STRESS MEDICINE, VOL. 10: 151-157 (1994)

PSYCHIATRIC MORBIDITY IN POLICEMEN AND THE EFFECT OF BRIEF

A PILOT STUDY PSYCHOTHERAPEUTIC INTERVENTION -

RONALD S. DOCTOR Portman Clinic, 8 Fitzjohns Avenue, London NW3 SNA, UK

DAVID CURTIS Accrdemic Depurtment of Psychiatry, St Mary's Hospital Medical School, Imperial College of Science, Technology and

Medicine, London. UK

GEOFFREY ISAACS Academic Department of Psychiatry, Charing Cross Hospital, London. UK

SUMMARY

The level of psychiatric morbidity and perceived sources of stress among police officers were investigated using the General Health Questionnaire (GHQ) and a stress situation questionnaire, which were sent to 171 officers. Half of the responders were invited to attend group counselling sessions weekly for 12 weeks. Outcome measures studied were a second GHQ completed at the end of the treatment period and the amounts of sick leave taken in the 12-week period before, during and after the treatment period. The results were that 61 people returned the first GHQ of whom 59 were male and of whom 14 were classed as 'cases'. Of the 31 assigned to the treatment group, 22 attended at least one session. Responses to the stress situation questionnaire and the content of counselling sessions tended to confirm the impression that internal aspects of the organization were viewed as prime sources of stress and dissatisfaction. There were no significant changes in GHQ score within or between groups, nor were there significant differences in the amount of sick leave taken. Nevertheless the sessions appeared to be valued and we conclude that this sort of intervention is at least feasible. We recommend that similar studies measure psychiatric morbidity during treatment and at follow-up, rather than immediately after finishing, when reactions to this termination are prominent.

KEY WORDS-Police, group, GHQ, therapy, counselling, stress.

Police work represents an example of an occupa- tion which might be expected to expose people to high levels of stress. Police officers concerned with the detection of crime and apprehension of suspects are obliged to deal with members of the public who may hold them in low esteem or be overtly hostile, and at times this results in exposure to real physical danger. Other aspects of police work might also be deemed stressful, for example mediating in con- flict, dealing with the victims of crime and casualties of road traffic accidents, and breaking news to bereaved relatives.

Most studies in this field have been carried out

Correspondence to first author.

on American police forces. Walrod found that mor- bidity and mortality figures for police officers indi- cate that they do indeed suffer from more stress- related health problems than most other workers.' A study by Blackmore of 2300 police officers in 29 departments showed that 37 per cent had serious marital problems, 36 per cent serious health prob- lems and 23 per cent serious alcohol problems2 However, in terms of visits to public mental health facilities, police ranked well below other occupa- tions. This work suggests that there is a relative unwillingness to seek help in dealing with stress. This unwillingness has a damaging effect, and might be to a certain extent institutionalized. Offi- cers would attempt to conceal stress-related

Received 28 July I993 Accepted 7 January 1994

CCC 0748-8386/94/030151-07 0 1994 by John Wiley & Sons, Ltd.

152 R. S . DOCTOR, D. CURTIS AND G. ISAACS

problems and the organization would collude in ignoring them. Violanti and colleagues related the high alcohol intake of police officers to stress, and subsequently showed that rates for cancer and sui- cide were raised, the latter being almost three times as prevalent as in the general pop~lation.'.~

Several other researchers have commented on the high level of occupational stress attaching to police work and the strategies used for dealing with it. Hageman wrote in terms of officers becoming detached and emotionally uninvolved, and des- cribed how this mechanism becomes stronger with increasing length of service until it seems to become incorporated into per~onality.~ Kirkham also found that police who work regularly under stress- ful conditions develop a defence mechanism by which they repress unacceptable thoughts and con- sciously assert confidence and aggression as a means of coping with underlying feelings of fear and anxiety, feelings that would be incapacitating were they to reach awareness6 Reiser described a particular type of organizational stress on police officers which he termed the 'John Wayne syn- d r ~ m e ' . ~ There is an expectation of an authori- tarian and tough outlook on life and a constant pressure to appear efficient. These militate against expressing emotion or taking any action which might make the police officer appear weak or in- effective. Bonifacio has given a psychodynamic formulation elucidating the internal conflicts which mean that expression of emotions cannot be toler- ated.8 All these authors regard this denial in the face of stress-provoking situations as problematic and some suggest that it contributed in part to observed high levels of ulcers, myocardial infarc- tion, alcohol abuse and suicide.

Although one might expect that it is mainly exter- nal factors which make police work stressful, in fact police officers seem also to complain of marked stress resulting from sources within the institution. Kroes offered the view that police suffer severe strain as a result of the job and although the line of work is dangerous, this affects police morale and health less than other factors.' Police feel 'hassled' by their own administrators, by judges who repri- mand them, by attorneys who humiliate them and by a public that is openly contemptuous. In addition, much stress originates in the department's organizational structure. Blackmore proposed that four types of stress are frequently found in police work: (1) external stress related to negative public attitudes towards police or inability to stem crime; (2) organizational stress such as low pay or arbi-

trary rules; (3) performance-related stress including work schedules, boredom or fear; and (4) personal stress such as marital problems or minority affilia- t iom2 Spielberger and colleagues developed the Police Stress Survey, and using this found that administrative and organizational factors were as important sources of stress as were physical danger and emotional distress brought on by police work." Other studies have found that organizational and management issues are perceived as being the most important sources of In a British study, Alexander and Wells found that police officers did not suffer detectable ill effects following body hand- ling after a major disaster, but that during routine work the factors which seemed to be much more potent causes of stress, illness and absenteeism were principally organizational and managerial ones.I3 Examples of these were paperwork, lack of per- sonal recognition, obstacles at work and lack of opportunity to display initiative and discretion. However, they also suggested that organizational and managerial factors could act as powerful anti- dotes to the deleterious effects of unpleasant tasks (such as body-handling), and this claim was reiter- ated in a follow-up study 3 years after the original incident . I 4

Some authors have suggested psychological interventions aimed at relieving stress among police officers. Klyver described a peer-counselling pro- gramme and thought that while officers were un- likely to seek professional help, they might feel more comfortable discussing problems with a fel- low-officer. " Graf suggested that a psychological counsellor might be engaged to provide counselling where necessary.16 However, he feared that this would meet with a large amount of resistance and uptake would be low. Ellison and Genz advocate counselling based on cognitive-behavioural tech- n ique~.~ ' However, we have been unable to find examples in the literature of any outcome studies which might provide evidence for the efficacy of such psychological interventions in the police force.

The study reported here was instigated partly by the police force, which had become concerned about high levels of stress-related problems among officers. The aims were to assess the levels of occu- pational stress and the natures of the stressors and to examine the feasibility of reducing stress-related problems by providing group counselling sessions. These sessions aimed to supply a forum for ventila- tion of feelings in a supportive atmosphere so as to provide a safe space for the expression of emo- tion and reduce the need for denial.

PSYCHIATRIC MORBIDITY IN POLICEMEN

Table I-Stress situation questionnaire. Items have been rearranged into rank order according to their perceived importance as sources of stress. 0, no stress; 1, minimal stress; 2, moderate stress; 3. marked stress: 4. severe stress

153

Mean SD

Effect of transfers under new regulations on your family 2.35 1.56 Effect of transfers under new regulations on you 2.23 1.56

Effect of leave cancellation 1.75 1.34

Situations involving the issue of firearms 1.39 1.27 Discipline procedures or the serving of a form 163 1.38 1.24 Attending magistrates and crown court hearings 1.36 1.03

Attending emergency calls with insufficient information 1.30 1.03 Informing relatives of a bereavement 1.27 0.92 Dealing with dead bodies 1.11 1.04 Paperwork - preparation of reports, etc 0.95 0.88 Dealing with the mentally ill 0.89 0.82

Using the new stop and search procedure 0.83 0.92 Patrolling alone at night on foot 0.76 0.86 Patrolling alone at night in a vehicle 0.75 0.87

Effect of shift work on your family 1.96 1.12

Effect of shift work on you 1.52 I .22

Employment on public order/football duties 1.32 1.05

Seeking help from senior officers 0.84 1.02

Seeking help from colleagues of same rank 0.25 0.55

METHOD

Following an invitation by a senior police officer, a number of meetings were set up with the Police Federation representatives of the officers at two neighbouring police stations in order to address the issue of stress-related problems. From these preliminary discussions a stress situation question- naire was devised to allow officers to report the degree of stress they experienced subjectively as arising from various aspects of police work. This contained 19 items which are presented in Table 1. Each item was to be rated on a five-point scale according to its perceived importance as source of stress. All 171 male and female uniformed officers of constable and sergeant rank at the two stations were sent an explanatory letter accompanied by a 30-item General Health Questionnaire18 and the stress situation questionnaire, to be returned to a sealed ballot box.

Of the 171 GHQs that were sent out 61 (36 per cent) were returned, and these responders were randomly allocated to control treatment groups. Members of the treatment group were invited to attend a 12-week course of 1 -hour group counsell- ing sessions led by a registrar in psychiatry. Attend- ance at these sessions was not obligatory but was encouraged by giving an equivalent amount of time off work in lieu. The sessions took place in the

evening in the central station house on the same day at the same time of each week. Initially there were three groups, but as attendance declined dur- ing the study period these were amalgamated into two. The results of the stress situation question- naire were used to form an initial basis for discus- sion. The sessions were unstructured. The honest expression of thoughts and feelings in a safe environment was encouraged, and particular emphasis was put on the fact that all material was confidential. A general aim was to promote the ven- tilation of feelings in relation to police work and to reduce denial. Interventions attempted to ensure a healthy group culture which would support emotional expression, and aimed to elucidate and validate the feelings of participants.

Basic demographic data were collected on all 17 1 subjects, as were their sick leave records for the 12 weeks leading up to the study. The 61 responders were sent a second letter with a second GHQ after the last of the counselling sessions, and for them sick leave records were also collected for the two 12-week periods during and after the active phase of the study.

The GHQ results were scored in two different ways. The more conventional method described in the manual is to score as 1 responses of ‘Rather more than usual’ and ‘Much more than usual’, with a threshold to identify cases at a total score of 5

154 R. S . DOCTOR. D. CURTIS AND G . ISAACS

or above. A different method has been recom- mended to detect chronic illness by Goodchild and Duncan-Jones,” and for this a response of ‘No more than usual’ is also scored as 1 and the thresh- old score is taken as 13 or above.

Appropriate non-parametric tests were used to compare the data between the responders and non- responders, and between the active treatment and control groups. Chi-squared tests were used to compare categorical data in contingency tables, Wilcoxon’s rank sum test was used to compare quantitative measures between groups and Ken- dall’s rank correlation coefficient was used to exam- ine the relationship between quantitative measures. Two-tailed significance levels were used through- out.

RESULTS

The 61 subjects who returned the first GHQ and the stress situation questionnaire differed from the 110 non-responders in a number of ways (Table 2). They were older (p < 0.05), had been in the force longer (p < 0.01) and were more likely to be married (p < 0.05) and male (p < 0.05). In fact, only two of the responders were female although there were 18 women among the original 171 targeted.

Table 2

Responders Non-responders

Age Mean, SD (range) 35.0, SD 8.2 32.1, SD 10.0

Wilcoxon’s rank sum,p < 0.05

Years in force Mean, SD (range) 12.7, SD 7.8 9.2, SD 8.7

Wilcoxon’s rank sum,p < 0.01

Married 72.1% 52.7% Chi-squared, 1 df,

(22-52) (20-55)

( 1-29) (1-31)

p < 0.05 Male 96.7% 85.5% Chi-squared, 1 df,

p < 0.05

The responses given to the stress situation ques- tionnaire are shown in Table 1.

Using the conventional method of scoring the GHQ, the two women reported GHQ scores of 0 and 1. The men had a mean GHQ score of 3.0 (SD 4.6), and 14 of them (23.7 per cent) could be classed as ‘cases’ on the basis of having a score of 5 or higher. There was no significant tendency for the GHQ score to be correlated with sick leave, nor for GHQ cases to have more sick leave than non-cases.

Using the modified method of scoring the GHQ to detect chronic illness, the two women had scores of 0 and 12. The men had a mean score of 8.5 (SD 10.11). Twenty-three (39 per cent) had a score of 13 or above and would therefore be classed as cases according to this method.

Thirty-one subjects were allocated to the treat- ment group and 29 to the control group. There were no significant differences between the groups following allocation in any of the variables studied. Of the 31 allocated to active treatment 22 (71 per cent) attended at least one session, and for these 22 the mean number of sessions attended was 5.4 (SD 2.7). Attendance was not correlated with initial GHQ score, but it was correlated with age (Ken- dall’s tau = 0 . 2 9 , ~ < 0.05).

Subjects attending the group counselling sessions tended to devote much of the time to airing dissatis- factions about various aspects of the work. The main topics which emerged were the hierarchical organization of the police force and the lack of support within the organization, seeing younger, frequently better educated officers being promoted ahead of them, the boredom of walking the beat, negative public attitudes towards the police and the frustration of arresting suspects without secur- ing a conviction. It was striking that many of the complaints and subjective sources of stress seemed to pertain to intrinsic factors within the organiza- tion rather than to extrinsic factors such as dealings with the public and suspected criminals. Attenders seemed generally to value the sessions, although as the end of the treatment period approached there was some expression of disillusionment with them. This disillusionment seemed especially marked among younger subjects.

Twenty-four (75 per cent) of the treatment group and 22 (76 per cent) of the control group returned the second GHQ. There was no significant differ- ence between the treatment and control group for this second GHQ score, nor for the change of GHQ score. There was a slight tendency for those in the treatment group to report higher GHQ scores than before the treatment period (Wilcoxon’s rank sum,

PSYCHIATRIC MORBIDITY IN POLICEMEN 155

p = O.l), but the interpretation of this is compli- cated by the fact that in the treatment group those returning the second GHQ tended to have had lower GHQ scores before treatment than those who did not (p = 0.1). The change in GHQ score did not correlate with the number of sessions attended. There were no significant differences in the amount of sick leave taken between treatment and control groups. Nor were there differences within the treat- ment or control group between the 12-week periods before, during and after treatment. However, there was a non-significant trend for the amount of sick leave taken by the treatment group to be reduced during the weeks when the counselling sessions were being held.

DISCUSSION

The results of the GHQ confirmed that there was what appears to be a fairly high level of psychologi- cal morbidity among those subjects who returned it. However, since the response rate was only 36 per cent it is not possible to say how representative these subjects were of the group as a whole. The fact that they differed in a number of variables from the non-responders, especially in age and length of service, may suggest that we were dealing with a non-representative subgroup. However, the vari- ables that distinguished the responders from non- responders were not correlated with GHQ score within the responders. It is also of note that although the levels of ‘caseness’ detected may appear to be high, in fact the results are not very different from those reported in a large sample of civil servants for whom the Goodchild and Dun- can-Jones scoring method yielded an overall mean GHQ score of 9.5, with 31 per cent of subjects being classed as cases.’’

Both the stress situation questionnaire and the content of the counselling sessions themselves sug- gested that the police organization itself was sub- jectively perceived as being a major source of occupational stress. This is in line with the findings of other workers mentioned above, for example Alexander and Wells.” Again it is possible that the responders were not representative of the group as a whole, and that in fact we were dealing largely with an older, disaffected subgroup who felt par- ticularly resentful about their treatment by the organization. On the other hand, these older sub- jects might be the very ones who have the more pathological defence mechanisms - denying the

impact of external stressors but complaining of their frustrations with their interactions with the institution to which they belong.

One should not necessarily take complaints about the organization at face value. Although its procedures might appear to be rigid and to deny individual expression and autonomy, these same procedures may in fact protect members of the organization from assuming excessive personal res- ponsibility and from experiencing overwhelming anxiety from external sources. It may even be that the organization comes to act as a container for many of the anxieties and persecutory experiences unavoidably associated with police work, and that subjects who perceive the organization as persecu- tory are actually responding unconsciously to these contents.

The outcome measures we used failed to show a definite objective benefit of the counselling ses- sions, and it is indeed possible that these were in- effective. It may be that non-specific supportive interventions have little value and it might be that more structured interventions such as the cognitive- behavioural treatments advocated by Ellison and Genz” would have produced a more measurable effect. It may also be that clinical interventions generally can only be of limited benefit and that efforts should additionally be directed towards management and or anizational issues to reduce the sources of stress! Although there was a slight trend towards reduced sick leave in the treatment group during the treatment period this was not statistically significant, although this may be due to the small numbers studied. The other outcome measure that we used, GHQ score, may also be too insensitive to changes in issues such as anger and frustration which may be important to this group. The GHQ score of the treatment group if anything tended to increase rather than decrease. A complicating factor is that those subjects who responded to the second GHQ tended to have lower GHQ scores originally and thus had more room for deterioration and less for improvement.

Assuming, however, that there was a real trend for the GHQ scores to rise in the treatment group, a number of explanations are possible. Of course, one possibility is that the counselling sessions were in some way harmful and actually increased rather than decreased the stress of those participating in them, perhaps by focusing on stressful aspects of the situation without offering any hope for their amelioration. Another possibility is that there was a decrease in denial that might be regarded as bene-

156 R. S. DOCTOR, D. CURTIS A N D G . ISAACS

ficial, and that subjects were more ready to acknowledge to themselves and others the prob- lems and stresses from which they suffered. The fact that diminishing attendance necessitated the amalgamation of three counselling groups into two may have reduced the cohesiveness of the groups and this may to some extent have undermined their effectiveness.

A third possibility is that what we were measur- ing was a short-term transient deterioration occur- ring at the end of the group. No specific work was done with termination issues and subjects attending the final sessions expressed disillusionment which was most marked among those who had attended well. This could be seen as an expression of anger at being deserted, and given that the groups were designed to be supportive rather than to produce fundamental change one could argue that such anger was not unjustified and that a transient deter- ioration in psychological well-being would be expected. de Mare and Kreeger state that it might be difficult to assess the results of group therapy in the early period following the ending of treat- ment, because of the ongoing emotional conflict at this time.** As with the process of mourning, resentment and anger may be felt and expressed towards the group or conductor; it may be better for these feelings to come out rather than be pushed away by denial, or overidealization of the group experience. Often it is not until much later, perhaps 1 year after the completion of treatment, that the full benefits are to be seen. In the present case it might have been appropriate to have had subjects complete an additional GHQ in the middle of the treatment period to assess the effect of the sessions at a time when they were ongoing, and perhaps also at follow-up to assess any lasting effects.

Although objective measures did not prove the value of the counselling sessions, subjects attending them in general said that they found them helpful. They especially valued the opportunity to express their problems and the experience of universality - the discovery that others shared similar prob- lems. The sessions were also valued by the superior officers who had helped set up the project, and they expressed considerable enthusiasm and a wish for the groups to continue. We did not come across the extreme resistance to professional intervention that was predicted by Graf.I6 A substantial propor- tion of those invited did attend at least some ses- sions, despite not being selected in any way apart from through returning the questionnaire. Nor was

there any suggestion of stigma in attending the groups nor in discussing personal problems.

One might expect that workplace groups of this nature would be essentially supportive and would not produce lasting change after they had disconti- nued. It is therefore necessary to consider what kind of arrangements might be made to provide such a facility on an ongoing basis. From our exper- ience we might expect that such a group conducted during working hours might be attended by on average 20-30 per cent of staff. It is possible that groups could run on a self-help basis without any external input (as is the case for many staff support groups in psychiatric units), or it might be desirable to provide a facilitator from one of the helping professions, or this role might be filled by a suitably trained senior officer. We would conclude that such groups are feasible to run in practice, are valued generally by the people who attend them and are, on theoretical grounds at least, likely to be of bene- fit to police officers and by implication to the public they serve.

REFERENCES

1. Walrod, T. H. Causes of stress to police officers detailed. Nut. Sherzfl1978; 30.5: 16-29.

2. Blackmore, J. Are police allowed to have problems of their own? Police Mag. 1978; 1.3: 47-55.

3 . Violanti, J., Marshal, J. and Howe, B. Stress, coping and alcohol use - the police connection. J. Police Sci. Admin. 1985; 13.2: 106-1 10.

4. Violanti, J., Vena, J. and Marshall, J. Disease risk and mortality among police officers - new evidence and contributing factors. J. Police Sci. Admin. 1986; 14.11: 17-23.

5 . Hageman, M. J. C. Occupational stress of law enforcement ojicers and marital andfamilial relation- ships. Doctoral dissertation, Washington State University, Pulman, Washington, 1977.

6 . Kirkham, G. L. Metamorphosis. In: Job Stress and the Police Oficer: IdentiJying Stress Reduction Tech- niques: Proceedings of Symposium. Kroes, W. H. and Hurrel, J. J. (Eds) US Government Printing Office, Washington, 1975.

7. Reiser, M. Some organisational stresses on police- men. J. Police Sci. Admin. 1974; 2.2: 156-159.

8 . Bonifacio, P. The Psychological Eflects of Police Work - a Psychodynamic Approach. Plenum Press, New York and London, 1991.

9 . Kroes, W. H. Psychological stress in police work. Presented at Joint Colloquium of the Illinois Depart- ment of Mental Health and Northwestern University Medical School, 1974.

10. Spielberger, C., Westberry, L., Grier, K. and Green-

PSYCHIATRIC MORBIDITY IN POLICEMEN 157

field, G. Police Stress Survey - Sources of Stress in Law Enforcement. University of South Florida Human Resources Institute, Tampa, Florida, 1981.

11. Cooper, C., Davidson, M. and Robinson, P. Stress in the police service. J. Occuput. Med. 1982; 24: 30- 36.

12. Brown, J. and Campbell, E. Sources of occupational stress in the police. Work Stress 1990; 4 305-318.

13. Alexander, D. A. and Wells, A. Reactions of police officers to body-handling after a major disaster. A before and after comparison. Brit. J. Psychiut. 1991;

14. Alexander, D. A. Stress among police body handlers: A long-term follow-up. Brit. J. Psychiut. 1993; 163: 806-808.

15. Klyver, N. Peer counselling for police personnel: A dynamic programme in Los Angeles Police Depart- ment. Police Chief 1983; 50.11: 66-68.

16. Graf, F. The relationship between social support and

159 541-555.

occupational stress among police officers. J. Police Sci. Admin. 1986; 14.3: 178-186.

17. Ellison, K. W. and Genz, J. L. Stress and the Police Offcer. Charles C. Thomas, Illinois, 1983.

18. Goldberg, D. P. The Detection of Psychiatric Illness by Questionnaire. Oxford University Press, London, 1972.

19. Goodchild, M. and Duncan-Jones, P. Chronicity and the General Health Questionnaire. Brit. J .

20. Pilgrim, J. A., Stansfeld, S. and Marmot, M. Low blood pressure, low mood? Brit. Med. J. 1992; 304: 75-8.

21. Ainsworth, P. B. and Pease, K. Police Work. British Psychological Society and Methuen, London and New York, 1987.

22. de Mare, P. B.and Kreeger, L. C. Introduction to Group Treatments in Psychiatry. Butterworths, Lon- don, 1974.

Psych. 1985; 146: 55-61.