Therapist and operator experiences utilizing multi-modal motion-assisted Memory Desensitization and Reconsolidation (3MDR) for treatment of combat related posttraumatic stress disorder amongst military and veteran populations

Figures & data

Table 1. Sample demographics.

Sample demographics (N = 18)	Participants n (%)
Gender	18 (100)
Man	9 (50)
Woman	9 (50)
Location	18 (100)
Canada	7 (41)
Netherlands	6 (35)
United Kingdom	3 (17)
United States	2 (11)
System	18 (100)
CAREN	12 (67)
GRAIL	3 (17)
CAREN Light	2 (11)
3MDR role	18 (100)
Therapist	13 (72)
Operator	5 (28)

Table 2. Education and experience of sample.

Education and experience (N = 18)	Participants n (%)
Military experience	18 (100)
Yes	2 (11)
No	16 (89)
Experience with 3MDR	18 (100)
Less than 1 year	5 (28)
1–3 years	9 (50)
3–5 years	3 (17)
Education	18 (100)
Bachelor’s degree	1 (6)
Master’s degree	11 (61)
Doctorate	6 (33)
Profession	18 (100)
Occupational Therapist	1 (6)
Clinical Psychologist	6 (33)
Nursing	1 (6)
Mental Health Therapist	1 (6)
Mental Health Chaplain	2 (11)
Researcher	8 (44)
Technician	5 (28)
Experience in pProfession	18 (100)
Less than 1 year	1 (6)
1–4 years	3 (17)
5–10 years	9 (50)
11–20 years	0 (0)
Over 20 years	5 (28)

Figure 1. Themes and sub themes of the thematic analysis.

Table 3. The personal costs and benefits of 3MDR.

Same – Same	T22: ‘There is no one here who says, ‘well you worked here for 10 years you shouldn't have problems with this.’ No! Everyone knows that even working there for 30 years you can still be touched by something and I hope I still will in the future.’ T1: ‘I don’t know if you do this work [trauma therapy] without being unscathed. It leaves some measure of damage but then you weigh that out with the benefits. If it’s not lethal or deeply damaging as the saying goes: ‘if you don’t want to be nicked, don’t be a cook, get out of the kitchen.’ T5: ‘It can be challenging work because some of the stories that they share can be pretty horrific, but in all sincerity it’s quite an honour to have people talk with you and give you that amount of trust to tell you something about them that exposes a lot of vulnerabilities.’
Same and different	T20: ‘During the cooling down, the patients turn on their own music, and sometimes that song that you know, I don't want to hear that song because it touches me, I think it happens twice or more. I'm not in tears but I feel the emotions, the music moves me.’ T18: ‘It’s [similar to] supportive counselling, but how much do you push them? There’s different ways avoidance presents itself … even when they are looking at the pictures.’ T8: ‘3MDR sessions are a bit more intense with the immersive space, so sometimes feels more fatigued after.’ Useful to take breaks after sessions or go for a walk ‘because you are also really immersed in that virtual environment, I find it a bit more. I am a bit more tired after a 3MDR session than after a normal exposure session.’
Becoming emotionally involved	T21:‘It's harder to not get emotionally involved in the material, so I have more respect for patients and more respect for the events they have been through. I feel I have seen more pain and emotion and I have more appreciation for the patients.’ T13: ‘I think it's probably quite a stereotype but all big strong men and then when you have them in the room they are really vulnerable and the things they experienced are so horrible … I think what struck me the most was that some of them went to an area 25 years ago and it still affects them every day so much that they cannot live their normal life … you really experience the impact of trauma working with these veterans.’ T21: ‘It’s so intensive: People are literally walking to the things they avoid and fear the most, and the impact it has is really impressive.’

Table 4. The professional paradox of a 3MDR therapist.

Prior clinician experience	T15: ‘So long as you have some sort of psychology background, counseling experience, anything like that nurse experience honestly any people skills and you have the script then you can really do it, you adjust for every person.’ T4: ‘I would be very hesitant to put a new clinician in, or someone who has not worked with this population (i.e. military) before … It was a bit of a shock the first time doing the full 3MDR protocol with my first client, feeling slightly underprepared.’ T19: ‘I wouldn’t have gone straight into working with a patient, I think you need to practice beforehand.’
Trauma training	T5: ‘I think you need to have some trauma training. You need to have it because yes I know there’s a fairly specific protocol when you are on the CAREN, but it's how to talk to people afterwards and if you need to check in with them throughout the week that’s where that training comes in.’ T4: ‘I think this can be even harder depending on the type of psychotherapeutic training you have received and the modalities that you predominately work in, so this might be an area that needs to be worked on in training so that clinician feel that more confident in the protocol.’ T2: ‘The training was well suited for the therapists. No formal training was provided to the operators. XXX and XXX (CAREN Operators) helped me figure it out.’
Self-awareness	T20: ‘I always have 15 minutes after a session where I can process with myself. If I know I have a complex patient or awful story I can add more time, and best coping is doing it together. Not specifically with 3MDR but at our centre, we have intervention hours, where as a team we can reflect on what is happening in our room and what they are exposed to.’ T14: ‘The subject areas are familiar and I’ve got a degree of habituation, if you will, to help people with trauma problems. But that doesn’t mean I wouldn’t have a reaction.’ T15: ‘I actually decided before starting 3MDR to find myself a therapist to work on potential problems that I might have because I wasn’t super exposed to traumas in the past, I happened to be prepared because I knew there things that might happen, I might interpret things differently so I had a therapist before I even started training to be like, ‘hey I want to meet with you, I am going to be working with people with really intense traumas and I want to be able to unload on you,’ and that really really helps.’

Table 5. Perceived effects of 3MDR on patients.

Punching through avoidance	T4: ‘What this system seems to do very well is drop the client into whatever trauma they are struggling with and seemingly ‘punch-through’ whatever barriers or walls … to help clients either continue exploring what happened on a deeper level or come to some resolution.’ T21: [3MDR] will help with the avoidant part to work on that. It helps people get physically aroused and get more, they are able to search in the memory and make contact with certain parts of their memory, that is often a problem with treatment as usual’ T5: ‘They [the patients] are willing to engage in it but they’ve all said they can’t avoid it, and that’s one of the biggest obstacles … that constant avoidance, because it’s uncomfortable, it’s not pleasant, it’s not fun.’
Empowerment	T8: ‘Patients really have the sense of actively engaging in the therapy, going toward something, going toward their traumatic memories so I think 3MDR can add to the therapeutic toolbox’ T22: ‘They take control of the process … [3MDR] empowers people, they can experience themselves, and they can address their avoidance with the therapists standing next to them, instead of sitting with each other. That empowerment, they do it themselves, and overcome their fear.’
Self-awareness shifts	T4: ‘Is this positive change was more obvious, but even in the other client it was clear that some things had shifted for him, and that for both they had a deeper understanding about their traumas’ T15: ‘And noticing that their voice change and they are more upbeat and then my favorite change that I noticed if you do the debriefs after each where they write their journal entry and at their follow up when they finish and I would go through the things they said in the very beginning and going through this study .. and it's so amazing to see how they talk about themselves.’
Therapeutic alliance	T8: ‘I think equally important, is also the alliance with the therapists, I think that is more a common factor, but I do think it's a different kind of set up, actually standing next to the patient and seeing those images.’ T14: ‘I don’t know if it made a difference to my patient whether they liked the fact that I was a veteran … I was able to interweave and try to help them where there may be a shift that for me was definitely because of my knowledge and previous experience with somebody else.’ T5: ‘Standing beside somebody and seeing a visual or the picture of their experience leads to a much more intimate connection … There’s a lot more honesty in the treatment.’

Table 6. Recommendation for future 3MDR use.

Mentorship	T4: ‘I was able to do a co-session with someone else before I had to be on my own, which was very useful. Ideally, I think it would be great if you could do a session, or even a series of sessions, where you are the co-therapist [so] you can just get the feel for the protocol.’ T19: ‘I think the supervision was monthly and that was helpful, because it’s good to know where everyone is at, how many clients you see, and did you have any problems.’ T8: ‘This [3MDR] was something new again, so I would video record it and show it to my supervisor … getting into it, it is massively helpful to have regular supervision and will definitely improve the quality of what you are doing.’
Therapist operator collaboration	T2: ‘It would be nice to warn the operators of the content of the photos before they see them. T8: ‘It's almost kind of a trust thing, that you know that they [the operator] will manage everything smoothly so that you can really focus on the patient. And I think that if you don’t have that, you have to divide your attention.’ T5: ‘I think with the group you have to check in with each other enough to offer support that’s needed’ T14: ‘The technician [ran] the system so my only role was to do the therapy. It was quite nice because we can talk to the [technician] at the end of the session to hear their perspective, and what they had noticed, and we would debrief. That was quite cool.’
Debriefing post session	T4: ‘One of the ways that I process and do self-care is to debrief with the team after the session. Doing this helped me to express what I was thinking and feeling about the session and to also check in with my peers about their experiences. Moreover, doing this also offered very valuable feedback for me about how I was doing as the clinician, what they noticed about what was happening to the client, and suggestions/hypotheses to try and test out the next week. I think debriefing with the team is a hugely valuable component of the study and something that should be included going forward for all 3MDR work.’ T19: ‘Whereas the operator is there all day and they are looking at all and they don’t necessarily have that debrief the same way that we do, so that’s one thing I have always been aware of.’ T22: ‘Every 2 weeks we have inter-vision [supervision] with the team for a month … part is about the therapist, if you are emotional towards a patient we have two processes: inter-vision [supervision] and self-care for therapists.’
Customizability of 3MDR	T18: ‘Do 7 pictures a session’ but we were doing 4 because that’s all we could get through in terms of time so I think that probably impacts the number of sessions that a person may wanna have and I know that’s not adjustable but I think that’s something that would have been helpful to know..How do you adjust for that?? How do you make it more standardized if they are not being exposed to the same number of pictures? T4: ‘I also wondered if the intervention could be improved by having a few more sessions –say 8–10 – as it seemed like the really intensive and deep work didn’t seem to occur until about session 3 or 4 which then only left you with a couple of sessions before the intervention finished.’ T1: ‘What i want in the future, I want to make it more personalized … I think we should let our patients decide which virtual environment they want to walk in.’

Data availability statement

Data available on request only due to privacy/ethical restrictions.

The data that support the findings of this study are available on request from the corresponding author, CJ or SBP. The data are not publicly available due to their containing information that could compromise the privacy of research participants.