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The efficacy of eye movement desensitization reprocessing in resolving the trauma caused by the road accidents in the Sultanate of Oman.

The purpose of this study was to investigate the efficacy of eye movement desensitization and reprocessing (EMDR) in Resolving the Trauma Caused by the Road Accidents in the Sultanate of Oman. Three measures were used in this study, Trauma symptoms inventory, Subjective Units of Distress scale and the Dissociative Experiences Scale. Fifty- one volunteer participants from the University of Nizwa students and three hospitals in the Sultanate of Oman, with post- traumatic stress disorder (PTSD)caused by the road accidents were randomly assigned to either a treatment (N= 25) or waiting list group(control group)(N=26), after that they received a training to apply the EMDR for 2-3 sessions, in this study, EMDR was shown to be effective in reducing overall PTSD scale in both of posttesting and follow--up measurement, as well as for all participants, key words: EMDR, PTSD and road accidents.

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The fact that psychological problems may occur after accidents is well known. Since then there has been a controversial discussion about the validity of psychological sequelae of traffic accidents and the problems in differentiating between physical and psychological sequelae. Despite the long-lasting debate and the amount of injured accident victims, knowledge about the prevalence, validity and predictors of psychological sequelae after injuries is sparse. (Stieglitz, Nyberg & Berger, 1998) Accidents are one of the most prevalent traumas in western culture as like as in the Arab countries (Taylor and Koch 1995). After accidents, responses such as depression, phobic anxiety or PTSD may occur (Malt 1988; Mayou, Ehlers, Bryant, 2002). The psychological symptoms that can occur as a result of road accidents are increasingly being documented as well as efforts being made at early detection and understanding of who is vulnerable to post-accident psychological disorder. The major types of disorder that people suffer include symptoms of (PTSD) such as nightmares, flashbacks, avoidance symptoms, hyper arousal and emotional numbing, as well as phobic anxieties about travel, depression, grief and changes in driver behavior (Stieglitz, et al., 1998).

Apart from the experience of the accident itself, many of these injuries cause significant, lifelong difficulties. Therefore understanding the processes of trauma recovery is critical for social workers located in acute, rehabilitation and community settings (Harms, 2004).

(EMDR) is a new method of therapy that employs both exposure (desensitization) and cognitive processing of the traumatic memories. Francine Shapiro, an American psychologist, first described EMDR in 1989 as a psychological treatment to alleviate the distress associated with traumatic memories (Hogberg, Pagani, Sundin, Soares and Aberg-Wistedt, 2007). An unusual aspect of the technique is that it also involves having the patient engage in therapist directed, saccadic eye movements during the treatment procedure (Boudewyns and Hyer, 1996; Shapiro, 2001).

During EMDR the patient is asked to attend to emotionally disturbing material (distressing traumatic image) in brief sequential doses while simultaneously focusing on an external stimulus (eye movements, hand taps or bi-lateral audio stimulation). Therapists usually encourage patients to focus on traumatic material or image for around 25 eye-movements as they follow the therapist's fingers over a 1-2 minute period (Hogberg, et al., 2007). Brief feed backs then obtained about any noticeable cognitive, emotional or physical changes. Further eye movements are then made with the patient focusing on this new material. This process continues until the individual reports a subjective reduction in levels of distress related to the traumatic experience. An individual treatment session normally lasts around 90 minutes and several sessions might be required to process a single memory or image (Kathryn, MacCluskie; Kitchiner, Roberts and Bissori, 2006).

EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution, including relief of affective distress, reformulation of negative beliefs and reduction of physiological arousal. There is also some empirical support for the proposal that eye movements can reduce levels of physiological arousal. EMDR might promote change by inhibiting intellectualization about traumatic experience, instead promoting mindful experiencing of traumatic material (Silver, Rogers, and Russell, 2008).

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EMDR strategy is an especially useful thought stopping tool that can help counselee manage or control stress and anxiety that are caused by past events such as car accidents. Once you are familiar with EMDR, you can successfully use it for all types of stress from chronic anxiety to event specific fears. The strategy is simple, safe, ethical and can be inconspicuous, allowing you to use it even when you are in a crowded room. Sometimes, you could face difficulty to use EMDR because you are sitting in public situation. In this case, you can close your eyelids, so, any observer may believe your eyes are closed simply because you are in deep thought or resting (Aldahadha, 2010a), see figure (1). An example of how one individual can utilize and benefits from using this strategy (Aldahadha, 2010b, Feener, 2004; Plummer, 2007)

Shapiro (2001) argues that EMDR helps clients reduce or remove the negative affect associated with traumatic memories by activating a neurophysiological process that permits a form of relearning. The eye movements are presumed to activate brain chemistry that permits changes in memory structures and related emotional responses. Further discussion of the theory and alternative explanations follow a description of the intervention. The basic application of EMDR involves eight phases of treatment. It is possible that all eight phases can be completed within one treatment session, but the number of sessions needed can vary from one to many, depending on the client (Bronner, Beer, Vaneldik, Grootenhuis, and Last, 2009; Shapiro, 2001).

(EMDR) is a controversial, new therapy being used as a rapid treatment modality for both anxiety and traumatic memories (Shapiro, 1989a, 1989b). Although a comprehensive overview of this intervention is beyond the scope of this article, the reader is encouraged to review Shapiro (2001) for a thorough overview of this approach. The EMDR procedure, as described by its most basic features, involves pairing therapist guided rapid eye movements with imaginal exposure of traumatic memories and stress-related symptoms (Shapiro, 1989a). EMDR incorporates various aspects of different therapies with the use of imagine flooding, body awareness, and cognitive modification.

Review of Literature

There has been an increasing number of studies that support the effectiveness of EMDR in overcoming the symptoms of PTSD some of these studies were for (Gosselin & Matthews, 1995; Hekmat, Groth, & Rogers, 1994; Jensen, 1994; Silver, Brooks, & Obenchain, 1995; Wilson, Silver, Covi, & Foster, 1996; Burgmer & Heuft, 2004).

Previous research dealing with road trauma victims is limited at the global level and not conducted yet in the Arab region, The cognitive reprocessing that occurs with EMDR treatment leads to changes in the appraisals of the traumatic event and of oneself that are more -adaptive (Thomson, 1994). Positive therapeutic effects using EMDR have been reported in the treatment of combat veterans (Lipke & Botkin, 1992), crime victims (Page & Spates, 1993), individuals who have been sexual assaulted (Rotham, 1997), individuals with phobias (Muds & Merckelbach, 1998), individuals with panic disorder (Goldstein, & Feske, 1994), and individuals with test anxiety (Bauman & Melnyk, 1994).

Shapiro (1989b) published reports on a rapid process for resolving traumatic memories employing a new procedure referred to now as (EMDR). Subjects were asked to bring up target distressful memory while employing rapid saccadic eye movements directed by the therapist. Shapiro's study dealt with traumatic memories of 22 patients. They were compared to a (control group) where a narration of the trauma with periodic interruption was used. Dramatic relief of the traumatic memories was achieved with EMDR in one or two sessions with an accompanying drop in pulse rate averaging about 13 beats per minute in the EMDR group. These results persisted at a three-month follow-up.

Previous studies on (PTSD) investigated a variety of treatments and included mostly patients who were victims of sexual and combat assault. Hogberg and his colleagues (2007) studied the short-term efficacy of (EMDR) in occupation-based PTSD. Employees of the public transportation system in Stockholm, who had been experiencing a person-under-train accident or had been assaulted at work were targeted. Subjects with trauma exposure since more than 3 months but less than 6 years were included. Twenty-four subjects who fulfilled the DSM-IV criteria for PTSD were randomized to either EMDR therapy (N=13) or waiting list group (WL, N= 11). They were assessed pre-treatment and shortly after completion of treatment or WL period. The study indicates that EMDR has a short-term effect on PTSD in public transportation workers exposed to occupational traumatic events.

Aldahadha (2010b) conducted a study aimed at investigating the effect of (EMDR) Technique upon test- Anxiety reduction, among the University of Nizwa students. The study sample consisted of (21) students, who are suffering from severe and high test-anxiety level. They were divided randomly into two groups: Experimental group of (10) students and control (delayed) group of (11) students. The subjects in the Experiment were trained on (EMDR), whereas the subjects of the control (delayed) group were not trained at all. Results of non-parametric test for Mann-Whitney and analysis of Mancova revealed significant effect for the manipulation in reducing the means of Test-Anxiety level in the post-test and follow-up test, in favor of the experimental group compared with the (control group).

Kemple (2010) presented a study investigating the efficacy of four EMDR sessions in comparison to a six-week wait-list control condition in the treatment of 27 children (aged 6 to 12 years) suffering from persistent PTSD symptoms after a motor vehicle accident. An effect for EMDR was identified on primary outcome and process measures, including the Child Post-Traumatic Stress--Reaction Index, practitioner rated diagnostic criteria for PTSD, Subjective Units of Disturbance and Validity of Cognition scales. All participants initially met two or more PTSD criteria. Treatment gains were maintained at three and 12 months follow-up.

Significance of Study

The results of this study will help the victims of vehicle accidents to overcome their trauma symptoms, when they learn how to practice the EMDR strategy. Also, it will enhance the quality of life by discovering the positive effects of this technique. We expect the victims will extinct and hide the image of car accident and they will improve their adjustment, and mental health, especially when they get awareness and insight of themselves, absolutely by knowing the nature of trauma symptoms, side effects and the correct way of applying EMDR strategy. Despite the controversy about its novelty and other competing trauma-specific treatment methods, like cognitive behavior therapy (CBT), EMDR seems to be an effective and efficient trauma-specific treatment method particularly to be used by psychodynamic oriented therapists (Harvey, Bryant, Tarrier, 2003).

This study aimed at investigating the effectiveness of (EMDR) upon reduction of (PTSD) among a sample of car accidents victims, the victims of car accidents overcome their trauma caused by road accidents in Oman, after completing a 2-3 training sessions on (EMDR) strategy. There were also accompanying clinical measures that applied at pre, post, and follow-up. The subjects were chosen from participants volunteers who exposed or saw car accidents, and got a high score on the trauma symptoms inventory. To fulfill this purpose, the study included a random assignment treatment group and a random assignment waiting list group (control group, a group that received treatment, but at a later date).

Problem Statement

The world report on road traffic injury prevention is no doubt a compelling reading document about the increasing of road accidents rate. This issue became the most concern for most decision makers in all countries of the world. The Sultanate of Oman has brought up the issue of road safety seriously and played a major role in raising global awareness to the growing impact of deadly road traffic injuries, especially in the developing world. The magnitude of the problem encouraged the United Nations General Assembly to adopt a special resolution and the World Health Organization to declare the year 2004 as the year of road safety (Peden, Scurfield, Sleet, Mohan, Hyder, 2004). In taking these two important steps, both organizations started the world battle against trauma caused by road accidents and we hope that all sectors of our societies will cooperate to achieve this noble humanitarian objective.

There is a little follow-up of road accidents victims once they leave hospital, much road-accident research has been focused either on severely physically injured patients or those referred for medical treatment or medicolegal assessment sometime after the accident, However, in the authors' experience, people with relatively minor injuries may still experience significant, treatable psychological problems. Unless they require ongoing rehabilitation. Psychological symptoms and emotional issues dealing with effects of trauma, anxiety, loss, or disability may be ignored because of the limited time available for counseling in general practice, accident and emergency departments, and orthopedic clinics (Jeavons, Greenwood, and Home, 2000).

In Oman and other Arab world countries hospitals, patients who attend following road accidents, particularly if only to the Accident and Emergency Department tend not to be followed up or given any information about possible psychological counseling to the accident. Much treatable post-accident anxiety remains untreated; so there is a need for acute services to provide counseling following accidents. Therefore, in this study we tried to test the following hypothesis: Is there a significant effect for EMDR strategy in resolving the trauma caused by the road accidents in the Sultanate of Oman between the experimental group and the waiting list (control group)(before and after the treatment) at the pretesting, posttesting and--follow-up testing?

Method

Participants

Participants for this study were 51 volunteers with PTSD from the University of Nizwa and three hospitals in Oman (Khawla hospital N=11, Nizwa Hospital N=4, Sultan Qaboos university hospital N=7, and the University of Nizwa students N=29,). Participants were recruited using a formal letter to the directors of the hospitals calling for volunteers suffering from PTSD who have the desire to participate in a research project related to treatment. Additionally, the researchers presented a lecture to general students in the university of Nizwa in order to collect the participants and providing the auditors with knowledge and some of coping skills about the PTSD and EMDR strategy.

The treatment group comprised of 25 participants (12 men and 13 women); while the waiting list group (control group) comprised of 26 participants (12 men and 14 women). The average age for the entire sample was 26.41 years (ranging from 19 to 37 years).The average self-reported grade point average of participants was 3.87. The participant group comprised 48 Omanis and 3 expatriates. 44 of the participants were available for the follow-up posttesting. The 7 participants who did not respond to follow-up posttesting were 3 women from the treatment group and 1 woman and 3 men participants from the waiting list group (control group) see Table 1.

Instruments

This study used three measures. Trauma symptoms inventory. Posttraumatic Stress Scale (Norris & Hamblen, 2003). A self-report measure to assess the symptoms of PTSD according to the PTSD criteria of DSM-IV-TR. The trauma symptoms inventory Oman version (Al-Marhon, 2011) and Jordan version (Al-Momani, 2008) consists of 17 items (scores range from 17-85). A diagnostic measure based on DSM-IV-TR (which was in use when the study was commenced) (Hasson, 2007); to each question there are five alternative answers (Likert scale-5 points) depending on the severity of the symptom; l=/none, 2=/a little, 3=/some, 4=much, 5=/most. Participants responded on a scale indicating how frequently they experienced specific symptoms of PTSD. The PTSD was used in this study to assess participants at pretesting, posttesting, and waiting list testing times. Reliability and validity and other psychometric proprieties were applied and accounted step by step the Omani society by Al-Marhon (2011) taking in consideration the psychometric properties done by Al-Momani (2008). In this study the PTSD has demonstrated good test-retest reliability (r = .95) and internal consistency (r = .92).Concurrent validity assessed by comparing the PTSD with Al-Qadomi and Al-Helew (2003) PTSD scale. The two scales were correlated at the level of significant .05.

Subjective Units of Distress scale The SUDS (Wolpe, 1991) was developed for the use of systematic desensitization and was incorporated into the standard EMDR protocol. Participants rate the level of distress they experience on the SUDS from 0 to 10, with 0 indicating the participant experiences no disturbance and 10 reflecting the highest disturbance possible. SUDS are used in the EMDR protocol to monitor the participant's level of disturbance during the session.

The Validity of this scale was developed in order to monitor shifts in participants' beliefs regarding their desired self-assessment or positive cognition during administration of EMDR. Participants were asked several times during the EMDR procedure to rate the believability of their preferred, desired cognitions about themselves and their PTSD. Increases in the scale validity score indicate a stronger validity of the desired cognitions.

The Dissociative Experiences Scale (Bernstein and Putnam, 1986) was used as a prescreening instrument. This test is meant to be used as a starting point, not as a diagnosis tool. The score of the dissociative experiences scale is not intended as a mental disorder diagnosis, or as any type of healthcare recommendation. Furthermore, the EMDR institute, which trains of practitioners in EMDR, suggests that every individual should be screened for a dissociative disorder before the use of EMDR. The DES was administered to screen participants for the possibility of major dissociative psychopathology. On the basis of the results of the DES, 2 individuals were referred to the long- life center for assistance with PTSD. The scale was a 28-item self-report instrument for the measurement of dissociative experiences; It has been found to have a test-retest reliability of 0.89 and to be highly reliable, internally consistent, and temporally stable. Cronbach's alpha was 0.91 in our study. The DES exhibited exemplary reliability, suggesting that the instrument is suitable to measure the construct understudy. The scale takes approximately 10 minutes to complete and yields item, subscale, and total scores, which all range from 0 to 100. The individual's total score is the mean of the 28 items, and higher scores indicate greater levels of dissociation. The scale has been used earlier in population samples, and has been shown to discriminate significantly between patients with dissociative disorders, other disorders and normal control subjects when a cutoff score of 30 was used (Carlson, Putnam, 1993; Maaranen, Tanskanen, Honkalampi, Haatainen, Hintikka, 2005; Putnam, Carlson, Ross, 1996).

Scale Translation Process

Four bilingual translators (University of Nizwa, University of Jordan, and Sultan Qaboos University) (English and Arabic) translated the English version of the DES into Arabic. These translators were instructed to retain both the form (language) and the meaning of the items as close to the original as possible with a priority to the meaning equivalence. When the Arabic translation was finalized, the DES was then back-translated (from Arabic to English) by other four bilingual department members. The back-translated items were then evaluated by a group of five faculty members to ensure that the item meanings were equivalent between the original English version and the back-translated version. Meanings were found between items. Those items were put through the forward and back-translation process again until the judges were satisfied that was substantial meaning equivalence.

In further step, both the Arabic and the English forms of DES were administered to 54 senior students in the English Department who speak both languages fluently. The order effect was controlled by giving the English DES to half of the group as the first scale and the Arabic DES to the other half. The correlation between these two forms was found to be r = .89.

The Arabic version of the DES was then pilot tested with a group of 10 faculty members to collect feedback about instrument content and usage. The feedback from the faculty members emphasized that the instrument has both face and content validity.

Factor analysis was carried out on the 28-item DES (N=309). The factor analysis and loadings of the DES items using the confirmatory factor analysis (varimax rotation) as following: Factor 1: absorption and imaginative involvement (DES-ABS), DES Item Numbers: .67, .71, .46, .51, .60, .45, .67, .55, .60, .77, .62, .52, .48, .72, .66. Factor 2: The Amnestic (DES-AMN), DES item Numbers: .61, .44, .51, .45, .49, .71, .63, .58. Factor 3: Depersonalization-Derealization (DES-DD), DES Item Numbers: .55, .43, .62, .48, .51.

The result of factor analysis shows that there were three factors or subscales, all measuring different aspects of dissociative experiences, loading above .42 were accepted as the criterion for inclusion of an item into a factor. Factors have consisted more of questions measuring pathological dissociation. This result is consistent with the studies of Ross, Joshi and Currie (1991), Sanders and Green (1994) and Kleindorfer (1998).

Procedure

This study used a pretest-posttest, waiting list group(control group) design with random assignments of participants. A waiting list group(control group) design was used so that no participants were denied treatment. A waiting list group was necessary to measure the impact of the treatment. Pretesting involved administering the DES and the PTSD to volunteers who responded to participate in the experimental treatment of FrSD. Fifty three individuals responded to the invitation which was coordinated by hospitals and student counseling center staff. They met with the researcher for a description of the study and completed the pretesting materials. Two individuals were not selected because of their results on the DES (their total score over 30%). Participants were rejected if they scored high on the DES and were referred to the long- life learning center in the University of Nizwa if they like to pursue assistance for their PTSD. After pretesting, participants accepted for the study were separated by gender and then randomly assigned to either the experimental or the waiting list group (control group). The experimental group members individually received 2-3 sessions of EMDR, 3 weeks apart, and then both the experimental and waiting list group (control group) were posttested. After posttesting, the waiting list group (control group) members were given the experimental treatment, again 3 weeks apart, and posttested. A follow-up test in which participants completed the PTSD Scale was continued by mail and telephone on all targeted participants 1 month after their last EMDR session. The dependent variable in this study was the total score of PTSD Scale, while the independent variable was the EMDR treatment. All members received the EMDR sessions training in the student counseling center in the University of Nizwa or in the hospital also received medical treatment after the recovery of road accident.

Eye Movement Desensitization and Reprocessing

This technique, as it is now practiced, is much more than eye movements and more than pure exposure (Shapiro, 2001). In a short time EMDR has evolved into a sophisticated technique that blends exposure with a non-directive, free associative processing and other treatment components common to good <traditional> therapy. In the procedure the patient is asked to focus on traumatic memory--usually the most traumatic point. There is no need to even describe the trauma. Then the therapist queries for the salient negative and positive cognitions related to the targeted memory. Words that attribute negative connotations are common (e.g. <helpless>, <out of control',' sad>, <angry>, <shame>). (Andrade, Kavanagh, & Baddeley, 1997; Barrowcliff, Gray, Freeman, & MacCulloch, 2004; Christman, Garvey, Propper, & Phaneuf, 2003; Kuiken, Bears, Miall, & Smith, 2002; Lamprecht et al., 2004; Rogers & Silver, 2002; Shapiro, 2001; Stickgold, 2002; Van den Hout, Muds, Salemink, & Kindt, 2001).

During this procedure, all aspects of the memory-representation are activated: image, cognitive, emotional and physical sensations. When this is achieved the patient was asked to focus internally on emotionally disturbing information, evoked by the memory and simultaneously externally on bilateral stimulation. The therapist asks for aerating on the believability of the positive cognition. Next, the therapist acquires the most notable feeling state from the patient. The patient is asked to concentrate on the memory, picture and attribution words and as sign a rating using the SUDS(0-10). Before the eye movement processing, the therapist obtains information on the body sensation associated with the target memory. Now the trauma processing begins. The therapist instructs the patient to visualize the traumatic scene, recall the negative statement and feeling, concentration of the physical sensations in the body, and move his/her eyes to the therapist>s index finger(e.g. following the horizontally moving fingers of the therapist with the eyes. Following each set of dual attention (internal and external) during 30-45 seconds, the patient is asked to report shortly whatever comes to mind. This alternating process of giving dual attention and making notice of whatever changes is repeated until the arousal evoked by the memory is neutralized. The distress level is rated by the Subjective Units of Disturbance Scale (SUDS) from 0(meaning neutral) to 10 (meaning maximal distress) (Wolpe, 1991). This scale is used for measuring the subjective intensity of disturbance or distress currently experienced and functions as a benchmark to evaluate the progress of treatment. When a positive cognitions rated high and the SUDS is 0 or 1 the EMDR procedure is terminated. (Bronner, et a1., 2009; Russell, 2006; Shapiro, 2001; Silver, et al., 2008).

Results

The study aimed to test the hypothesis that said whether there is a significant effect for EMDR strategy in resolving the trauma caused by the road accidents in the Sultanate of Oman between the experimental group and the waiting list (control group) (before and after the treatment) at the pretesting, posttesting and--follow-up testing? (See Table 1)

Table 1 shows that there is a gap between the scores average of waiting list (control group) and experimental group in favor to experimental group for the pre, postt and follow-up testing, in purpose to test the significance of differences for these measures, the one-way ANOVA was carried out. (See Table 2)

Using t tests and a .05 level of significance, the experimental and waiting list group (control group) were found to be equivalent on all dependent variables of the pretest, t = -.436, P < .05. Hence, we can use one-way analysis of variance (ANOVA) which was performed on the pre, post and follow-up testing as obtained on total PTSD scale scores. Results in table (2) indicated that the treatment group and waiting list (control group) differed significantly, F=23.0791, P < .0001. The treatment group had a significantly lower total PTSD mean score on pretesting and posttesting, F = 67.3249, P < .0001, whereas the waiting list group (control group) showed no significant difference between pretesting and posttesting (before treatment), F = .3866, P = .5397.

Using One-way analysis of variance ANOVA, the participant group as a whole was compared across pretesting, posttesting (after all had received treatment), and follow-up testing of total PTSD scale, see Table (1, 2). Significant differences were indicated F = 146.0040, P < .0001. Planned contrasts revealed significantly lower total PTSD mean scores on posttesting as compared to pretesting, F=143.6738, P<.0001,and on follow-up testing as compared to pretesting, F = 36.2207 , P < .0001. No significant difference was found between posttest and follow-up test means for total PTSD scale, F = 6.2537, P = .0163. The sessions of EMDR treatment seemed to have been effective in significantly reducing total PTSD scores on posttesting. The PTSD reduction was maintained at the time of the 1-month follow-up testing.

Discussion

A strength of this study is that the methodology was based on Enright, Baldo and Wykes, (2000) and followed the treatment protocol as taught in official EMDR training (Shapiro, 2001). The study examined the efficacy of EMDR as a treatment of PTSD. The sessions of EMDR were shown to have significantly reduced the overall measured PTSD amongst a sample of some participants who suffered from PTSD; all participants were divided randomly into two groups, experimental group which was compared with waiting list (control group). The waiting list group (control group) after obtaining the posttesting received the EMDR treatment as a delayed condition, total PTSD was equally equivalent on the pretesting between the two groups, and significantly reduced in favor of experimental group as well as the reduction in the PTSD total score was maintained after the 1-month of posttesting, after most participants had experienced taking a test.

The results suggested that EMD had several advantages over exposure including greater improvement in PTSD symptoms, was provocative of less anxiety for patients as well as therapist, and had fewer adverse complications. It is not known why EMDR works, but it was conceived as and has been primarily viewed in a cognitive/behavioral framework. It has been described as an exposure therapy technique.

Despite previously reported treatment impediments, our results provide optimism that EMDR therapy technique may be useful in reducing PTSD caused by road accident. It may be beneficial to further assess the extent to which other trauma-related emotions may affect the success of therapy. Another important research direction will be to examine the effects of EMDR, relaxation training on trauma-related road accident. PTSD consists of cognitive and affective components, and includes beliefs in a negative global evaluation of the self as not being decent, good, or competent, combined with a sense of worthlessness or powerlessness (Street & Arias, 2001).

It is also quite possible that counseling practitioners might encounter clients who have presenting symptoms such as traumatic memories or symptoms of anxiety, either in practicum and internship placement, or after they complete their training and are working in the field. In our experience as a clinician in a Student Counseling Center in Sultan Qaboos University and University of Nizwa, there were occasionally clients who would call for an appointment and specifically request a counselor who had training in coping with PTSD. As the research process continues, EMDR might evolve into a very significant contribution in the field of counseling and psychotherapy. Counselors will find it helpful to be apprised of the EMDR technique and potential movement in the field, especially in the Arab world. It may spark interest for research, and it also will equip counselors to respond to clients' needs for informed consent with the broadest range of information possible (Shapiro, 2001).

Future studies could investigate how the treatments examined in the present study are able to reduce PTSD associated with experiences of road accident. Amyriad of possibilities exists with regard to differential treatment effects, specific symptom configurations that respond to EMDR, and clear identification of the curative component of treatment. The result of this study was consisted with results of the following studies (Andrade, Kavanagh, & Baddeley, 1997; Barrowcliff, Gray, Freeman, & MacCulloch, 2004; Christman, Garvey, Propper, & Phaneuf, 2003; Kuiken, Bears, Miall, & Smith, 2002; Lamprecht et al., 2004; Rogers & Silver, 2002; Shapiro, 2001; Stickgold, 2002; Stapleton, Taylor, & Asmundson, 2006; Van den Hout, Muris, Salemink, & Kindt, 2001).

Conclusion

In summary, EMDR is probably an efficacious treatment for civilian with PTSD and possibly an efficacious treatment in resolving the trauma caused by the road accidents in the Sultanate of Oman. The authors propose that EMDR's treatment effect results after 2-3 sessions. Therefore, we advise the psychologists, practitioners and psychiatrists to benefit from these results in alleviating the PTSD symptoms caused by road accidents. We are of the opinion that EMDR could become an effective and useful psychotherapy technique. Whatever the eventual merits and impact of eye movements; EMDR applies the active treatment ingredient of exposure in a patient-acceptable manner. In addition, EMDR appears to us to be in compliance with important tenets of psychotherapy. Finally, only more comparative studies will bear its eventual efficacy.

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Dr. Basim Aldahadha, University of Nizwa. Dr. Hussain Al-Harthy, University of Nizwa. Dr. Suad Sulaiman, Sultan Qaboos University.

Correspondence concerning this article should be addressed to Dr. Basim Aldahadha at basim@unizwa.edu.om.

* Funded by the central budget of the University of Nizwa
Table 1
The Means and Standard Deviations of the Participant's Response on the
EMDR Scale Accordingly to their Group and Time of Testing

Time of Testing     Treatment Group

                    M        SD       N

Pretesting          58.48    6.659    25
Posttesting         43.76    5.109    25
Posttesting                           25
Follow-Up testing   42.18    5.844    22

Time of Testing     Waiting list Control Group

                    M          SD       N

Pretesting          59.31      6.898    26
Posttesting         58.08 *    6.621    26
Posttesting         45.19 **   6.518    26
Follow-Up testing   41.82      5.243    22

* Waiting list (Control group) before treatment. ** Waiting list
(Control group) after treatment.

Table 2
The Effect of EMDR on PTSD for the Pre, Post and Follow-up Testing

                       Source of           Sum of
Level of Variables     Variation           Square       DF

Pretestting and        Between Measures    1568.6275    1
Posttesting within     Residual            3398.3725    50
the Two Groups         Total               8165.9608    101

pretesting and         Between Measures    2708.4800    1
posttesting within     Residual            965.5200     24
the Experimental       Total               4399.2800    49
Group

pretesting and         Between Measures    19.6923      1
posttesting (before    Residual            1273.3077    25
treatment) within      Total               2305.0769    51
the waiting list
group

pretesting,            Between Measures    6256.4091    1
posttesting (after     Residual            1842.5909    43
all had received       Total               9381.5909    87
treatment), and
follow-up testing
(as a whole)

Posttesting (after     Between Measures    5296.3235    1
all received           Residual            1843.1765    50
treatment) and         Total               9273.5784    101
pretesting (as a
whole)

follow-up and          Between Measures    1800.0455    1
pretesting (as a       Residual            2136.9545    43
whole)                 Total               7305.9545    87

follow-up (as          Between Measures    120.5568     1
a whole) and           Residual            828.9432     43
posttesting (after     Total               2858.4432    87
all received
treatment)

                       Source of           Mean
Level of Variables     Variation           Square       F

Pretestting and        Between Measures    1568.6275    23.0791 *
Posttesting within     Residual            67.9675
the Two Groups         Total               80.8511

pretesting and         Between Measures    2708.4800    67.3249 *
posttesting within     Residual            40.2300
the Experimental       Total               89.7812
Group

pretesting and         Between Measures    19.6923      0.3866
posttesting (before    Residual            50.9323
treatment) within      Total               45.1976
the waiting list
group

pretesting,            Between Measures    6256.4091    146.0040 *
posttesting (after     Residual            42.8510
all had received       Total               107.8344
treatment), and
follow-up testing
(as a whole)

Posttesting (after     Between Measures    5296.3235    143.673 *
all received           Residual            36.8635
treatment) and         Total               91.8176
pretesting (as a
whole)

follow-up and          Between Measures    1800.0455    36.2207 *
pretesting (as a       Residual            49.6966
whole)                 Total               83.9765

follow-up (as          Between Measures    120.5568     6.2537
a whole) and           Residual            19.2777
posttesting (after     Total               32.8557
all received
treatment)

                       Source of
Level of Variables     Variation           Prob.

Pretestting and        Between Measures    0.0000
Posttesting within     Residual
the Two Groups         Total

pretesting and         Between Measures    0.0000
posttesting within     Residual
the Experimental       Total
Group

pretesting and         Between Measures    0.5397
posttesting (before    Residual
treatment) within      Total
the waiting list
group

pretesting,            Between Measures    0.0000
posttesting (after     Residual
all had received       Total
treatment), and
follow-up testing
(as a whole)

Posttesting (after     Between Measures    0.0000
all received           Residual
treatment) and         Total
pretesting (as a
whole)

follow-up and          Between Measures    0.0000
pretesting (as a       Residual
whole)                 Total

follow-up (as          Between Measures    0.0163
a whole) and           Residual
posttesting (after     Total
all received
treatment)

* Significant at the level of P < .0001
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Author:Aldahadha, Basim; Harthy, Hussain Al-; Sulaiman, Suad
Publication:Journal of Instructional Psychology
Article Type:Report
Geographic Code:7OMAN
Date:Sep 1, 2012
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