Blazing the trail

The Occupational Health Unit of South Wales Fire Service
initiated a six-week course of psycho-education to raise awareness of stress
triggers in the course of firemen’s everyday work. It helped attendees identify
normal level of stress, by Lyndon Davies

The management and prevention of occupational stress and caring for the
psychological well being of staff is a major challenge facing occupational
health professionals.

Employers have a legal, economic and ethical responsibility to manage health
and safety in the workplace and relevant legislation includes the Health and
Safety at Work Act 1974 and the Management of Health and Safety at Work
Regulations 1999.1,2

Work stress in ageing police officers and A Study of stress and support in
the Staffordshire Fire and Rescue Service are two studies that have identified
that the potential causes of stress in emergency services result from a
combination of organisational, operational and external (personal)
stressors.3,4 However, Stress in the Service: who does it affect? suggests
there is evidence that firefighters do not suffer from occupational stress to
the extent one might think due to inbuilt factors that affect their resilience.5

During the financial year 2001-2002, data collected at the Occupational
Health Unit of South Wales Fire Service demonstrated that 21 per cent of all
appointments were devoted to stress and psychological-related consultations.

The Brigade introduced a series of innovative stress initiatives, which
included a partnership with a NHS Department of Liaison Psychiatry in order to
respond to the psychological needs of staff.

Through this partnership, the Brigade has been able to implement a stress
control course (Stresspac), developed by J White in 2000, Treating Anxiety and
Stress, following a series of studies.6 White provides eight years of follow-up
data on Stresspac’s effectiveness in treating stress and anxiety disorders in a
clinical psychology setting.7,8,9,10

The stress control course

The six-week course, totalling 12 hours of psycho-education is based upon
the model explained by White, who states that, "Stresspac is a didactic,
cognitive behavioural group therapy approach to anxiety disorders. It is a
robust six-session ‘evening class’ designed for either small or large-group
format." The main aim of the course is to "turn individuals into
their own therapist".

The course attempts to achieve a compromise between best practice and best
value in providing training to a large number of people. It relies heavily on
the written material accompanying the course and issues a comprehensive manual.

It encourages students to recognise patterns of distorted thinking and
dysfunctional behaviour that may contribute to a state of stress. It introduces
techniques that will provide the student with a toolkit to achieve their own
stress control. See the course model shown below.

The course is advertised throughout the organisation and students are
encouraged to self-refer to develop their ability to manage stress now or in
the future. Students are discouraged from self-disclosure about their own

Brief outline of sessions

Introduction and information aims to provide the framework for the
subsequent sessions. By offering easily understood, personally relevant
information, employees can begin to understand their problems more readily,
making them more open to change.

Controlling your body aims to educate employees about the physical effects
of anxiety, to provide a rationale for the use of progressive muscular
relaxation, breathing retraining and aerobic exercise.

Controlling your actions aims to educate employees about the effects of
anxiety on behaviour and behaviour on anxiety. It provides a rationale for the
use of exposure therapy where avoidance is a problem and other behavioural
techniques within a cognitive behavioural framework.

Controlling your panic and sleep problems aims to educate employees about
the nature of panic and insomnia and how to assess and control them. The
treatment uses stimulus control techniques along with sleep hygiene advice and
the cognitive and relaxation approaches previously learned on the course.

Controlling your depression and the future aims to educate about the nature
of depression and how to assess and control it. It revisits key elements from
previous weeks during this session, tying the whole course together.
Participants should now feel they have the ability to continue assessing and
controlling their own problems. However, it is recognised that in some
situations additional contact with a therapist will be required.

The extent of stress as a problem in the sample group

It emerged that 42 per cent of the group did not feel they were suffering
from the harmful effects of stress, whereas 58 per cent felt that stress was
negatively affecting their health.

Twenty-nine per cent believed their stress was purely work-related, 4 per
cent that their stress was purely non work-related (personal problems) and 25
per cent felt their stress was caused through a combination of both work and
non-work related factors.

Of students who returned the qualitative assessment questionnaire, 57 per
cent did not regard themselves as suffering from any of the psychological
conditions listed – for example, depression, panic disorder, fear or phobia or

Although 42.9 per cent of the sample perceived they were suffering from
depression and/or panic disorder, only 17 per cent had been diagnosed and were
being treated for their condition with medication under the supervision of
their GP. This may support theories that an individual’s perception plays a
major role in stress.6,11,12,13

There is a perception among these individuals that they are depressed,
although there is no evidence of clinical confirmation of this.

Student opinions in relation to the course

Students were asked to provide a series of opinions on a scale of 1-10 (1
being no benefit and 10 being of most benefit).

Students gave a favourable score of 7.6 that Stresspac had helped and
benefited them. Students provided similar opinions on the value and usefulness
of each session on a scale of 1-10.

The general opinion seen in Table 1 demonstrates that students favour the
course and believed it to be beneficial. It appears that the most useful
sessions were weeks 2 and 3, with all other sessions displaying a mean student
opinion score of 6.5.

The author believes the likely explanation for this pattern is that weeks 2
and 3 are probably the most applicable to the majority of individuals who
relate to stress. Students are taught relaxation and thought-challenging
techniques that are easily adaptable to general stress and anxiety. Subsequent
sessions on controlling actions, panic, insomnia and depression may not be
applicable to all students at this stage. It was established that only 14.3 per
cent admitted to suffering from depression and panic attacks.

Students were then asked three questions to provide the author with their
opinions on how applicable was the course in relation to their own personal

Examples of student comments include:

– "I found it useful to address my reaction to stress. I now understand
much more about stress/depression and how to help myself on any bad days".

– "I have a more confident feel to my life. I find it easier to cope. I
still slip back occasionally but I bounce back quicker".

– "I was suffering from crippling anxiety prior to the course and now I
feel normal. Stresspac is a toolbox which helps sufferers to control the
situation – but it takes time and effort to learn how best to use the

Similar comments were echoed in other responses, reinforcing the view that
that the course is well received by students. They were then asked to give
their opinion on a scale of 1-10 (1 = no stress, 10 = high stress) on their
stress level pre-Stresspac, compared to that on the three-month follow-up.
Examples of comments include:

– "I found Stresspac very beneficial. The techniques were easy to
follow as well as being easy to implement."

– "I thought challenging and breathing control has enabled me to face
situations previously I would have avoided. Most people suffer some degree of
stress in everyday life. Explaining what it is and how to cope, and the
pitfalls could help someone avoid falling too far."

Many commented that they obtained comforting reassurance and peer support
from attending with other colleagues.

It would appear that individuals realised ‘they are not alone’ in their
stress and many of the reactions experienced are ‘normal’ symptoms of stress
that can be controlled.

Large mixed groups are advantageous in assisting individuals to normalise
symptoms and change their negative perceptions surrounding stress.

Mixed groups will also contribute to the acceptance and understanding of
stress in a ‘macho cultured’ organisation such as the Fire Service. Many
expressed views, for example: "It was a wonderful relief that I was not
alone in my distress", reinforcing this point.

Individuals who attended complaining of insomnia prior to the course,
reported improvements in their sleep patterns by the three-month follow-up
stage. Those who did not particularly suffer from stress reactions commented
they had found the problem-solving techniques and coping strategies useful in
helping them organise busy days, preventing potential stress reactions.

Although not elaborated upon in this article, statistically significant
evidence was obtained from clinical measures completed under the supervision of
the nurse therapist pre–course and repeated post-course and on three months
follow-up. Highly significant improvements were seen in the Beck Depression
Inventory II,14 A Users Guide to the General Health Questionnaire,15 and Life
and Social Adjustments Scale.16


These results support the view that the self-help cognitive-behavioural
package is significantly effective in assisting staff to manage and control
their general stress and anxiety and that students continue to see benefits at
the three-month follow-up stage, suggesting that the course is beneficial in
preventing relapse.

Implementation of Stresspac as an evening class allows many staff to attend
from various disciplines within the Brigade. This has a normalising effect, as
stress affects many individuals in many ways and at different times of their
lives. The social aspect of the course encourages effective peer support and networking
among staff.

Data obtained so far demonstrates the course has been helpful in reducing
anxiety, depression and general health concerns in the majority of individuals.
The qualitative data is favourable, producing many examples of positive comments
that the course was relevant and useful.

The course continues to run and it is hoped it will receive a high
self-referral rate among staff. It has certainly proved itself to be an
exciting, popular and innovative stress control/prevention initiative within
South Wales Fire Service.

The author believes that as more data becomes available, the credibility of
the course will be further reinforced and it will benefit greater numbers of
Brigade employees, increasing attendance, efficiency, psychological and
physical wellbeing, morale and ultimately reducing unhelpful stress and

Lyndon Davies, RGN, BSc (Hons), is the occupational health nurse for the
South Wales Fire Service.


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