EMDR Psychotherapy and Individual Prevention from the Psychosocial Risks at Work: A Clinical Case Study

Abstract

The international recommendations concerning prevention from suffering at work target mainly organizations. The World Health Organization (WHO) recognizes the role of psychological factors in the onset of anxiety disorders related to stress at work.

This paper aims to expose a clinical report leading to the elaboration of a hypothesis on the efficiency of Eye Movement Desensitization and Reprocessing (EMDR) in the tertiary prevention from the psychosocial risks at work.

We expose four clinical cases expressing anxiety troubles related to their capacity of adaptation at work. For each subject, EMDR psychotherapy has been proposed based on a standardized protocol.

The results show that within less than six EMDR sessions the anxiety troubles and their behavioral and cognitive consequences weakened or disappeared even if the clinical profile of the patients doesn’t correspond to the PTSD diagnosis.

EMDR could be an interesting approach in the treatment of psychological factors involved in anxiety troubles with a professional etiology. An EMDR treatment could be proposed for tertiairy prevention of psychosocial risks at work. The effect of EMDR on the neuroendocrine mecanisms of stress might explain its efficiency.

Keywords: Psychotherapy; EMDR; Stress; Psychosocial risks; Prevention; Anxiety disorders

Resume

Les recommendations internationals concernant la prevention de la sufferance au travail visent principalement les organisations. L’Organisation Mondiale de la Santé reconnaît pour autant la place des facteurs psychologiques dans le déclenchement des troubles anxieux liés au stress au travail.

Cet article a pour but de présenter un constant Clinique meant à l’élaboration d’une hypotheses sure l’efficacité de l’EMDR dans la prevention tertiary des risqué psychosociaux au travail.

Nous developing quarter études de cas présentant des troubles anxieux liés à leurs capacités adaptatives au travail. Pour chacun des sujets, une psychothérapie EMDR est proposée à partir du protocole standardisé.

Les résultats montrent qu’en moins de six séances d’EMDR les troubles anxieux et leurs conséquences comportementales et cognitives diminuent ou disparaissent même si le tableau clinique de ces patients ne permet pas un diagnostic de PTSD.

L’EMDR peut être une piste intéressante de prise en charge des facteurs psychologiques impliqués dans les troubles anxieux ayant une étiologie professionnelle. Un traitement EMDR pourrait être proposé en prévention tertiaire des risques psychosociaux au travail. L’effet de l’EMDR sur les mécanismes neuroendocriniens du stress pourrait expliquer son efficacité.

Theoretical Framework

Stress at work is an issue of public health. The psychosocial risks joined the regulated framework of professional risks. They trigger the appearance of cardiovascular disorders [1]. Stress at work impacts directly the appearance of these physical disorders through neuroendocrine mechanisms of stress such as Corticotrophinreleasing Hormone transmissions in sub-cortical structures (the amygdale for instance) [2].

In the field of mental health, the emotional exhaustion and the depersonalization at work is mentioned through the term of “burn out” [3]. The burn out status has been debated within Scientifics. The WHO doesn’t mention a fully-fledged disorder but further a factor that impacts the state of health. The involvement of psychosocial exposition at work is recognized in the etiology of mental disorders such as major Depressive Disorder [4]. We will deal with the implications of stress at work through its neuroendocrine mechanisms to avoid protracted debates associated with the status of the «burn out».

The recommendations of the WHO and INSERM relative to stress at work focus on prevention on two levels of the model established by Kompier: the individual or the organization [5]. Recently these recommendations were applied placing the emphasis on organizational factors [6]. On the individual level, psychological resources are recognized for their impact on stress management.Psychotherapies are proposed in the framework of tertiary prevention to limit, to stabilize or to treat the pathological consequences of chronic stress.

A few studies have been conducted on the impact of prevention on an individual level [7].

Such prevention could have effects on psychological resources and on the symptoms of stress at work. But the prevention on the individual level isn’t enough to guarantee the stability of the therapeutic effects. The methodological biases inherent in evaluation of psychotherapies prevented INSERM from ruling on the key parameters of their efficacy in the prevention of stress at work [8].

However, we notice that only some kind of therapies is mentioned including psychodynamic, systemic, behavioral and cognitive psychotherapies. To date the literature on efficiency of EMDR as part of the secondary and tertiary prevention from stress at work is lacking. Nevertheless, its methodology and its standardized protocol enable a rigorous evaluation of its effects.

Recent studies dealing with EMDR show its impact on infracortical brain structures [9]. Such as the amygdale, known for its implication in the neuroendocrine mechanisms of stress [2]. More generally, it has been shown that within an EMDR session, limbic hyper activation decreases for the benefit of the activation of cortical structures [9]. Besides its efficacy, the stability of EMDR effects has been noticed during 38 months after therapy [10]. These results have led the WHO to recommend EMDR in the treatment of Post- Traumatic Stress Disorders (PTSD).

Hypotheses and Method

The effects of EMDR have shown their efficiency and stability in treatment of PTSD. Yet, PTSD is a disease that depends on the neuroendocrine mechanisms of stress. We hypothesize that EMDR is an efficient and stable device of secondary and tertiary prevention from stress at work.

This paper aims to expose the empirical observations that contributed to the elaboration of our hypothesis concerning the methodology for the treatment of stress at work.

Clinical Cases

Mrs. G: A 46-year-old woman, Sessions of desensitization: 4, alternated bilateral stimulation (ABS): Eye Movements (EM)

After months of psychological pressure at work, Mrs. G gets on sick leave at the request of her doctor who diagnoses a Burn out.

His doctor referred her to our institute specialized in EMDR therapy. Her psychiatrist records a reactive depression. He noticed the presence of a sadness associated with obsessive rumination, with extreme anxiety and with a sleep disorder. The anamnesis revealed a stressful event that she related to her feelings when she thought of the day when she left her work.

We began with the reprocessing of this past event when she had to separate from the body of a close friend during his funeral, 30 years ago. The next session Mrs. G noticed the disappearance of her depressive mood.

Then we have targeted the past moment, more recent than the first one, when she left her work with the image of the managing director who abandoned her.

The following session, Mrs. G reports an improvement of her sleep quality. We then reprocessed a situation of her everyday life that triggered a state of hyper vigilance related to the revival of an intrusive image in which she saw herself alone on her desk full of files.

The next session the patient noted the disappearance of these states of hyper vigilance and even the anxiety vanished when she mentioned her work. However, she announced to her therapist that she was avoiding the confrontation with her colleagues even though she should negotiate a contractual termination. We have decided to reprocess the striking situations, that she remembered, which consisted of repeated moments of fear every day she was forced to take the way to her work during the last months before her sick leave.

After this session, Mrs. G told us that she was now able to return to her workplace to negotiate the contractual termination and she confirmed the stability of the therapeutic effects of the previous sessions. She also evoked several professional projects and she even considered creating her own company.

Mrs. R: A 53-year-old woman, session of desensitization: 1, ABS: EM

Mrs. R works in a private practice in the domain of health care. One day a family member of one of his patients lodged a complaint against her. After this complaint the family members harassed Mrs. R and her circle of acquaintances through phone calls. They even harassed her at her workplace every day during several months in the course of which other complaints were pronounced. After three months of harass, Mrs. R went on sick leave and consulted her psychiatrist. She reacted to the medical treatment with a serotoninergic syndrome which deteriorated her medical condition leading her psychiatrist to stop the treatment and to refer her to our institution.

Given the facts collected during the anamnesis we decided to reprocess a current trigger of her fear that led her to refuse to return to her workplace. After this session Mrs. R declared that she was able to take control over her fears without medication. Indeed, her panic attacks had significantly decreased in time and in frequency. She was now able to return to work. As Mrs. R is still exposed to the harass of that family, the therapy is still going on but Mrs R continues her professional activity with new projects in mind that might materialize.

Mrs. S: A 22 year-old-woman, sessions of desensitization: 3, ABS: EM

Mrs. S started an EMDR therapy because she couldn’t take control of her stress that she considered as disproportionate as she found herself in a repetitive state of hyper vigilance when she mentioned her upcoming professional evaluation. Even if this evaluation was important for her career, the proportion of her stress level expresses a state of hyper vigilance. The anamnesis revealed a series of stressful events in her childhood.

We started with the desensitization and reprocessing of a situation related to this evaluation that used to trigger a disproportionate level of stress. During this session, the image of the situation wasn’t desensitized so that the session was considered as «incomplete».

During the second session of desensitization, we continued the reprocessing of the same target. Mrs. S provided more associations in the form of images and cognitions and this time the level of perturbation decreased but the perturbation did not completely disappear.

During the third session of desensitization we reprocessed the same target. However, the level of perturbation of Mrs. S raised. Indeed during the reprocessing of this trigger, Mrs. S evoked and reprocessed new elements of stressful memories of the past. After this session, Mrs. S said: «In any case, for the first time, I feel a normal level of stress». She was able to decrease her stress level caused by the perspective of this evaluation but she couldn’t make completely disappear the stress that she considered as necessary to set up adequate strategies during her pivotal evaluation for her professional future.

Mrs. M: A 26-year-old woman, sessions of desensitization: 2, ABS: EM

Mrs. M is a driving instructor. After an accident, she developed a phobia of driving associated with panic attacks when she was forced to take the highway. She then went on sick leave. Mrs. M declared during the anamnesis that she associated these panic attacks with the first fears that came up during the separation of her parents when she had to face her violent father.

We targeted the most ancient situation. The reprocessing of the event was very fast but didn’t help the patient face the daily situations that kept triggering the panic attacks.

During the second session we targeted the main trigger: the driving on a highway. After this session the patient didn’t avoid the highway anymore, the exposition to these situation didn’t trigger the fear responses anymore. Mrs. R went back to work as well.

Analysis of the Results

These four case studies display the efficiency of EMDR in the treatment of psychological consequences of stress at work and the associated decrease and disappearance of the anxiety disorders. But the efficiency of EMDR reveals itself also in the capacity to confront with previous stressors, to resume work or the possibility to return to the workplace.

Yet in each of these cases, the absence of either the symptoms of revival or the symptoms of avoidance or even the presence of medication with psychotropic’s do not allow us to establish a diagnosis of PTSD on a psychiatric level.

To understand the efficiency of EMDR on the pathological consequences of stress at work, we are going to establish the common points between PTSD and stress at work from a methodological and a theoretical perspective.

On the methodological level

EMDR is a reproducible method as it is a standardized protocol that allows treating PTSD from a memory of the traumatic event that arises in the reality and breaks into the subject’s life. The different aspects of the striking memory that have to be identified in the protocol are:

• The images related to the event
• The dysfunctional auto-accusatory cognitions
• The emotions
• The physical sensations

As part of the pathological consequences of the chronic stress at work, we find the same aspects of the memory that enable us to apply the standardized EMDR protocol.

Moreover, in PTSD as well as in stress at work, symptoms appear following an external trigger easy to spot as the origin of the pathology. It is an element of an external etiology that breaks into the subject’s life and that causes an intensive stress that becomes chronic with a pathological response to the stress.

On the theoretical level

The report of INSERM concerning suffering at work emphasizes the neuroendocrine mechanisms of stress. These mechanisms are equally present in PTSD.

The effect of EMDR on neurological mechanisms of stress helps to explain partially the speed of the efficiency of this therapy.

Yet PTSD and the pathological consequences of suffering at work have in common an etiology based on the reaction to an external stressor.

We explain the empirical results of EMDR in the domain of suffering at work by the connivance with PTSD concerning the involved neurological mechanisms and clinical expressions. Two levels of treatment on which EMDR acts through its standardized protocol.

Discussion

We notice on the clinical level the efficiency of EMDR in the care of the psychopathological consequences of stress at work even in the absence of a PTSD diagnosis.

The possibility to apply the standardized EMDR protocol in PTSD as well as in suffering related to stress at work leads us to hypothesize that similar neuroendocrine mechanisms are involved in both problematic in spite of some variations concerning the clinical expressions.

This preliminary empirical observation requests further investigation using an experimental methodology containing quantitative evaluation of signs of stress at work as well as measures of brain mechanisms involved in EMDR therapy.

In terms of public health, the stakes could be new recommendations in the secondary and tertiary individual prevention of stress at work.

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