with similarity to previous traumatic jobs they attended, focussing on specific cues of distress (e.g., a crowd of people watching, a beach location) to enhance the visual exposure to personalised triggers. A list of distressing triggers will be developed for each person in the baseline assessment interview to support a personalised exposure treatment plan. This interview is approximately 30 minutes. Treatment is delivered individually in nine 60-minute sessions. Sessions begin with low-intensity, trauma-related imagery and the pacing of exposure is deliberate and responsive, with no progression unless the participant demonstrates adequate tolerance. The aim is to support gradual and repeated exposure to trauma-related memories, situations, and cues in a structured and supported way, helping to reduce distress, avoidance, and emotional reactivity over time. Participants are supported to focus on as many details as possible and describe these to the clinician as they are viewing them. Additional exposure in vivo elements such as sounds may be included to increase arousal levels. At the beginning of each session, participants will state their expected negative outcomes (e.g. ‘I won’t cope’, ‘I will scream’), which will then be reviewed at the end of the session to assess whether the outcome occurred as initially expected. Towards the end of the session, between session activities that involve in vivo exposure will be established with the participant and recorded on a printed worksheet to reinforce the learning effects. For example, participants may develop a list of feared scenarios and make a plan to expose themselves to one or two situations such as visiting a triggering location or looking at their Ambulance Victoria uniform. It is anticipated these activities will take 30 minutes of time per week. Each session will typically involve the following steps: Review and Preparation – The psychologist will review the participant’s current wellbeing, discuss any between-session experiences, and confirm readiness to engage in exposure work. The rationale for the session and planned exposure activities will be reviewed. Exposure Planning – The participant and psychologist will identify the specific trauma-related reminder, situation, environment, or memory to be targeted during the session. Exposure activities will be selected based on the participant’s individual formulation and treatment goals. Development or Selection of VR Environment – The psychologist will select or generate immersive VR content relevant to the participant’s experiences. Content will be tailored to the participant’s needs and graded according to their readiness. Initial Exposure and Distress Monitoring – The participant will engage with the VR environment while remaining physically seated. The psychologist will monitor emotional responses, subjective distress, and engagement throughout the session using discussion and distress ratings. Graduated Exposure and Processing – Exposure activities may be repeated, extended, or modified as the session progresses. Participants will be encouraged to remain engaged with the feared or avoided stimulus while observing emotional, cognitive, and physical responses. The psychologist may assist participants to identify changes in distress, beliefs, avoidance behaviours, and confidence over time. Learning and Reflection – The participant discusses observations from the exposure experience, including any changes in distress, expectations, beliefs, confidence, or perceived ability to cope with trauma-related reminders. Session Debrief and Consolidation – The session will conclude with a review of key learning experiences, discussion of any ongoing reactions, and planning for future exposure activities where appropriate. Grounding and emotional regulation strategies may be utilised before leaving the session. iii) Psychoeducation Group The group psychoeducation intervention is a semi-structured group program informed by evidence-based psychoeducation and group therapy principles. There are nine 60-minute group session modules that focus on common symptoms and everyday challenges frequently experienced following trauma exposure, such as intrusive memories and flashbacks, dissociation, sleep difficulties, relationship strain, emotional distress, reduced engagement in activities, and challenges returning to meaningful routines or work. Participants are provided with information about these potential experiences and introduced to practical, evidence-based strategies that may support coping and recovery. Sessions are delivered flexibly by trained psychologists, with content selected based on the ongoing needs and interests of each group. Group discussion and reflection with other participants is encouraged to support shared learning, normalisation, and connection. The group also provides an opportunity to discuss EMDR and VR exposure therapy techniques and to review progress and additional needs of participants. Participants receive printed worksheets to develop a plan to practice content outside of sessions (e.g., activity planning, sleep hygiene planning). It is expected participants will practice and record these for approximately 30 minutes per week. The program incorporates evidence-based strategies drawn from cognitive behavioural therapy (CBT), behavioural activation, acceptance- and values-based approaches, and psychoeducation for PTSD. Topics include understanding PTSD symptoms and recovery; anxiety, fear, avoidance, and Subjective Units of Distress (SUDS) ratings; mood, functioning, and moral injury; identification of unhelpful coping styles; sleep and physical activity; social engagement and communication; values clarification and identity; post-traumatic growth; and return-to-work planning. Practical strategies include behavioural activation (pleasant activity scheduling), sleep hygiene and behavioural sleep strategies, graded re-engagement in valued activities, values-based goal setting, communication and help-seeking skills, and personalised relapse prevention and return-to-work planning. Sessions are educational and skills-based, with participants not required to disclose details of their traumatic experiences. 2-4 participants will be enrolled at once. iv) Somatic Group Participants will take part in 8 group somatic (body-based) regulation sessions that aim to support nervous system regulation and recovery from trauma-related stress responses. These 60-minute sessions led by trained psychologists focus on developing practical “bottom-up” coping skills that use the body and attention systems to help manage physiological arousal. Strategies include breathing techniques, grounding and orienting exercises, gentle movement, awareness of physical sensations, and practices to support emotional regulation and present-moment awareness. The purpose of these sessions is to help participants strengthen self-regulation skills to use when faced with future work-related stressors, reduce distress associated with heightened arousal, and support participation in the ITTP program. Content is delivered using presentation slides and psychologist-led information. Participants complete in session exercises, including breathing or postural techniques and then disuses their experiences with the group. Participants receive printed worksheets to develop a plan to practice somatic skills outside of sessions. Participants will be asked to complete the worksheets and practice for approximately 30 minutes per week. A final group session at the end of day 9 is dedicated to the end of treatment, reviewing program experience, booking in follow up assessments to be completed approximately one week later, and information around accessing additional support if needed. This session does not deliver somatic treatment content. Participants have existing care through DXC and Ambulance Victoria. At the end of the program, participants will be given an end of treatment report to share with their care team. Some participants will have existing psychologists. Options for accessing private or community-based psychologists will be provided if needed. The existing case manager will continue to support individuals and assist with any ongoing treatment needs. 2-4 participants will be enrolled per group. There is flexibility and personalisation built into the program delivery. The group psychoeducation and somatic programs have structured modules and suggestions for delivery and group discussions; however, facilitators are encouraged to deliver these with clinical consideration of the pace and needs of each group. EMDR and VR exposure include a protocol for intervention delivery although the specific memories and avoidance criteria are assessed and tailored to each individual. Any deviations from the protocol are recorded by clinicians on a fidelity rating sheet at the end of each session, with qualitative descriptions for any changes that were made. During the treatment phase, clinicians will enter information regarding session attendance, fidelity checks, and outcome ratings. There are clinician fidelity checklists for each of the interventions (EMDR, Virtual Reality, Somatic, Psychoeducation). The order of interventions on each treatment day is as follows: group psychoeducation, Virtual Reality Exposure Therapy, EMDR, Somatic group. There is some flexibility for Virtual Reality Exposure Therapy and EMDR depending on clinician availability and multiple individual clients, but the day will always begin with group psychoeducation and end with group somatic therapy.