EMDR AND THE WORKPLACE - Helpful hints for the practitioner
David C. Blore, EMDR Consultant
September 2002


Here we are in 2002, no less than 13 years on from Francine Shapiro’s first published article on Eye Movement Desensitisation. Now called EMDR, the intervention carries on despite those with agendas to the contrary. The author nears 10 years use of EMDR himself and reflecting upon the cases seen, finds that over half of the 500+ EMDR cases during that time have had significant connections with the workplace. It is the benefit of experience that I wish to pass on here. Please forgive me for starting with some basic issues which are likely to be obvious to many and could be described as ‘common sense’. The problem is that ‘common sense’ could be described as ‘not common enough’ and in any case, preparation - like preparation in EMDR - can and does play a major role in the success or otherwise of any enterprise.

Over the years, I have found that unlike the normal client-therapist relationship, and more so than with traditional interventions, the ‘industrial’ use of EMDR requires an understanding of the subtleties of multi-relationship working, which is different from the ‘cosy’ NHS relationship between referrer (e.g. GP) and patient (i.e. client). It is not just about clinical change, but about commerce, time, efficiency and, more frequently than ever these days, compensation. Like all practitioners, the novice EMDR practitioner needs to be aware of these relationships - and stay independently minded. It is advisable therefore, to consider certain issues before taking that first referral and to work out your position / opinion on each one of the following (which in itself, is by no means an exhaustive list): Only when satisfied with your answers (and your level of insurance), should you then proceed.

Returning to the cases treated, I found that the ‘workplace-related’ cases I have dealt with could be divided into four, roughly homogenous groups:

The work-related trauma category included accidents at work for which there was generally a compensation case in progress. All such cases involved injury, of some description, to the employee (the client), but not all were cases where the employer was liable. During EMDR sessions it became clear that the issue of liability was no nearly as clear cut as might have been anticipated - or for that matter, as instructing solicitors would have you believe.

The second category was less homogenous and consisted of stress at work issues, a multitude of secondary gain (more about this later as well) and/or bullying at work. Bullying could be seen to have belonged to the trauma category, but since it is my experience that the legal profession was never involved and that this was a clinically important issue - I have placed bullying in the non-trauma category. The third category frequently involved relationship ‘turmoil’, grief and bereavement issues and debt problems - the connection between work, wages and debt being obvious. The fourth category is, as yet in the UK at least, a major untapped area and is clearly very different from the first three ‘pathological’ categories. Such ‘cases’ treated included communication skills development, pre-empting promotion chances and interview technique.

Splitting cases up into categories may be somewhat academic, but it did help identify the specific points within the EMDR 8 phase model that need attention. Please note I am not suggesting that the points recognised by Shapiro (2001, chapters 4-6 & 8), which do not appear in the text beneath, are not important - they are. However, the points listed beneath are of particular relevance.

Within Phase 1 (Client History) the issues requiring particular attention are: Let us now examine each one in some detail:

In the case of ‘truth telling’, don’t assume that a referral from an employer provides an accurate reflection of a given incident - at least from the employee’s point of view. By the same token be wary that the employee’s version may be biased too. A good strategy is to address potential assumptions about your role as therapist by explaining you role / position. Reassurance of independence from employer, union or other significant group (such as personnel department / human resources and occupational health provider) often helps bypass some of the secondary gain issues. Generally speaking, be independent not naïve!

In the case of the employee’s support network. There is a host of possibilities including members of the family, partner, friends outside work, work colleagues, the occupational health provider (e.g. a nurse), human resources department / personnel department, union, employer (usually an individual manager) and even a solicitor or other legal representative. it is useful to be mindful that all of the above may have their own agendas and the old adage ‘blood is thicker than water’ definitely applies.

The issue of medicolegal cases, already mentioned above, is fraught with potential communication problems. The following (also not exhaustive) are some of the issues that I have had to deal with on a regular basis: Who actually is instructing you to proceed? This might sound obvious, but needs a definite answer. Instructions to proceed from more than one source - joint instructions - is a feature of the relatively new Civil Procedures rules. Other than in this case, it is advisable to have only one instructing agency. I once mistakenly accepted referrals from management and occupational health provider from the same company - with totally confusing results. Proceed on written instructions only and be wary of emailed instructions that aren’t backed up in snail-mail written form. Faxed instructions are OK but be aware of who has access to the fax machine. This obviously raises the issue of employee confidentiality. Never disclose anything without the employee’s signature specifically to do so. Just because someone cites the Access to Medical Records Act, 1988, does not entitle them to your records. Strangely enough, it is my experience that one specific Government Agency often says they have an authorisation signature ‘on their records’ but don’t send a copy. Not good enough - contact them for a hard copy for your records first. Some basic knowledge of the legal process such as the Access to Medical Records Act 1988 and the Civil Procedures rules (also known as chapter 35 of the Woolf Reforms 1999), is useful here and courses run by solicitors and related medicolegal agencies can be useful. A healthy degree of paranoia when it comes to secondary gain has stood me in good stead in relation to work related medicolegal cases and the watchword seems to be: Maintain your independence!

More specifically relating to treatment, is the issue of timing. This is an area for preparation before your first referral, specifically being clear about others’ expectations of your clinical practice. Does treatment need to fit around a shift system or is there a system for allowing time off to attend therapy? What are the implications of time off on the employee’s wage packet and for that matter what is the potential for secondary gain? One employee I treated later admitted to slower than anticipated progress in order that his wife could complete the Christmas shopping each time her husband visited my clinic in a town the family didn’t usually travel to. And, just how urgent is urgent? More specifically who’s urgency is it? The company wanting their financial manager to be at his desk at the end of the financial year is not a clinical indication of priority - or is it? Be wary of the employee who is OK about his annual leave being utilised, is this because he/she anticipates this is likely to anger the employer least? So even with treatment timing, secondary gain is an issue.

As for case ‘case complexity’, by far and away the most common issue I have encountered is sleep. If one bears in mind that sleep problems didn’t exist before the Industrial revolution and its attendant need to sleep at a specified time. the psychological problems of insomnia soon become clear. Shift work (or for that matter virtually any work schedule) and insomnia are a deadly combination. “I must sleep”, subsequent lack of sleep, inevitable worry and further problems with sleep frequently lead to secondary problems such as the effect of medication on work performance. It may not have occurred to an occupational health provider that a psychological problem exists since physically the employee is OK. Of course sleep problems are symptoms of both depression and of PTSD, either of which may need treating.

As can be seen from the points raised above, without doubt the issue of secondary gain in the employee history taking, is by far and away the most complicated and potentially convoluted area to understand. Important questions (other than those already mentioned), include who exactly stands to benefit from successful treatment? What are the consequences for all sides of unsuccessful treatment? What ethical issues stem from being instructed by an employer but treating an employee?

With Phase 1 completed satisfactorily, at least if the employee is not suitable for EMDR this should now be clear. But my role in these situations has rarely ended here. By and large the need for providing recommendations, specifically whether EMDR would help at a later date, but also the employee’s suitability for current work or recommendations for modifications to work are indicated. Access to the services of either an occupational physician or occupational psychologist have frequently proved very useful. Although, in my case, in relation to the industry that I have several years experience of - namely mining - the above professionals (not just management), frequently anticipate that I will come up with answers. This is where further knowledge is useful, specifically Health and Safety at Work (or in the case of mines and quarries), Her Majesties Mines Inspectorate. Finally there is no substitute for committing pen to paper for making sure that both the employer (or instructing referrer), as well as the employee knows your recommendations.

Assuming that matters proceed to Phase 2 (Preparation), it would appear that the following are particularly important in this instance: As regards adopting a clinical stance, the key seems to be awareness of the difference between the standard hospital setting and the ‘everyday world of work’ setting. Obviously stressing independence from the ‘us and them’ view of management and union. Independence is stressed to counter the potential for being ‘recruited’ by either ‘side’. A useful start is to explain to the employee where you fit into system and at the same time stress the importance of employee confidentiality. This can then lead into the collaborative area of EMDR and issues such as aiding of self healing and provision of safety and reassurance.

The setting of expectations is an area that often needs to expand beyond merely the expectations relating to the employee’s idea of EMDR and include the employer’s expectations of EMDR. Once again preparation prior to the first referral is the key. With hindsight, I could have saved many telephone calls and a not inconsiderable amount of time and repetition had I considered from the outset offering a company’s human resources department a teaching session. Don’t assume either that the occupational health provider doesn’t require a teaching session. Even now, I would estimate that the majority of occupational health providers have yet to hear about EMDR. The receptionist’s reading of an article on EMDR in a magazine in the waiting room hardly suffices, but has been quoted to me as the only (and incidentally therefore, authoritative), source of information on EMDR.

Another important Phase 2 area not to neglect is that of addressing the employee’s fears. The following have frequently arisen: The overwhelmingly important issue in Phase 3 (Assessment) is that of understanding the workplace / industry and its jargon. Apart from helping to identify those negative and positive cognitions, it will later help you to know if processing is happening whilst at the same time developing an excellent therapeutic rapport. If the employee uses his work jargon, rather than translating into a language he/she thinks you’ll understand - you know you’ve cracked it.

The other Phase 3 guiding principle, is do not rush to get to Phase 4 - hopefully during preparation before your first referral - you took this into consideration when discussing the employer’s perceptions. Believe it or not, when I first started in this field of work, I not only didn’t make sufficient allowances for the first three EMDR phases, I made no allowance at all! It just shows.

Also important to Phase 3 are: do not press the employee to reveal more than they are comfortable with….. they may need time to be certain you aren’t ‘on the other side’ (management) and do not pass judgement on material revealed….. however, be clear in your own mind about issues related to Health and Safety at Work (or The Mines & Quarries Act) and what constitutes safe working practices. The employee who informed me of a prank at work that had gone badly wrong, had clearly broken both management procedures and HSE guidelines, yet no-one knew of what had happened. It took time to convince the employee that he must deal with what had happened properly, despite the potential for written disciplinary action, and that only then, was EMDR likely to help bring about a resolution.

There seems to be little in Phases 4 to 6 (Desensitisation, Reprocessing and Body Scan) that is specific to work-related referrals’ EMDR treatment programmes, unless the issue is performance enhancement. Here, making thorough use of the full protocol (i.e. not just past events) is vital. Even with non-performance enhancement cases, there is no reason to merely desensitise the issue at hand. What untapped potential has the employee? If nothing else, it is going to help with employee expectations if a problem not only disappears, but a better than anticipated outcome transpires. If confidentiality permits - and I have found this to be a fruitful area to discuss with the employee - frequent dialogue with the employer on progress pays dividends. Happy is the employer who discovers the troubled employee is actually brilliant at ‘XYZ’ and no one knew before, not even the employee him/herself.

Phase 7 (Closure) issues that are important to address are: For the incomplete session scheduling extra sessions (if feasible), can be very useful - providing the employer or instructing agency is aware of this possibility. There have been several times when I have found it necessary to advise an employee not to return / go to work that day. Specific permission from the employee to contact the employer in such situations is desirable. An unhelpful strategy is using visual imagery that in some way relates to the work environment. An example I recall is that of an employee imagining that his company had been relocated to a tropical location - only to report back at the next session that he had got terribly anxious because he couldn’t avoid the imagery of all his work colleagues being transferred too - along with the very problems that precipitated the referral. My advice for some time has been to use visualisation totally unconnected with work environment. The usual check on the employee’s support network is also important and I have found that backing instructions up online with information and providing access to a 24 hour voicemail line has also saved a great deal of time.

As regards Phase 7 Safety assessment - the following are important issues: Phase 7 Debriefing reminders and answers to questions may also require time in session, or afterwards via voicemail. Again a check on support networks is useful. My experience of log keeping with this clientele is that compliance is poor. Some success can be achieved by providing either online ‘text box’ or email submissions for people to complete at the time, or by providing specific hard copy sheets of paper for completion between sessions.

Finally, Phase 8 (Re-evaluation) issues can establish whether there was any incongruity between any version of the original narrative of a given event (i.e. employer/ employee /union etc. versions). Also, whether the work environment itself changed, whether the employee can cope / perform more effectively and crucially whether the employee has readjusted to a healthy occupational system.

In conclusion, the above has been the experience of one EMDR consultant over a period of nearly 10 years’ use of EMDR at varying degrees of skill level from pre Level 1 training to consulatnt/facilitator. The majority of that experience has been gained in working closely with the coal industry although employees from many settings have been involved from heavy construction work (concrete fabrications, mine support companies, stone quarries, the railways, public sector support workers, recycling industries and, increasingly, the service sector and leisure industry). EMDR has produced many rapid, successful and long-lasting returns to work - putting a value on this to the nation - is quite another matter.

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