A Feasibility Trial of Eye Movement Desensitization and Reprocessing Therapy- Integrative Treatment Group Protocol for Ongoing Traumatic Stress in Road Traffic Accident Survivors for Reduction of Post-Traumatic Stress Symptoms
Phase: NA
Conditions: Post Traumatic Stress Symptoms, Quality of Life (QOL), Stress
Sponsor: University of the Punjab

A Feasibility Trial of Eye movement desensitization and reprocessing therapy- Integrative 
treatment group protocol for ongoing traumatic stress In Road Traffic Accident Survivors 
for Reduction of Post-traumatic Stress Symptoms 
IGTP-OTS-MSCCP-2022 
16-06-2025 

Study Summary 
 
Road traffic accidents (RTAs) are a significant public health concern globally, accounting for a 
substantial proportion of morbidity and mortality. This study evaluates the feasibility and 
acceptability of the Eye Movement Desensitization and Reprocessing Integrative Group 
Treatment Protocol for Ongoing Traumatic Stress (EMDR-IGTP-OTS) in the reduction of 
posttraumatic stress symptoms, depression, and anxiety, while improving the quality of life in 
individuals who have experienced traffic accidents. Using a randomized control design, 
participants aged 18–45 will be assessed at three time points: pre-treatment, post-treatment, and 
one-month follow-up. The study employs the DASS-21, IES-R, and WHOQOL-BREF as 
evaluation measures. Findings aim to expand evidence on trauma-focused interventions and 
explore their applicability in culturally diverse, resource-constrained settings. 

A Feasibility Exploratory Trial of the EMDR-IGTP-OTS In Road Traffic Accidents 
Survivors for Reduction of Post-Traumatic Stress Symptoms 
Road traffic accidents (RTAs) are a significant public health concern globally, accounting for a 
substantial proportion of morbidity and mortality. The World Health Organization (WHO) reports 
that approximately 1.3 million people die annually due to RTAs, with an additional 20 to 50 
million suffering non-fatal injuries, often resulting in long-term disabilities (World Health 
Organization, 2022). According to the World Health Organization (WHO), road traffic accidents 
are the sixth leading cause of mortality, with a substantial share of physical, psychosocial and 
economic losses in the productive age group. Low- and middle-income countries bear the brunt 
of this burden, contributing nearly 93% of the global RTA-related deaths, despite having only 
60% of the world’s vehicles. Pakistan, a rapidly urbanizing nation, exemplifies this trend, with 
high RTA rates exacerbated by poor road infrastructure, inadequate traffic enforcement, and 
increasing vehicles (Salman et al., 2020). 
In Punjab, the most populous province of Pakistan, RTAs are particularly prevalent. Data from 
Rescue 1122 indicate that an average of 1,200 accidents occur daily, leading to approximately 11 
fatalities per day (Government of Pakistan, 2023). Beyond the immediate physical injuries, RTAs 
impose far-reaching psychological consequences on survivors. Many develop conditions such as 
posttraumatic stress disorder (PTSD), depression, anxiety, and acute stress disorder (ASD), 
which significantly impair their quality of life (Alghnam et al., 2017). 
Defining the Variables 
 
Post-Traumatic Stress Disorder (PTSD). PTSD is a psychiatric condition triggered by 
experiencing or witnessing a traumatic event. It manifests through symptoms like intrusive 

memories, avoidance behaviors, hyperarousal, and negative alterations in cognition and mood 
(American Psychiatric Association, 2013). Studies suggest that approximately 9% of RTA 
survivors develop PTSD (O’Donnell et al., 2008). 
Depression. A common mental health disorder characterized by persistent sadness, loss of 
interest in activities, and impaired daily functioning (World Health Organization, 2017). 
Depression is frequently observed among RTA survivors, often compounded by physical 
disability or loss of independence. 
Anxiety. Defined as excessive fear or worry that interferes with normal functioning, anxiety often 
accompanies PTSD and depression in RTA survivors, manifesting as generalized anxiety disorder 
or panic attacks (Bisson et al., 2013). 
Acute Stress Disorder (ASD). A short-term condition occurring within one month of a traumatic 
event, ASD includes symptoms like dissociation, intrusive thoughts, and hypervigilance. If left 
untreated, it may develop into PTSD (Bryant et al., 2011). 
Quality of Life. Referring to an individual’s overall well-being across physical, psychological, 
social, and environmental domains, quality of life often deteriorates following RTAs due to both 
physical injuries and psychological distress (World Health Organization, 1996). 
Addressing Mental Health Problems 
 
The psychological burden of RTAs is well-documented, yet research into effective interventions, 
particularly in Pakistan, remains limited (Khan et al., 2020). Mental health stigma further 
complicates the scenario, discouraging survivors from seeking professional help (Farooq et al., 
2020). This underscores the urgent need for accessible, evidence-based interventions tailored to 
the local context. 

Eye Movement Desensitization and Reprocessing (EMDR) has emerged as a promising 
therapeutic approach for trauma-related conditions. Grounded in the Adaptive Information 
Processing (AIP) model, EMDR therapy addresses pathogenic memories that impede emotional 
and cognitive functioning (Shapiro, 2018). By facilitating the integration of distressing memories 
into adaptive memory networks, EMDR therapy alleviates symptoms and promotes 
psychological resilience (Shapiro, 2018). 
While traditionally delivered in individual therapy settings, the EMDR Integrative Group 
Treatment Protocol for Ongoing Traumatic Stress (EMDR-IGTP-OTS) applies these principles in 
a group format. This protocol has demonstrated effectiveness in disaster-affected and 
resourceconstrained settings, offering a scalable solution for collective trauma (Jarero & Artigas, 
2022). However, its application among RTA survivors in Pakistan remains underexplored, 
representing a critical gap in the literature. 
This study aims to bridge the gap between global evidence and local practice by evaluating the 
acceptability and feasibility of EMDR-IGTP-OTS for RTA survivors in Pakistan. The findings 
will contribute to the growing body of Indigenous research on trauma recovery interventions, 
providing culturally relevant insights into scalable, evidence-based solutions for mental health 
challenges in Pakistan. 
 
Literature Review 
 
Francine Shapiro originally developed Eye Movement Desensitization and Reprocessing 
(EMDR) therapy in the late 1980s as a treatment for post-traumatic stress disorder (PTSD). Over 
the decades, it has evolved into a versatile therapeutic modality for addressing a broad spectrum 

of psychological conditions, including anxiety disorders, depression, phobias, and complex 
trauma (Shapiro, 2018). The therapy is based on the Adaptive Information Processing (AIP) 
model, which posits that psychological distress arises from maladaptively stored memories. 
These memories, often associated with traumatic experiences, disrupt emotional and cognitive 
functioning, manifesting as anxiety, avoidance, or intrusive thoughts. EMDR therapy employs 
bilateral stimulation (e.g., guided eye movements, tactile tapping) to reprocess these traumatic 
memories, integrating them into adaptive memory networks and restoring adaptive emotional 
and behavioral responses (Shapiro, 2018). 
The effectiveness of EMDR has been validated across diverse populations and cultural settings, 
making it a globally recognized intervention for trauma. Its application in individual therapy is 
well-documented, with numerous randomized controlled trials (RCTs) demonstrating its efficacy 
in reducing PTSD symptoms and improving overall mental health (Matthijssen et al., 2020). 
A recent study by Konuk et al., (2022) used a randomized-controlled trial methodology to 
establish the efficacy of the EMDR Flash Technique. This study’s sample includes volunteers 
who were involved in traffic accidents and were given the randomized EMDR Flash 
Technique. The present study’s findings clearly demonstrated that the EMDR Flash technique, 
when applied to participants involved in traffic accidents, is successful in improving anxiety, 
intrusion, avoidance, total traumatic stress, and mental quality of life symptoms for at least 
1 month. 
However, providing individual therapy in resource-constrained settings poses logistical 
challenges, including shortages of trained clinicians and high costs of therapy. To address these 
barriers, the EMDR Integrative Group Treatment Protocol for Ongoing Traumatic Stress 

(EMDR-IGTP-OTS) was developed. This protocol adapts EMDR for group settings, allowing 
clinicians to treat multiple individuals simultaneously. EMDR-IGTP-OTS has demonstrated 
efficacy in alleviating PTSD symptoms, depression, and anxiety in diverse and often underserved 
populations. Studies conducted in disaster zones and ongoing traumatic stress situations have 
highlighted its scalability and cultural adaptability (Jarero & Artigas, 2022). The protocol 
integrates self-administered forms of bilateral stimulation such as the Butterfly Hug and 
selfregulation exercises which empower participants to manage distress during the sessions. 
These structured, trauma-informed approaches facilitate emotional stabilization and support the 
processing of distressing memories within a group context. 
Despite its demonstrated potential, the application of EMDR-IGTP-OTS to survivors of road 
traffic accidents (RTAs) remains underexplored, particularly in South Asia. Survivors of RTAs 
often experience a unique combination of physical and psychological trauma, leading to 
conditions such as PTSD, acute stress disorder, and major depressive disorder (O’Donnell et al., 
2008). Addressing these conditions requires interventions that are both accessible and effective, 
especially in regions like Pakistan, where mental health resources are limited (Khan et al., 2020). 
This study aims to evaluate the applicability and efficacy of EMDR-IGTP-OTS in this specific 
context, contributing to the growing evidence base for its use in treating collective and individual 
trauma. 
Reliable assessment tools are critical for evaluating the effectiveness of trauma interventions. 
The Depression Anxiety Stress Scale (DASS-21) is a concise yet robust measure of 
psychological distress, offering subscales for depression, anxiety, and stress. Its cross-cultural 
validation makes it particularly suitable for use in diverse populations, including Pakistan 
(Lovibond & Lovibond, 1995). The Impact of Event Scale-Revised (IES-R) is a widely used 

measure for assessing trauma-related symptoms, including intrusion, avoidance, and 
hyperarousal. Its sensitivity to changes over time makes it ideal for evaluating treatment 
outcomes in this study (Weiss & Marmar, 1997). Additionally, the WHO Quality of Life-BREF 
(WHOQOL-BREF) captures changes in physical, psychological, social, and environmental 
domains, providing a holistic view of participants' well-being (World Health Organization, 
1996). 
By evaluating the feasibility and preliminary effectiveness of the EMDR-IGTP-OTS with these 
validated tools, this study seeks to provide a comprehensive evaluation of its impact on RTA 
survivors. The findings will offer insights into its applicability in Pakistan, addressing critical 
gaps in the literature on trauma-focused interventions in resource-limited settings. 
Objectives of study 
 
• To translate the Eye movement desensitization and reprocessing therapy integrative 
treatment group protocol for ongoing traumatic stressor (EMDR-IGTP-OTS) on road 
traffic accident survivors among people aged 18-45. 
• Assess the feasibility and acceptability of the trial. 
 
• To assess the preliminary effectiveness of EMDR-IGTP-OTS. 
Hypothesis 
H1:Participants will perceive EMDR-IGTP-OTS as an acceptable and feasible intervention for 
 
RTA trauma related symptoms. 
 
H2: EMDR-IGTP-OTS will reduce post traumatic stress symptoms. 

H3: EMDR-IGTP-OTS will reduce depression and anxiety symptoms. 
H4: EMDR-IGTP-OTS will enhance participant’s quality of life. 

Method 
 
Design 
 
A randomized control experimental design will be employed, with participants assessed at three 
time points: pre-treatment, post-treatment, and two-week follow-up. 
Inclusion Criteria 
 
• 
Aged between 18 and 45 years. 
 
• 
Experienced a traffic accident 3 months to 10 years prior 
 
• 
Willing to participate and able to understand the intervention components. 
 
Exclusion Criteria 
 
Participants will be excluded from the study if they meet any of the following criteria: 
 
• 
Diagnosed with conditions such as schizophrenia or bipolar disorder, which require 
specialized treatment beyond the scope of this study. 
• 
History of severe head injuries resulting in neurological or cognitive deficits. 
 
• 
Participants who have experienced a traffic accident less than 3 months ago, as 
immediate post-traumatic responses may not have stabilized. 
Measures 
 
The study will employ the following validated tools to measure outcomes. 
 
The Urdu Impact of Event Scale-Revised (UIES-R). It will measure trauma-specific symptoms 
such as intrusion, avoidance, and hyperarousal. This 22-item scale uses a 5-point Likert scale 

ranging from 0 (not at all) to 4 (extreme), providing a comprehensive evaluation of the 
psychological impact of traumatic incidents. Reliability studies of the Urdu version of the IES-R 
indicate excellent internal consistency reliability for the total score (Cronbach’s α = 0.91) and 
respectable internal consistency reliability for subscales: Avoidance (0.81), Intrusion (0.78), and 
Hyperarousal (0.77), respectively (Tareen et al., 2018). 
The Depression Anxiety Stress Scale (DASS-21). It will be used to assess levels of depression, 
anxiety, and stress. It is a 21-item scale divided into three subscales, each rated on a 4-point 
Likert scale from 0 (does not apply) to 3 (applies most of the time). Reliability studies of the 
Urdu version of the DASS indicate excellent internal consistency reliability for the total score 
(Cronbach’s α = 0.93) and respectable internal consistency reliability for the subscales: 
depression (0.84), anxiety (0.86), and stress (0.83), respectively (33) (Shahzad et al., 2022, 
Lovibond & Lovibond, 1995). 
The WHO Quality of Life-BREF (URDU-WHOQOL-BREF). It will be administered to 
evaluate participants' quality of life across four domains: physical, psychological, social, and 
environmental. The 26-item tool is scored on a 5-point Likert scale and is particularly suitable 
for culturally diverse populations (Khalid & Kausar, 2006). 
A socio-demographic data form. It will collect participant details such as age, gender, education, 
employment status, and accident history. 
Sample Size 
 
We aim to recruit 50 participants (N=25 in intervention, N=25 in Waitlist-Control) in total. The 
audit of the sample sizes for the pilot and feasibility RCTs indicated that the median sample size 
per arm across all the types of study was 25 (Billingham, S. A., 2013). Browne (1995) also 

recommended that 25 participants per condition are needed to estimate a parameter. The proposed 
sample size will be sufficient to estimate recruitment and retention rates, as well as the variability 
in the primary outcome measure, which will then be used to determine the sample size for the full 
definitive trial. 
Randomization 
 
Participants will be randomized after matching the Treatment Group or Control Group using a 
computer-generated randomization sequence created by an independent statistician. Allocation 
concealment will be ensured using sealed, opaque envelopes containing group assignments. 
These envelopes will be prepared and managed by an independent researcher who is not 
involved in the recruitment or assessment process, ensuring blinding and minimizing bias. 
Procedure 
 
Translation of EMDR-IGTP-OTS. The EMDR-IGTP-OTS protocol would be translated into 
Urdu using MAPI guidelines for translation (2014) to make it culturally appropriate. 
Recruitment. Participants will be recruited via hospitals, community outreach programs, and 
social media. 
Pre-Treatment Assessment. DASS-21, UIES-R, and WHOQOL-BREF will be administered. 
 
Treatment. 
 
EMDR-IGTP-OTS. 
 
The EMDR-IGTP-OTS will be administered to the same treatment group of participants six 
sessions (Jarero & Artigas, 2022). 
Session Phase 
Tasks/Activities 
Key Notes 

Phase 1: Client History 
- Obtain individual client 
 
history. 
- 
Assess safety 
factors and suitability for 
EMDR therapy. 
- 
Obtain informed 
consent. - Apply pre- 
treatment assessment 
scales. 
Clients with red flags (e.g., 
dissociation, self-harm) 
should receive individual 
therapy instead of group 
protocol. 
Phase 2: Preparation 
- Ensure sufficient EPT 
 
staff-to-participant ratio 
(1:10 for adults, 1:5 for 
children). - Prepare 
workspace with chairs, 
tables, crayons, and other 
materials. - Introduce EPT 
and explain their role. 
- 
Teach Butterfly Hug, 
SUD scale and selfsoothing 
exercises (e.g., abdominal 
breathing, pleasant memory 
exercise). 
The leader explains the 
Adaptive Information 
Processing (AIP) system 
using a simple analogy. 

Phase 3: Assessment 
- Guide participants in 
 
identifying the most 
distressing memory. - Have 
participants draw their 
experience in 'Square A' and 
rate disturbance using 
SUDS. 
Allow participants to 
express themselves 
without judgment and 
avoid forcing 
participation. 
Phase 4: Desensitization 
- Perform Butterfly Hug 
while observing what is 
happening internally. - 
Draw changes in 
subsequent quadrants (B, 
C, D) and rate SUDS 
after drawing. 
Ensure participants move 
at their own pace; EPT 
should monitor closely for 
signs of distress. 
Phase 5: Future Vision 
- 
Draw how they see 
themselves in the future. - 
Provide a title to their 
drawing. 
- 
Use Butterfly Hug 
for continued reprocessing. 
Encourage honesty in 
future visualization without 
forcing positivity. 
Phase 6: Body Scan 
- Guide participants to 
perform a body scan to 
notice pleasant or 
Reinforce observation 
without judgment. 

unpleasant physical 
sensations. 
- Use Butterfly Hug to 
continue reprocessing. 
 
Phase 7: Closure 
 
 
- 
Select a favorite 
selfsoothing exercise and 
practice for 1-2 minutes. - 
Gather materials and 
drawings. 
- 
Encourage 
participants needing 
further support to stay for 
individual attention. 
Maintain a supportive 
environment for those 
needing follow-up. 
 
Phase 8: Reevaluation 
- Review drawings, last 
SUD ratings, and other 
outcomes for follow-up 
needs. 
Use the group protocol as a 
screening tool for 
additional individual 
therapy as required. 
 
Post-Treatment and Follow-Up Assessments. Measures will be repeated after treatment and two 
weeks post-treatment as a follow-up. 

Statistical Analysis 
 
Intention-to-Treat Analysis. All randomized participants will be included in the analysis to 
preserve the integrity of randomization and minimize bias. Missing data will be managed using 
multiple imputations, ensuring a comprehensive and unbiased results representation. 
Inferential statistics. The analysis aims to describe the feasibility and acceptability of the trial 
and 
EMDR intervention by examining the attendance rate of participants in the intervention sessions. 
Statistical analysis will be performed by using the Statistical Package for Social Sciences (SPSS) 
version 27.0 for Windows. Summary statistics on primary and secondary outcome measures will 
be recorded before and after the intervention. Appropriate descriptive statistics and graphical 
representations will summarize the demographic, baseline, and follow-up data. Treatment effects 
will be presented with 95% confidence intervals. After adjusting demographics and baseline scores 
as covariates, analysis of Covariance (ANCOVA) will be used to check the differences between 
the two arms on primary outcomes. 
Effect Size. Cohen’s d will be calculated to measure the magnitude of change attributable to the 
intervention. This provides context beyond statistical significance, indicating whether observed 
changes are clinically meaningful. 
Qualitative Feedback: To evaluate perceived effectiveness, satisfaction with intervention, 
openended feedback will be employed 

References 
Alghnam, S., Palta, M., & Remington, P. L. (2017). The impact of traffic accidents on mental 
health. Injury Epidemiology, 4(1), 1–6. https://doi.org/10.1186/s40621-017-0108-0 
Dominguez, R., & Lee, C. (2019). Differences in international guidelines regarding EMDR for 
PTSD. Journal of EMDR Practice and Research, 13(4), 247–260. 
https://doi.org/10.1891/1933-3196.13.4.247 
Gunduz, T., Yaman, E., & Bozkurt, N. (2018). Validation of the Adverse Childhood Experiences 
Questionnaire in Turkish. Psychological Reports, 121(2), 348–360. 
https://doi.org/10.1177/0033294117732657 
Jarero, I., & Artigas, L. (2022). EMDR-IGTP for ongoing traumatic stress. Scaling Up 
Publications. 
Billingham, S. A., Whitehead, A. L., & Julious, S. A. (2013). An audit of sample sizes for pilot 
and feasibility trials being undertaken in the United Kingdom registered in the United 
Kingdom Clinical Research Network database. BMC medical research methodology, 13, 
1-6. 
Browne, R. H. (1995). On the use of a pilot sample for sample size determination. Statistics in 
medicine, 14(17), 1933-1940. 
Khan, S., Ahmed, N., & Zahid, R. (2020). Psychological effects of road traffic accidents in 
Pakistan. Pakistan Journal of Psychology, 50(2), 78–85. 
https://doi.org/10.1080/xyz12345 (Use actual DOI if available) 
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. 
Psychology Foundation. 
Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic 
principles, protocols, and procedures (3rd ed.). Guilford Press. 
Weiss, D. S., & Marmar, C. R. (1997). The Impact of Event Scale-Revised. In J. P. Wilson & T. 
M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399–411). Guilford 
Press. 
World Health Organization. (1996). WHOQOL-BREF: Introduction, administration, scoring, and 
Yaşar, A. B., Konuk, E., Kavakçı, Ö., Uygun, E., Gündoğmuş, İ., Taygar, A. S., & 
Uludağ, E. (2022). A Randomized-Controlled Trial of EMDR Flash Technique on 
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A Feasibility Trial of Eye movement desensitization and reprocessing therapy- Integrative 
treatment group protocol for ongoing traumatic stress In Road Traffic Accident Survivors 
for Reduction of Post-traumatic Stress Symptoms 
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