Mark Lawson Dunn and Dr Eileen Cahill-Canning report on the findings of an initiative within the Metropolitan Police Service that set out to aid the speedy rehabilitation of staff off sick with work-related stress
In 2002, the Home Office set new targets for rehabilitating police officers and staff on sick leave and returning them to work.1 It was noted that sickness absence among some officers and staff was due to psychiatric symptoms that were stress-related, such as depression, anxiety and post-traumatic stress disorder (PTSD).
Results from the 1999 Eurostat ill-health module of the Labour Force Survey (Office for National Statistics/Health and Safety Executive 2001) indicated that 438,000 people suffered from self-reported work-related stress, depression or anxiety in 1998-99.2 By contrast, this figure stood at 268,000 in 1995, and 207,000 in 1990.
This data clearly shows that rates of work-related stress, depression and anxiety are on the increase. And most of the susceptibility factors reported in the Eurostat report for high rates of stress-related illness also apply to the Metropolitan Police Service (MPS):
According to the survey, London (where the MPS is based) has the highest rates of work-related stress
- Full-time workers have higher rates of work-related stress than part-time workers
- Those working more than 40 hours per week have higher rates of work-related stress than those who work less than 31 hours
- There are higher rates in medium to large workforces
- Managerial and technical workers are at a higher risk than manual workers
- Rates of stress increase with the length of time in a job
- Those working in public administration and defence are at risk of higher rates of work-related stress.
The OH department of the MPS introduced an innovative scheme to determine whether cognitively-based, short-term psychotherapy could effectively reduce these symptoms and facilitate a rapid return to work.
The Private Psychotherapy Pilot Scheme (PPPS) was initiated in February 2003, and funded by the Home Office, to treat a cohort of 50 officers and staff. It took nine months to complete and evaluate, and was deemed a success. The scheme was repeated for another 50 officers and staff in 2004, which was also a success.
This article describes the parameters of the scheme, and the return-to-work and clinical outcomes for the two cohorts.
Selection of staff
The selection of police officers and staff for participation within the scheme involved a three-stage process, which is as follows:
Stage 1: Recruitment
The scheme was advertised to all human resource managers in the MPS through presentations and the circulation of a leaflet detailing the scheme and the referral criteria.
Stage 2: Selection and assessment
The project co-ordinator selected suitable referrals that met the scheme’s criteria. These were passed to the assessor with the psychotherapy team. Applicants were assessed at a location external to the MPS.
The objective of the assessment was to determine whether the following eligibility criteria for the scheme had been met:
- Diagnosis
- Sickness absence patterns
- No long-term associated physical illness requiring current treatment
- No ongoing disciplinary or suspension issues
- No significant current or previous psychotherapy treatment
- A willingness to participate fully in the private psychotherapy programme
- A willingness to return to work within the MPS
- Full agreement with the use of psychometric testing for the evaluation and reporting of outcomes.
Stage 3: Allocation to treatment
Applicants who fulfilled the eligibility criteria and consented to the treatment programme were directly referred to the psychotherapy team for treatment.
Cognitive Analytic Therapy (CAT) and Cognitive Behavioural Therapy (CBT) were both chosen as treatments, because they are both suitable for short-term problem and solution-focused work.3,4
In addition, both CAT and CBT are extensively used within NHS clinical settings and OH settings. The effectiveness of cognitive-based psychotherapies has also been demonstrated through clinical research.
For the purposes of the scheme, CAT and CBT were considered equally effective, as their comparative effectiveness was not under investigation. Clients were offered eight one-hour sessions.
The psychotherapists
The work was tendered by the MPS, and The Bridge Psychotherapy & Counselling Service was awarded the contract for the scheme.
All the psychotherapists were clinically registered with either the United Kingdom Council for Psychotherapy (UKCP), and/or British Psychological Society (BPS), and were highly-trained clinicians with many years’ experience in the NHS and/or OH settings.
All referrals were seen for appointments at a location outside the MPS. Most of the appointments were held within a hospital setting. The majority of participants preferred being seen at an external location by therapists who were not directly employed by the MPS.
The scheme was designed from the outset to facilitate rapid access to assessment and treatment, recognising the fact that long periods off sick without treatment can make problems regress from acute to chronic. The time between referral and assessment usually took no longer than 14 days. The time between the assessment and the first treatment appointment was also no longer than 14 days, and therapists saw many clients within the same week.
The clinical team (of assessor and therapists) had rapid liaison with the scheme co-ordinator at the MPS, and met regularly to review progress.
The team also operated a telephone help-line for clients in the scheme. Therapists were responsible for record keeping and psychometric testing as well as the provision of discharge reports and clinical data at the end of treatment.
Return-to-work data
Staff accepted for treatment must have been off sick for at least 28 days, which was confirmed with HR.
At the end of treatment, the therapists recorded their clients’ work status; whether they continued to stay off work sick, returned to work full-time, or went on recuperative duties. Those who resigned or retired were recorded separately. This data were checked with HR, and was checked again 28 days after the treatment had ended.
Clinical data
Psychometric testing is a widely used and well-established practice within clinical settings, both for the purpose of rating symptoms for clinical research, and for making diagnoses. The tests can only be administered and interpreted effectively and appropriately by specifically qualified trained registered practitioners. These practitioners include psychiatrists, clinical psychologists and clinical psychotherapists.
Three clinical psychometric tests were administered to all clients both before and after psychotherapy treatment. It was the purpose of these tests to record:
- the presence or absence of symptoms (for example, anxiety and depression),
- the severity and change of symptoms over the course of the treatment. The tests allowed rapid assessment of overall symptomatology and were routinely completed by clients before and after treatment. This is important in influencing which symptoms and problems are to form the initial focus for the treatment
- The pre- and post-treatment clinical data contributing to the overall evaluation of the scheme’s effectiveness.
The psychometric tests
This scheme used three tests:
- The Beck Depression Inventory (BDI): This is a 21-item inventory on a three-point scale with a maximum score of 63. Symptom ranges are generally: 0-13 = minimal depression, 14-19 = mild depression, 20-28 = moderate depression, 29-63 = severe depression.5
- Beck Anxiety Inventory (BAI): This is a 21-item inventory on a three-point scale with a maximum score of 63. Symptom ranges are generally: 0-9 = mild anxiety, 10-18 = mild to moderate anxiety, 19-29 = moderate to severe anxiety , 30-63 = severe anxiety.6
- The Brief Symptom Inventory (BSI): This instrument measures general psychiatric symptomatology with a 53-item inventory on a four-point scale with a maximum score of 212.7
The sample
Clients referred to the project came from all levels and ranks within the police service. They included senior operations officers, firearms and flying squad officers, beat officers, admin and clerical staff, photographers, drivers and traffic wardens. More men were referred than women (55%, compared with 45%). In the first cohort, the age ranges of clients was 19-30 = 5 clients, 31-40 = 14, 41-50 = 14, 51-60 = 3.
In 2004, 62 staff were referred to fill the 50 places available. Twelve did not continue beyond assessment for a variety of reasons, including non-attendance for assessment (7), deciding against treatment (3), being too ill for treatment (1) and taking up NHS treatment (1).
Comparing clinical data: 2003 and 2004
A comparison of the outcomes for the two cohorts (2003 & 2004) shows almost equal effectiveness of outcome. The combined outcomes for the two groups confirm the efficacy of early cognitive psychotherapy in rehabilitating individuals with stress-related illness back to the workplace.
The Beck depression scores for both cohorts were on average in the severe range before therapy, and were reduced to within the mild range at the end of therapy. Similarly, the Beck anxiety scores were reduced from moderate to severe before therapy, to mild to moderate post-therapy. The general measure of the BSI also shows a similar reduction of moderate to severe, improved to mild.
Psychometric test cores for 2004 showed a slight overall improvement on scores for 2003 – perhaps reflecting the therapists’ increasing experience with this client group’s issues.
In the 2003 cohort, no client had test scores that were worse at the end of therapy. In the 2004 cohort, one client’s scores were worse at the end of therapy, and he decided to resign from the police service.
The small percentage in both groups who were still on sick leave four weeks after the end of therapy were those with long-standing difficulties, whom the therapists felt needed more than the eight sessions available to make significant progress.
The general feeling was that about 10% of each cohort needed more than eight sessions (perhaps 12-16), but that this was balanced by 10% who would have been happy with three to four sessions.
Conclusions
The Eurostat statistics cited at the start of this article also show that the highest rates of work-related stress are among the age group of 35-44, which was reflected in the age range for the first police cohort. The Eurostat statistics also revealed that more than 10% of those reporting work-related stress, depression or anxiety are affected by at least one other work-related illness. Although this data was not formally collected within the study – many in the study reported somatic symptoms such as back pain, headaches and stomach troubles, while others were suffering from and being treated for physical injuries sustained in the course of duty.
Given this, it is perhaps not surprising that police officers and staff need effective counselling and psychotherapeutic support, and that they must be able to make good use of it. The figures for this study suggest this is the case.
Bearing these points in mind, the key findings of this study can be summarised as:
- Cognitively-based brief therapy of eight one-hour sessions is useful to staff off sick due to work-related stress, depression and anxiety
- This type of scheme is demonstrably effective in getting 80-90% of staff with these types of problems back to work
- Cognitively-based therapy is shown to produce significant reductions in psychiatric symptoms. It is particularly effective on measures of anxiety and depression
- Staff off-sick found this type of therapy both an acceptable and effective treatment in helping them return to work
- Staff found it helpful to seek treatment from a private scheme.
Mark Lawson Dunn is a consultant psychotherapist at The Bridge Psychotherapy & Counselling Service.
Dr Eileen Cahill-Canning is senior physician at the Metropolitan Police Service
References
1. Strategy for a healthy Police Service 2002, www.policereform.gov.uk/implementation/healthypolice.html
2. Office for National Statistics/Health and Safety Executive (2001) Self-reported work-related illness in 1998/99. Results from Eurostat ill health module in the 1999 Labour Force Survey summer quarter
3. Ryle, A and Kerr, IB (2002) Introducing Cognitive Analytic Therapy: principles and practice. Wiley and Sons, Chichester
4. Beck, AT (1976) Cognitive therapy and the emotional disorders. NY, International Universities Press
5. Beck, Ward, Mendelsohn, Mock and Erbaugh (1961) An inventory for measuring depression. Archives of General Psychiatry, 4. 561-571
6. Beck, Epstein, Brown and Steer (1988) An inventory for measuring clinical anxiety. Journal of Consulting and Clinical Psychology. 56 (6) 893-897
7. Derogatis, L & Melisaratos, N (1993) The Brief Symptom Inventory; an introductory report. Psychological Medicine. 13 (3) 595-605
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