High Court of Justice in Northern Ireland Queen's Bench Division Decisions

The Importance of Context

"the horrific and widespread violence which characterised the early years of the 70s has declined to a very considerable extent."

And the equivalent document for 1980 contained the following remarks:

"… 1980 was in fact the least violent year in Northern Ireland for a decade and there was an improvement in regard to serious crimes of all types."

The Relevant Law

"We do not accept these submissions.  As is apparent from the way is which the judgment in Hatton is expressed and as Lord Walker pointed out in Barbour the guidance must be read as such and not as anything like statute.  Each case will depend on its own facts.  Those parts of the Hatton judgment relied on by Mrs Outhwaite were primarily intended to help judges resolve the issue as to whether an employer ought to have foreseen the risk of psychiatric injury attributable to stress at work.  The guidance recognises that such injury is more difficult to foresee than physical injury.  The question of whether the particular employee has shown indications of impending harm to health is a very relevant question when considering a situation where the employer has not in fact foreseen the risk of psychiatric injury and the employee's workload would not ordinarily carry a foreseeable risk of such injury."

That was clearly not the case in Melville in which the only evidence before the court was that the employer plainly had foreseen that employees who were exposed to particular traumatic incidents might suffer psychiatric injury. 

Foreseeability

"What then is it reasonable to expect the employer to do?  His duty is to take reasonable care.  What is reasonable depends, as we all know, upon the foreseeability of harm, the magnitude of the risk of that harm occurring, the gravity of the harm which may take place, the cost and practicability of preventing it and the justification for running the risk (see the off-quoted summary of Swanwick J in Stokes v Guest, Keen and Nettlefold (Bolts and Nuts) Limited [1968] 1 W.L.R. 1976 at 1983)."

In closing, both sides drew my attention to the passage in the 19^th edition of Clerk & Lindsell on torts at paragraph 8-16 at which the learned authors observed:

"The criterion of reasonable foreseeability focuses on the knowledge that someone in the Defendant's position would be expected to possess.  The greater the awareness of the potential for harm, the more likely it is that this criterion will be satisfied."

Foreseeability by Whom?

Foreseeability of What?

(a)        existence of a recognisable stressor that would evoke significant symptoms of distress in almost everyone;

(b)       re-experiencing of the trauma as evidenced by at least one of the following:

            (i)        recurrent and intrusive recollections of the event;

            (ii)       recurrent dreams of the event;

(iii)     sudden acting or feeling as if the traumatic event was reoccurring, because of an association with an environmental or ideational stimulus.

(c)        numbing of responsiveness to or reduced involvement with the external world, beginning some time after the trauma as shown by at least one of the following:

(i) markedly diminished interest in one or more significant activities;

(ii)       feeling of detachment or estrangement from others;

(iii)      constricted affect.

(d)       at least 2 of the following symptoms that were not present before the trauma:

            (i)        hyper alertness or exaggerated startle response;

            (ii)       sleep disturbance;

            (iii)      guilt about surviving when others have not or about behaviour                    required for survival;

            (iv)      memory impairment or trouble concentrating;

            (v)      avoidance of activities that arouse recollection of the traumatic                       event;

            (vi)     intensification of symptoms by exposure to events that                                   symbolise or resemble the traumatic event.

In order for the condition to be diagnosed as chronic the symptoms must last for 6 months or more and in cases where the onset of symptoms is at least 6 months after the trauma the delayed condition is the appropriate diagnosis.  An acute form of the condition is diagnosed where the onset of the symptoms takes place within 6 months of the trauma and the duration of the symptoms is less than 6 months.

Foreseeability When?

"A4.  By 1972 in view of the escalating level of violence in Northern Ireland generally and towards the police in particular and in view of the increasing involvement in and exposure to traumatic incidents of police officers the Defendant ought to have ensured that management of the RUC at the appropriate level [namely a level at which suitable policy decisions could be made and the necessary instructions/orders issued and enforced] was provided with and made aware of the contents of (a) all literature in relation to the psychiatric/psychological aspect of occupational health (b) all literature in relation to psychological services available within other police forces particularly Law Enforcement Agencies in the United States of America (c) all literature in relation to the known and potential effect on personnel of stress (d) all literature in relation to the known and potential effect on personnel [both in general and in relation to personnel already exposed to stressful working conditions] of exposure to or involvement in one or more than one traumatic incidents."

The Plaintiffs pleadings went  on to allege that from about the same time the Defendants should have carried out studies into the effects on RUC officers of exposure to or involvement in traumatic incidents, that such studies and relevant literature should have been repeated on a continuing basis and that, had the literature been obtained and the studies carried out, the Defendants would have known or ought to have known that a large number of officers were suffering or were likely to suffer from one or other of the relevant psychiatric disorders.  At paragraph B6 of the same document the Plaintiffs alleged:

"B6. The Plaintiffs say that the Defendants were in breach of their continuing duty of care to the Plaintiffs in not making adequate mental health provision for the Plaintiffs from in or about 1972.  Adequate mental health provision (assuming detection) would have included the referral of all officers involved in the traumatic incident or incidents for assessment and where necessary intervention/treatment."

The Case for Earlier Foreseeability

[27]      During the course of his report for 1972 the Chief Constable noted that the number of days lost to the force through sickness and injury revealed an alarming increase in the previous year's figures.  As gross figures these were 70,158 compared with 45,756 in 1971.  The main causes of "ordinary illness" were noted as influenza, common cold, stomach upsets, nervous debility and tonsillitis.  Separate figures were not available in respect of each of these conditions.  Tables prepared by Professor Edgar Jones using a "days lost per officer" index confirmed an increase of approximately 42% from 11.2 in 1971 to 15.9 in 1972.  Thereafter the rate appears to have stabilised at an average of approximately 15 days per officer until raising again to 18.9 in 1978 before falling back again to the previous average levels.  A sustained increase was also recorded during the period 1988 to 1990.  A further table provided by Professor Jones indicated that the RUC was ranked between 3^rd and 18^th in terms of days absent through sickness and injury between 1980 and 1994 although caution is required when using figures provided by other UK forces for comparison with the RUC figures.

"28 in any case where – (a) having regard to the nature of the illness, resumption of duty is apparently being unduly delayed, or (b) a member is incapacitated for a period of 1 month, (c) for any reason it is considered that the Medical Officer's advice should be sought; a report will be forwarded to the Chief Constable in order that the case may be placed before the Medical Officer". 

In due course this provision was replaced by Force Order 22/83 which was entitled "Statutory Sick Pay Scheme Self-Certification (sick leave)".  Paragraph 7.4 of this scheme provided as follows;

"7.4 Referring of illness to the Force Medical Officer. 

In any case where; - (a) Having regard to the nature of the illness, resumption of duty is apparently being unduly delayed; or (b) a member is incapacitated for a period of one month; (c) for any reason it is considered that the Medical Officers advice should be sought; a report will be forwarded to the Chief Constable (Personnel) in order that the case may be placed before the Medical Officer".

Paragraph 7.6 of the same document provided:

"7.6 Frequent incapacity for duty. 

If a member is frequently incapacitated for duty, even for short periods, the person in charge of the station or branch will report the circumstances to the Sub-Divisional Commander/Head of Branch who will, in the first instance, on receipt of the file arrange to interview the member concerned to discuss his/her sickness report and ascertain if there are any underlying reasons other than ill health, which have a bearing on his/her frequent absences".

Annual reports provided by the Chief Constable for the period 1970 – 1980 demonstrated the way in which this system was used to monitor sickness absences.  During this decade the FMO to the RUC was also the Principal Medical Officer for the Medical Referee Service and both services were provided by the Department of Health and Social Services.  Members of the RUC who appeared to be suffering relevant symptoms would be referred by the FMO to Dr William Norris, a Consultant Psychiatrist, who carried out sessional work at Tyrone House, Ormeau Avenue, Belfast.  In addition, during that decade, Dr Norris was extensively involved in medico-legal work involving patients with psychiatric systems alleged to have been caused by terrorist incidents.

"(i)      affluence;

                        (ii)       alcoholism;

                        (iii)      marital instability;

(iv)      domestic/marital family stresses as a result of long and irregular hours on duty."

"… tendency for members of the Force to form closely integrated groups in that there is an inter-dependency necessary for operational duties, and a strong sense of camaraderie.  Sickness records and problems are often low in this group but it is important to monitor individuals who may come under stress in the process of their duties, and who may not wish to express views on this subject either to their colleagues or senior officers through a sense of loyalty but at the same time may be developing stress symptoms."

Memos produced by other persons attending this working lunch were generally consistent with that produced by Dr Norris.  The secretary, Mr G M Barr, staff officer recorded that "all present agreed that only in exceptional cases did danger or unpleasant duties appear to be a direct cause of stress" but the reference there was to general stress rather than psychiatric problems which Dr Norris had advised were "minimal" in those districts or areas in which officers were most vulnerable.

The Northern Ireland Literature

"It is impossible to ascertain what proportion of people involved in bomb explosions develop psychological symptoms, but it would seem probable that the majority have some subsequent emotional disturbance.  Those in the present study are self-selected to the extent that they are those who sought medical advice, but nevertheless are probably a fairly representative sample of the psychological casualties."

In a final paper entitled "Civil Violence – The Psychological Aspects" published in 1979 Dr Lyons carried out a review of the previous publications and relevant literature and expressed views as to the affects of terrorist violence upon a number of different groups.  He considered that those involved in bomb explosions, that is those whom he had studied as a result of referral from GPs, solicitors etc, probably represented a fairly random sample of the population since bombs were liable to explode in a wide variety of places but he added the specific caveat that it was impossible to ascertain what proportion of people who had been involved in explosions did not develop psychological reactions. In the "discussion" section of this paper he said:

"It is impossible to ascertain what proportion of people involved in bomb explosions develop psychological symptoms, but it would seem probable that the majority have some subsequent emotional disturbance." 

In view of his earlier remarks, it is difficult to see how he reached that conclusion unless the reference to "emotional disturbance" is taken to include normal transient reactions such as the anxiety reaction to which he referred earlier as being "appropriate to the dangerous situation". In an earlier paper entitled "Psychiatric Sequelae of the Belfast Riots" relating to patients seen by 3 general practices in West Belfast who had been involved in riot situations between August 15^th and the end of September 1969 Dr Lyons had concluded that the commonest presentation was what could be termed "normal anxiety" reporting that:

"In the community those who develop symptoms tended either to develop a short lived 'normal' anxiety reaction or in those with a previous psychiatric history the illness pattern usually repeated itself."

[45] In the course of giving his evidence Dr Bell candidly conceded the difficulty he faced in disentangling the affect of hindsight and his own subsequently developed strongly held views when attempting to report factually in relation to events and opinions almost 30 years ago.  In the course of direct examination Mr Irwin QC drew Dr Bell's attention to the symptomatology and diagnostic descriptions contained in Dr Lyon's 1979 paper "Civil Violence – The Psychological Aspects" and Dr Bell expressed his understanding of the contemporary approach in the following terms:

"The spectrum of people who had been subjected to what we now call a traumatic event, the vast majority of them would have been seen as suffering from a so-called normal stress reaction or normal anxiety reaction, a brief stress or anxiety reaction lasting a few days to a few weeks.  Large numbers of people would have fallen into this so-called normal reaction category.  A smaller number would have fallen into the 2 diagnostic categories that Dr Lyons mentions in this paper, namely anxiety and reactive depression and for me that would have been the practice generally amongst psychiatrists that I worked with in the late 70s/early 80s.  People who were subjected to trauma, a large number of them would have normal reactions, a smaller number developed anxiety and reactive depression."

When asked by Mr Hanna QC, in cross-examination, to comment upon paragraph 2.4 of the NICE Guidelines on PTSD 2005 recording the aetiology of PTSD prior to DSM-III in 1980 Dr Bell agreed that it reflected the attitudes which he had encountered when delivering papers between 1986 and 1989 although it was not particularly well expressed.  He went on to say:

"I think the real situation was much less black and white than that and, as I have said earlier, as this statement says, the vast majority of people after a traumatic event developed a transient reaction, a smaller number developed anxiety and depression and it was assumed that those people who developed anxiety and depression had some underlying vulnerability or were towards that end of the spectrum." 

He went on to agree with the suggestion put by Mr Hanna QC that some kind of underlying previous condition would have been presumed to be required for trauma to produce a chronic mental condition.  Dr Bell repeated this view to Mr Irwin QC in re-examination referring to the interaction between psychiatric vulnerability and adverse environmental stressors and saying:

"So I think there's a continuum of psychological strength and a continuum of severity of life events so that when psychiatrists interviewed people who had had traumatic events and saw that they had symptoms of anxiety and depression they diagnosed them as anxiety or reactive depression and then went on to assume that they must have some underlying constitutional vulnerability."

When asked by Mr Irwin QC if, therefore, it was his view that people thought only people with unstable personalities, pre-existing neurotic conflicts or mental illnesses would develop chronic symptoms he said:

"I think that's what we're stating.  I think that what most psychiatrists believed in those days was that people with personality disorders, with vulnerabilities as described here, would develop psychiatric illness with relatively minor stressors."   

However, he also said that most psychiatrists would have realised that with very severe or repeated traumatic events even the strongest psychological constituted individuals would have developed symptoms of anxiety or depression.  Doing the best that I can from a contemporary standpoint, aware of the dangers of hindsight, it seems to me that, had the Chief Constable consulted Dr Lyons between 1978 and 1981 he would have been advised that the vast majority of people exposed to a traumatic event, if they suffered any symptoms, would have suffered from a normal stress reaction or normal anxiety reaction lasting at most a few days to a few weeks.  A small number of people would have been diagnosed as suffering from reactive depression or anxiety and most psychiatrists would have assumed in such cases the existence of some form of underlying constitutional vulnerability or pre-disposition although there was a possibility that extremely severe or repeated traumas could produce symptoms of anxiety and depression in individuals with even the most strong psychological constitutions. 

The General Literature

 "It has and it hasn't.  It was an argument, it was an opinion, it was a prevalent trend at some point. It was then forgotten, and then people believed that trauma could not do more than reactivate peoples' previous trauma or vulnerabilities so it has been around forever, but it has not been the only interpretation of what people might experience in the aftermath of a traumatic event."

Professor Shalev agreed that in a paper entitled "Combat Stress Reaction" published in 1989 he and his co-author had written:

"Extreme behavioural and emotional reactions to combat have been known for centuries.  They can be divided into two groups: one is an immediate reaction to combat events (CSR) and the other is a prolonged condition that continues for a long time after the battle (PTSD) or stress response syndrome."

"In my opinion, there was much to inform a medical practitioner of the potential risks that the officers of the RUC were facing.  There was a substantial knowledge about the nature of traumatic reactions to stress and that these could not simply be dismissed as due to constitutional factors.  As would currently be the view, there are some individuals where the traumatic event leads to the onset of the disorder in the absence of any substantial pre-disposition.  Particularly with lower levels of traumatic exposure, personality and other risk factors are more likely to play a contributing role."

For his part, Professor Wessely summarised the text books to 1984 as follows:

"(a)        Overwhelming psychic trauma (although the word is never used in this context) can cause psychological symptoms.  These will be short lived

(b)        Prolonged reactions are not really related to the trauma, but their causes lie in childhood, genes, early upbringing, unresolved developmental conflicts and so on.  What is of interest is why the person has reacted in the way that they have, and the nature of the trigger is of little or no interest.  In all the text books I have studied there is hardly anything about the nature of the trauma, as we find in modern accounts of PTSD. 

(c)        Where they are not short lived, the most common explanation is compensation and/or secondary gain.

(d)        By the end of the 1970s and the middle of the 1980s, the influence of the British school of social psychiatry around Browne/Harris and the MRC Social Psychiatry Unit at the Maudsley is starting to be felt, mainly in the UK.  The general theme is how life events, especially those involving loss, can trigger or bring forward psychiatric disorders, but in those whose early life experiences had pre-disposed them to react in this way.    This literature is almost entirely UK. 

(e)        In contrast, the Vietnam experience is starting to be seen in the US.  The combat psychiatry literature is being re-discovered (it remains almost absent from all the UK text books), but the framework remains that overwhelming stressors do lead to breakdown, but this will be transient.  Treatment is always following the standard military psychiatry principles, and has little to no relevance to the civilian situation.

(f)         The arrival of PTSD as a result of the coup by the US psychiatrists opposed to the Vietnam War came as a surprise to the UK.  For some time little attention was paid, at least by the psychiatrists.  However, in the mid to late 1980s the literature started to expand, albeit largely with Vietnam papers.  The real trigger for the explosion of interest in the UK was the series of high profile disasters such as the Bradford fire, Herald of Free Enterprise and Kings Cross fire.  It is however possible that the steady stream of medico- legal cases arising out of the Troubles played a similar and slightly earlier role in NI." 

"The neuroses incidental to war alternate between being the most urgent topic of the times and being completely and utterly neglected.  Although there is no such thing as a specific neurosis of war those of a similar character that occur in peacetime are swallowed up in oblivion."

He went on to note that it was hard to find a province of psychiatry in which there was less discipline and that the relevant literature could only be characterised as anarchic.  He then continued:

"There is a widespread theory that war neuroses can only be a continuation of a pre-existing neurosis and that the war situation acts only as a precipitating agent.  Although it is true that a war situation can revive pre-existing syndromes heretofore dormant, it can also create new ones."

Writing in the American Handbook of Psychiatry Volume III First Edition 1966 chapter 54 Albert J Glass expressed the view that one of the major contributions of military psychiatry in World War I was repeated demonstrations showing that situational stress and strain could produce mental disorder in so-called normal personnel as well as those of neurotic predisposition but he also confirmed that, with the end of hostilities, the contribution of military psychiatry was largely disregarded.  He also recorded that following the cessation of hostilities in World War II military psychiatry, like civil psychiatry, ignored the lessons of war time experience with attention instead being focused on the then prevalent psycho-analytic concepts and practices. The linkage between warfare and interest in the relationship between trauma and mental disorder was also supported by Professor MacFarlane who referred to "lost knowledge" and the chapter headed "History of Trauma in Psychiatry" in the textbook that he edited in 1996, together with Bessel Van Der Kolk and Professor Weisaeth, referred to psychiatry suffering from periods of "marked amnesia" when well established knowledge was abruptly forgotten and the psychological impact of overwhelming experience ascribed to constitutional or intra-psychic factors alone.

"The fate of the category seems to have been tied to the history of warfare.  DSM-II was compiled during the relatively tranquil interlude between World War II and the Vietnam conflict.  Perhaps in the absence of military conflict and in the presence of a rather foolish optimism that did not contemplate its recurrence, the category no longer seemed necessary.  The Vietnam War, together with the dissatisfaction of psychiatrists interested in psychosomatic medicine and forensic psychiatry, soon provided convincing evidence for such a need.  The description of post-traumatic stress disorder in DSM-III was written to fulfil this need and to draw on the wide range of research which had been completed concerning this condition."

Professor Andreasen went on to acknowledge that at that time, 1980, the international nomenclature, as defined by ICD-9, referred only to acute reaction to stress which it defined as follows:

"Very transient disorders of any severity in nature which occur in individuals without any apparent mental disorder, in response to exceptional, physical or mental stress such as natural catastrophe or battle and which usually subside within hours or days."

She noted that this concept was nearly identical to gross stress reaction but conceptually quite different from PTSD and that the ICD-9 classification did not appear to provide for chronic reactions to severe stress in normal individuals such as had been recognised in European research, particularly in relation to investigation of concentration camp survivors.

"The diagnosis of PTSD was established to fill a gap in the prevailing mental health field by acknowledging that extremely traumatic events could produce chronic clinical disorder in normal individuals.  Although the idea that stress could contribute to psychiatric symptoms had been accounted for in previous diagnostic systems, those models primarily viewed enduring symptoms as being caused by pre-morbid vulnerability.  In DSM-I and DSM-II, for example, the categories of gross stress reaction and transient situational disturbance, respectively, were used to describe acute symptomatic distress following adversity, whereas more prolonged disorders were conceptualised as being anxiety or depressive neurosis.  Regardless of whether these conditions were considered as resulting from developmental fixation or genetic predisposition, the role of environmental stress was at best considered a non specific trigger that might serve to release, exacerbate, or prolong a predictable diathesis to psychiatric symptoms.  Thus, the primary philosophical shift involved in including PTSD in DSM-III was to create a diagnostic category that resolved a previous quandary of how to classify a chronic condition in normal people who develop long-term symptoms following an extremely traumatic event.  This formulation postulated a general concept of a `post traumatic stress disorder' and implied that PTSD involved a natural process of adaptation to extraordinarily adverse situations and that the pattern of symptoms did not depend on a constitutional vulnerability."

In a further article published in the Australian and New Zealand Journal of Psychiatry 2000 the same authors reviewed recent findings in the field of post traumatic stress disorder and examined their impact on conceptions of trauma-focussed clinical treatment.  In the course of that article Professors MacFarlane and Yehuda wrote:

"A major dilemma was posed for clinicians by the definition of PTSD in 1980 with the accompanying recognition that trauma survivors presented a unique range of reactions that could not be addressed using the prevailing models of treatments or explained by existing knowledge.  The lack of information at the time presented a major quandary for clinicians as to how to best manage patients and still remains an important issue in clinical practice." 

In the course of his cross-examination Professor MacFarlane expressed himself as feeling a little ashamed and embarrassed about this reference to the lack of information.  He accepted that, with hindsight he should not have made such a reference.  He also accepted that the "primary philosophical shift" noted in his paper with Professor Yehuda in 1995 had  not been reflected in either his first or second report for the trial and explained that, as a consequence of his further research, he felt that the 1995 and 2000 papers had overstated the degree of shift. Nevertheless, there can be little doubt that those papers were intended to reflect the authoritative views of these two well known experts at the time of publication.

"The first clear example of the new approach at work occurred in the late 1970s, when a coalition of psychiatrists in the Veterans Administration (VA) and Advocates for Vietnam-War Veterans propelled a condition called Chronic Post-Traumatic Stress Disorder (PTSD) into DSM-III.  It was, indeed, a perfect choice – itself a traumatic product, one might say of the Vietnam war and all the conflicts and guilts that experience engendered – and it opened the door of  the DSM to other and later disorders. 

Emotional distress during and after combat (and other traumatic events) has been recognised since the mid-19^th century.  The symptoms of `shellshock' as it came to be known in World War I, consist of a lingering anxiety, a tendency toward nightmares `flashback memories' of battle, and the avoidance of activities that might provoke a sensation of danger.  What was added after Vietnam was the belief that – perhaps because of a physical brain change due to the stress of combat – veterans who were not properly treated could become chronically disabled.  This lifelong disablement would explain in turn, such other problems as family disruption, unemployment, or alcohol and drug abuse." 

Professor McHugh referred to the apparently intractable problems manifested by the Vietnam Veterans in Westhaven Connecticut and the war veterans in Israel and went on to express the following view:

"After any traumatic event – whether we are speaking of a minor automobile accident, of combat in war, or of a civilian disaster like the Coconut Grove fire in Boston in 1942 – exposed individuals will undergo a disquieted, disturbed state of mind that takes time to dissipate, depending (among other things) on the severity of the event and the temperament of the victim.  As with grief, these mental states are natural – indeed, `built-in' species-specific – emotional responses.  Customarily, they wane over time, leaving behind scars in the form of occasional dreams and nightmares, but little more.

When a patient's reaction does not follow this standard course, one need hardly leap to conclude he is suffering from an `abnormal' or `chronic' or `delayed' form of PTSD.  More likely, the culprit will be a separate and complicating condition like (most commonly) major depression, with its cardinal symptoms of misery, despair, and self-recrimination.  In this condition, memories of past losses, defeats, or traumas are reawakened, giving content and justification to diminished attitudes about oneself.  But such memories should hardly be confused with the cause of the depression itself, which can and should be treated for what it is.  America's war veterans, who are entitled to our respect and support, surely deserve better than to be maintained in a state of chronic invalidism."

Professor McHugh went on to observe that while the new descriptive approach adopted by DSM 111 seemed, at first, significant progress, enhancing communications among psychiatrists, stimulating research and holding out the promise of a new era of creative growth in psychiatry, some 20 years later, the weaknesses inherent in a system of classification based on appearances – and contaminated by self-interested advocacy, had become glaringly evident.  He concluded his interesting article by observing:

"In its recent infatuation with symptomatic, push-button remedies, psychiatry has lost its way not only intellectually but spiritually and morally.  Even when it is not actually doing damage to the people it is supposed to help, as in the case of veterans with chronic PTSD, it is encouraging among doctors and patients alike the fraudulent and dangerous fantasy that life's every passing `symptom' can be clinically diagnosed and once diagnosed, alleviated if not eliminated by pharmacological intervention.  This idea is as false to reality, and ultimately to human hopes, as it is destructive of everything the subtle and beneficial art of psychiatry has meant to accomplish."

It is of course important to record that, while not doing so in perhaps quite such colourful terms, Professor MacFarlane himself has expressed considerable scepticism about the primary role attributed to trauma in the diagnosis of PTSD introduced by DSM-III which he considers to have been "exaggerated". 

"It is now recognised that the traumatic event is a major cause of the symptoms of PTSD.  Historically, this has been the subject of considerable debate.  Charcot, Janet, Freud and Breuer suggested that hysterical symptoms were caused by psychological trauma, but their views were not widely accepted (see reviews by Gersons and Carlier, 1992; Kinzie and Goetz, 1996; Van der Kolk et al 1996).  The dominant view was that a traumatic event in itself was not a sufficient cause of these symptoms, and experts searched for other explanations.  Many suspected an organic cause.  For example, damage to the spinal cord was suggested as the cause of the `railway spine syndrome', micro-sections of exploded bombs entering the brain as the cause of `shellshock' and starvation and brain damage as causes of the chronic psychological difficulties of concentration camp survivors.  Others doubted the validity of the symptom reports and suggested that malingering and compensation-seeking in `compensation neurosis' were the major cause in most cases.  Finally, the psychological symptoms were attributed to pre-existing psychological dysfunction.  The predominant view was that reactions to traumatic events were transient, and that therefore only people with unstable personalities, pre-existing neurotic conflicts or mental illness would develop chronic symptoms (Gersons and Carlier, 1992; Kinzie and Goetz, 1996; Van der Kolk and others 1996)."

The guideline went on to record the introduction of PTSD in DSM-III and subsequently in ICD-10 which emphasised the causal role of traumatic stress disorders in producing psychological dysfunction even more clearly in that a specific group of disorders, `reaction to severe stress, and adjustment disorders', was created. 

The Development of the Occupational Health Unit

"The recognition of stress as a major factor in job-related disorders for policeman is only beginning to be considered as an area for concern by police forces throughout the world.  It is one reason so few studies have been initiated and funded on the subject to date.  As more emphasis is placed upon the nature of stress-related disorders in policemen, more work will undoubtedly be done which will make it an unavoidable matter for chief officers everywhere.  The American experience in this field would seem to have a relevance to the Royal Ulster Constabulary, the latter force being the only British police service which operates in somewhat similar conditions to American Law Enforcement Agencies …"

"On the surface, the obvious risks of becoming a policeman are known and accepted.  Underlying this is an awareness that the reality of continual stress is harder to cope with than they had imagined.  Various coping strategies are mentioned, many of which are not in fact coping strategies at all, but repression.  This is unhealthy and will lead to problems for the individuals concerned."

When the draft preliminary report was considered by the CHMF at their meeting on 2 May 1984 ACC Steenson renewed his argument that the draft had not provided enough information or statistical data to support the view that there was a major stress problem and suggested that if the Chief Constable considered that any such further investigation was merited such study could be undertaken internally by the force.  The Chairman pointed out that the primary purpose of the pilot survey was to test the validity and method of gathering information and since the sample had consisted of a small number of volunteers the pilot itself would be much too small to use as a policy guide.  The main study would permit more detailed investigation of selected areas and would lay a proper foundation for future strategy.  The minute recorded that a discussion then took place with a diversity of views being expressed but the majority of those present were in favour of proceeding with the main study. 

"(a)      To identify any key symptoms of occupational stress and to indicate the likely causes and potential impact of exceptional stress within the force."

The terms also included the aim of establishing the incidence in the force of illness which might be stress related.  In the "Background" section of the report the CHMF also recognised that the organisational culture or value system, particularly of a police force, might be an impediment in dealing with stress related illnesses, usually because of the "macho" image of policemen and the associated reluctance to admit strain/stress as a sign of weakness.  It was noted that the rank and file perceived evidence of such conditions as likely to be damaging to promotion and possibly a reason for scorn.  At paragraph 2.2 the report acknowledged that to have served as a policeman in Northern Ireland at any time over the previous 15 years was to have experienced exceptional pressures and to have carried an enormous burden.  It recorded that it was generally accepted that police officers had an emotionally and physically demanding job which was at times dangerous and harrowing.  The authors noted of the police officer that:

"Too often in Ulster he is the target of murder and violence – the knock at the door and covert bomb are ever present threats.  The police pay heavily for the ills of our society often with scant appreciation."

In such circumstances, the report accepted that it was obvious that some officers would suffer directly or indirectly from the stressors of their job and that, contrary to general public perception, they were not immune to the stressful effects of the job, of crime and the obscenities of violence.  At paragraph 6.4 under the heading "Security" the report proceeded in the following terms:

"Contrary to what appears to be general expectation, the possibility of an attack leading to serious injury or death was not a major preoccupation with the average RUC officer.  The security risks were accepted as part and parcel of the policeman's life in Northern Ireland.  That is not to say he is not conscious of it, but has rationalised it, or developed coping strategies, which for the most part allow him to cope with it.  Within that broad generalisation obviously there will be some individuals who because of their particular personality, perhaps the branch or location they serve in, may suffer unduly from strain and there have been instances of this over the years.  But there was nothing in the sample to suggest any evidence of widespread breakdown or impending breakdown which would seriously affect the force's operational performance."

There was a reference to specific coping strategies such as "I just put it out of my mind" or "if your name is on the bullet you'll not stop it".   These were not seen as good coping strategies but as pointing to some form of avoidance or repression, unhealthy mechanisms which could lead to later problems.  However, the report also noted that if there was a rational approach there was little doubt that an officer could develop his own coping skills although some such skills could be taught and should be part of a preventative programme.  Section 6.5 concluded as follows:

"Given the moderately low incidence of strain symptoms revealed in the Health and Fitness Survey, the `security' threat is not a serious debilitating influence for the majority of the Force nor is it affecting efficiency unduly, but since it is an unusual phenomenon, and there are some underlying tensions, it calls for closer analysis in the Main Study and the establishment of a monitoring device to ensure that appropriate counteraction is taken if needed."

"10.1.1            To establish a small occupational health unit which will include both medical and psychiatric services so that a central professional resource is created which specialises in police-related illnesses.  This is a core component in a preventative strategy.  Implicit in this recommendation is the introduction of regular medical check-ups and the provision of a professional post-trauma counselling service. 

10.1.2              To organise a relevant and expanded data-base within the personnel function so that information about stress illnesses, various stress-related symptoms such as absenteeism etc is easily accessible.  This will allow regular monitoring of trends in a number of linked symptoms.   …

10.1.5              To introduce short training modules for all ranks on the value and importance of health, fitness and lifestyle in coping with the pressures of police life.   Allied with this is a firm backing for the Welfare Officers Awareness Programme on Alcoholism.

It must be stressed that the recommendations are linked and inter-dependent.  Action is needed in a number of different areas and it should be sensibly and carefully planned in light of resources, operational constraints and the need for rank and file support."

The report also recommended that training in basic stress management should be provided as a normal fully integrated part of training for all levels and that special modules should be incorporated on the identification of stress symptoms and basic counselling techniques. 

(a)        The health assessment of prospective recruits;

(b)        The health assessment of officers' suitability to undertake particular work, or work in particular environments;

(c)        The health assessment of officers who have had serious illness injury or appear to have other health problems;

(d)        Monitoring the general health of the Force and advising on protection against health hazards in the job;

(e)        Providing health guidance and education generally in the Force;

(f)         Coordinating the use of other external health functions in the Health and Social Services in support of the unit's work;

(g)        Liaison with personnel and welfare services on general health and welfare matters.

Paragraph 3.4 referred to the appointment of Dr Courtney and recorded that from 1 April 1986 he would assume full responsibility for the provision of the existing medical services to the force previously supplied by the FMO and his deputy.

The OHU – Staffing, Resources and Performance

"Workload:  we have analysed the workload within the Occupational Health Unit for the first six months of 1987.  During that period 427 `new' cases were dealt with which involved in broad terms psychological/psychiatric problems.  Clearly only a relatively small proportion of these require professional psychological assessment and treatment but there is a major requirement to provide such support and treatment.  As very often the problems are specific to the police force it is inappropriate and, indeed impossible to get psychological assistance through the normal NHS channels therefore we need to provide such service ourselves."

As seen by Dr Courtney, the alternative strategies were:

1.         Extend the current service to provide more time which was impracticable since the current sessional psychologist was unable to provide additional time;

2.         Refer to outside agencies which Dr Courtney considered to be unrealistic because of a lack of suitable expertise and the nature of the problems within the RUC not being suitable for outside referral; or

3 The course that he recommended, which was to employ a Clinical Psychologist. 

His letter went on to point out that: 

"The potential result of this strategy not being adopted is that the current service will shortly be unable to cope with the workload.  Not providing the proposed service would result in a grossly inadequate counselling and psychological service leading to an ineffective provision of psychological assessment and treatment."

"Approval has been given to increase the psychological support to a full-time position.  Even with this the `bread and butter' work will still be carried out by the basic professional staff.  At present it is becoming increasingly difficult with the workload. Patients are having to wait longer to be seen than is often desirable and follow-ups less frequent than is ideal.  This is particularly true of Post Traumatic Counselling.  This is an area of service which was established in early 1988.  This is vital preventative work in seeking to alleviate health problems resulting from traumatic incidents.  This is now widely accepted as a vital area of prevention as witnessed by arrangements made for those involved in various disasters, e.g. Kings Cross, Zeebrugge etc.  In the Royal Ulster Constabulary major traumatic incidents are a daily occurrence with far-reaching consequences.  It was originally intended to see individuals within 2 to 5 days of an incident.  In practice this has proved impossible and it is often several weeks before they are seen.  The self-referral has also increased.  I believe this is to some degree at least a reflection of some confidence in the unit by the Force and many of the problems presenting in this way are very real and treatable."

"Dear Miss Burnett

I understand from Dr Poole that when he met with you on 19 October 1997 you informed him that the Clinical Psychologist post with Occupational Health Unit would be advertised in the Belfast Telegraph on the Tuesday of the following week i.e. 27 October.  This did not happen, and the advertisement has still not appeared.

I am aware that the demands on Dr Poole, have for some time been considerable, and indeed it was in recognition of this that a request was made for the establishment of an additional post.  This was accepted and approval was granted approximately a year ago. 

Since then not only has the work pressure continued to increase but, in addition, there has been a marked further increase arising as a consequence of the Omagh bomb.  I am aware that this is adding to the stress which Dr Poole has been experiencing.  Indeed, he himself made this point at a meeting with the General Services Committee of the Authority on 21 September 1998 and was reinforced by myself on 16 November 1998 when presenting the annual report for `H' department.  The Chairman of Committee indicated that the matter should, and would, be addressed as a matter of urgency. "

Dr Courtney went on to express his concern about the affect that continuing excessive work pressures might have upon the health of Dr Poole.  Despite this letter, Miss Burnett remained firm in her recollection that the job had been advertised in October 1997 because she recalled having to seek an additional budget to meet the cost of advertising in the British Journal of Psychology.  In any event it appears that no suitable applicants came forward and the appointment was readvertised towards the end of 1998 with a closing date on 8 January 1999.  An interview/interviews took place in August of 1999 but no appointment was made.

"As a consequence of the demand for psychological treatment, and despite my colleague's assistance to limit referrals, a point has been reached where I feel I am unable to provide an adequate quality of service because of the quantity of demand.  For me this is professionally unsatisfactory …

The situation is particularly frustrating since, as far back as 1996, it was accepted by the Police Authority that the demand for psychological treatment justified the appointment of additional Clinical Psychologists.  It is my understanding that funding to appoint another psychologist was made available in 1997.  Certainly at the beginning of 1998 I was asked to provide a job description etc for a Clinical Psychology post.  Despite repeated requests, by Dr Courtney and myself, for information from PANI about progress on the appointment, answers were not forthcoming.

The matter was raised by Dr Courtney and myself with the members of the Police Authority at a meeting of the General Purposes Committee on 21 September 1998.  We were assured that the appointment would be pursued as a matter of urgency.  Despite this an advertisement did not appear until December 1998 with a closing date of 8 January 1999.  It was only last month that short-listing took place when, I believe, the recommendation made by the external Professional Advisor was rejected by the Personnel Department.  As a result arrangements have yet to be made to secure an appointment.  Consequently, more than 3 years after the need for additional psychology personnel was formally recognised, there is, as yet, little prospect of an appointment in the immediate future."

Despite the fact that it was marked as copied to her, Mrs Burnett was unable to recall receiving a copy of this letter.   However she did recall an earlier conversation with Dr Poole, at a time when he was thinking about resigning, during which he talked about his difficulties being increased by the Omagh bomb and expressed the view that by moving to PRRT he could provide better supported services than through the OHU.  Mrs Burnett emphasised in the course of giving evidence that, had she received the letter from Dr Poole on 7 June 1999, she would have specifically discussed it with him and dealt with it in writing and that she would not have written the short note that she addressed to Dr Poole on 8 June 1999 expressing regret at his resignation and wishing him well in his new chosen career.   There was a further attempt to recruit a Clinical Psychologist in 2001 with the appointment being advertised as attracting a Grade 6 salary.  The competition closed on 23 November but there were no replies.  No further attempt to recruit was made until Dr Reid was appointed in 2003. 

"Oh yes.  I think nurses and doctors always want to do their very best and we always want to do more.  There is no doubt about that.  I have never worked in a job whether hospital or anywhere else where I would have felt that I had enough people to do my utmost."

"However it must be emphasised that the psychological services both in the area of trauma management and indeed in the area of general psychological support have not been supplied only by the Clinical Psychologist.  Indeed the work that the Psychologist has been undertaking is only the `tip of the iceberg'.  The vast majority of psychological support work has been, and continues to be, provided by the Occupational Health physicians and nurses within the unit."

"Recent discussions with the Doctor and my own inquiries point to the fact that the appointments suggested are necessary and, indeed, essential to the efficient working of the Occupational Health Unit."

In the course of his evidence Sir Ronnie Flannigan, a former Chief Constable of the RUC, confirmed that no obstructions were placed in the way of obtaining a further clinical psychologist by senior command and, in his own words:

"Certainly my attitude was as I described earlier in my evidence, that whatever those in the unit headed by Dr Courtney felt they needed should be provided.  It is as simple as that My Lord."

"It bears repeating that OHU staff needs to be increased incrementally i.e. (a) to cope with the present workload, (b) to cope with the desired extension of workload, and (c)to cope with civil service element; and in that order."

In the same letter Mr McAllister pointed out that among other OHU services that were suffering from staff shortages were the assessment and treatment of officers with stress and other psychological problems and post trauma counselling. Mr McAllister left PANI in no doubt as to the seriousness of the situation as he wrote:

"Post-trauma counselling is an important service, however many incidents have to be 'selectively ignored' and it is not possible to provide counselling to all our members. The assessment and treatment of officers with stress and other psychological problems is time-consuming and stressful to the OHU staff. At present it is proving impossible to provide follow-up and adequate care and demand on the OHU is resulting in steady and remorselessly increasing demands on staff."

"It is of course highly unusual for any action to be taken in advance of a staff inspection report being received or its recommendations discussed. However, your letter stressed the severe pressure being experienced by staff in the Unit because of the heavy and concentrated workload and in these circumstances I am prepared, exceptionally, to authorise the recruitment of two additional Occupational Nurses, bringing their strength up to four."

It should be borne in mind that this letter was written some 18 months after Dr Courtney was told of the inspection process.

Training, Education and the Dissemination of Information

"It should be emphasised that these modules are only the foundation for other more advanced training.  Counselling skills for sergeants upwards need to be developed for a selective group of individuals as an essential preventative element."  

Paragraph 6.1.6 recorded that:

"As with any innovation in training, the proposals will only work if they have the understanding, backing and commitment of top management.  The evidence indicates that officers at this level are generally more 'stress hardy' than lower rank and to some extent 'less-stressed' for a variety of reasons.  The culture is one of a 'tough image' and signs of being stressed are signs of weakness.  It will need strong support by senior management to encourage and modify the attitude at every level to back new training initiatives in the way they deserve."

"A Pilot Scheme using these modules was never fully implemented due to the introduction of the PACE training programme."

Outreach

"It is now more clearly recognised that involvement in 'Traumatic Incidents', which are an integral part of a police officer's duties, can have a detrimental effect on the health of the officer.  This Force Order will provide the mechanism for a confidential Counselling Service by the Occupational Health Unit for police officers involved in traumatic incidents."

Traumatic incidents were then defined by reference to three broad categories including shooting incidents, horrific incidents and life threatening incidents.  The Force Order provided that when such an incident occurred the SDC (or equivalent) should identify all police officers involved, including specialists such as CID, Mapping, Photography etc.  No attempt was to be made to single out only those officers who appeared to be in some way affected by the incident and such officers were to be identified whether or not they reported non-effective.  The OHU was to be directly advised, in writing, not later than 48 hours after the incident and provided with details of the incident, details of the members directly involved and details of any members indirectly involved.  Provision was made for urgent contact to be made by way of telephone.  SDCs were specifically warned that health problems could develop even in individuals with close associations with the incident, such as a close friendship with those involved, and advised that they should refer anyone about whom they had concern even though that individual might not have been directly involved.  Home circumstances were also to be borne in mind and particular attention was to be directed to officers involved in a number of incidents.

"They are to be filed neatly in accordance with paragraph 118 and to be kept up to date and accessible to all members.  The Orders are to be read regularly by all ranks and the instructions strictly obeyed."

Mr McNeill confirmed that, in practice, it was the supervisory officers in the various stations who were tasked with the job of informing all ranks of the thrust of a particular Force Order.  As he said himself, realistically, people going out on duty simply did not have time to read through a 16 page Force Order which would get filed in the ordinary way.  Other witnesses confirmed that this was the practice at many stations.  Mr McNeill pointed out that while a couple of sets of Force Orders were available at every station they might not be available to everyone although they should have been read by the supervisory ranks who then had the responsibility for deciding how relevant they were to the officers' day to day activities.  However, he accepted that the wording of paragraph 116(A) was clear in placing an obligation upon every member of the force to read and familiarise him or her self with the contents of Force Orders and that they knew that Force Orders were the Chief Constable's instructions to the Force. 

"There remains substantial difficulty in the way the OHU is informed of incidents with considerable time being spent by Nursing Advisors establishing information and following through the contact process with officers concerned.  Better means of co-ordination is constantly being sought."           

It seems that Dr Courtney's concerns continued since, in 2003, within a few weeks of her taking up the post of Clinical Psychologist at the OHU, Dr Courtney asked Dr Tracy Reid to review the operation of Force Order 16/95.  However, due to pressure of her other duties, Dr Reid was unable to commence this work under November 2005.  Dr Reid's draft report was submitted to Dr Courtney on 24 March 2006 and was made available to the parties at the start of June 2006.   

"This Order is out dated according to recent research and guidelines for psychological care post-incident (NICE, 2005; CREST, 2005; Wessley and Deahl 2003).  Additionally, the current General Order is not fully adhered to by all managers and as a result not all critical incidents that should get reported to OH&W do so.  Many incidents that are reported are not deemed 'critical' to warrant the provision of support.  There is a lack of education regarding the use of this Order, and there appears to be ambiguity surrounding who is responsible for notifying OH&W when an incident is deemed 'critical' enough to refer, to whom it should be referred, and the procedures that should be in place following notification.  This has meant that OH&W do not always receive notification from managers of those individuals who require post-incident support.  Individuals are often left to self-refer, often after protracted periods of time.  As a result they are left feeling unsupported by their organisation.  By the time they are seen, with lengthy waiting lists for the Clinical Psychology Service, they are likely to experience deterioration, co-morbidity and feel demoralised with PSNI in general and OH&W in particular.

Following the current General Order, individuals exposed to a critical incident are sent a letter acknowledging the incident.  If the individual wishes to contact OH&W they are advised to do so.  Within the current culture many fail to request help and suffering often becomes protracted.  Officers will often reach a point of significant dysfunction and long-term sickness absence before they present to OH&W, if they are not referred by management.  For these cases, as evidenced above, many more therapy sessions are required for resolution than if intervention was provided at the earliest possible stage.  The Trauma Support Programme aims to significantly revise this system, and proposes a seamless system of support following exposure to critical incidents."

Stress Awareness Training

"Further research and review the causes, symptoms and coping mechanisms of stress with a view to changing existing policy and training strategy."

They looked at the 1987 proposals but decided against simply re-vamping that programme in view of the amount of new work that had been carried out within the RUC and mainland forces.  They reviewed stress training offered in a number of mainland forces but, having done so, concluded that the current inputs made by specialists in the OHU, Welfare and PE Department to the RUC training courses were more comprehensive and professional. A further meeting took place on 28 May when there was general agreement that adequate information was available to the force but there remained the question of "how to get it over to the men?" Subsequently, at the meeting on 17 June, Chief Inspector White stated that the training package approved by ACC B Department in 1987 was still worthy of implementation with minor changes and an action team was deliberately selected to include officers who had been involved in the compilation of the "Stress Package" in 1987. I note that during the same meeting Constable Pearson advised that problems existed not with training but for employees in the mid-service (15 year) bracket. The initial report from the action team was provided to the Working Party in October 1991. In 1992 the preliminary report from the Working Party confirmed that post traumatic stress had not been considered because of the existing force instructions involving the OHU and Firearms Branch.  The same report also referred to the recommendations of the Health and Management Survey in 1987 and the fact that the pilot scheme employing the stress training modules designed at Garnerville had never been fully implemented due to the introduction of the P.A.C.E. training programme.  The report recorded that, although the OHU, Welfare Branch and Department of Physical Education all had inputs to various courses relevant to their own disciplines, there was no co-ordinated approach and no formal stress management training pack was provided for initial recruits, probationers, sergeants and inspectors.  Chief inspectors and above might elect to attend Command courses at Bramshill Police College but again there was no formalised stress management training. 

"Short-term

1.         To raise the awareness of the Force to the signs and symptoms of stress.

2.         To increase the knowledge of positive coping mechanisms.

3.         To promote a healthy lifestyle.

4.         To promote the in-house assistance available; - from Welfare, the Occupational Health Unit and the Physical Education Department.

Long-term

1.         Extend the counselling services available through OHU and Welfare Department. 

2.         Consider establishment of welfare liaison officers, sub-divisional police officers.

3.         Provide stress management training for initial recruits and probationer constables.

4.         Improve management style by training police managers in stress awareness and management and to provide them with basis counselling skills.

5.         Research psychological screening for possible selection of recruits."

For the purpose of fulfilling the short-term recommendations the Working Party decided that a small specially selected project team should be briefed to re-make and update the video that had been produced in 1987 and to supply it together with an information pack (booklet, posters and leaflets) on stress to each sub-division.  The package was to be delivered to officers of all ranks by welfare officers together with a specific, sub-divisional trainer.  It was envisaged that all serving officers should be supplied with the package over a period of two years.  These recommendations were approved by Senior Assistant Chief Constable McAllister on 29 June 1992. 

"This was very much to bring it to the attention of the widest number of officers possible, particularly those who were not already presenting to the Occupational Health Department or any of the other Welfare Support Departments, to make them aware about the multi-factorial nature of stress, linked to their own behaviour and feelings.  To try and work in a preventative way in terms of individual coping, but I suppose as much as possible, to normalise the abnormal feelings that they might have over either events that they were involved in or any stressors about the job.  To normalise it to the extent that allowed them to step forward for help if necessary or to at least feel that there was some action they could take as individuals to ameliorate their distress."

As well as identifying the signs of stress the video drew attention to the fact that they might be more apparent in the family/domestic setting where there was generally less pressure to maintain a coping façade than at the place of work. The information leaflet pack dealt with the warning signs of stress in officers and their colleagues, the fact that stress was a normal reaction to an abnormal situation of which an example might be a traumatic incident, coping mechanisms and support systems.  The services of the OHU, Welfare Branch, Psychical Education Unit, Police Federation and other agencies were listed.  These were noted to be additional to and not in any way an alternative to the officers' normal relationship with his or her GP. 

"Minutes and other records show that these issues were the subject of prolonged wrangling in the working groups over such issues as overtime and discipline which whilst important no doubt in their way, were tangential to the clear and agreed benefits of the proposed developments and which seem to have contributed much to these projects running very late or into the sand over a number of years."

Dr Slovak recognised the ebbing and flowing of dialogue that the relevant papers disclosed from his own experience of trying to progress contentious issues in large bureaucratic organisations while at the same time pointing out that it was necessary to "live in the real world" in which the agenda of different interest groups within the organisation have to be managed in order to make progress. On a practical level Sergeant Wallace expressed the opinion that stress awareness training compared adversely with the detailed training and information that officers had received with regard to Equal Opportunities Sexual Discrimination and Harassment legislation.

Culture

"There were significant barriers to seeking help for mental health problems in the RUC. These are not unique to the RUC, being found in military systems everywhere. They are also found in the general population. The stigma of mental illness is a massive challenge to society, not just the RUC. There are no simple or proven solutions to this problem."

"As I have mentioned in my statement, one of the biggest problems in giving this type of service is the resistance of police officers to admitting that there may be something wrong with them at all, in particular, in the context of the terrorist situation.  By admitting that it was like scoring an own goal.  They saw themselves that they should be invulnerable to this.  The macho culture at the time.  They would be resistant to the concept of 'I may need a bit of help.'  A lot of the efforts in the early post trauma counselling were to try to educate people that was not a good way to do it, that positive coping is to accept that you have a problem and to know when to seek help."               

In 1984 the preliminary report of the CHMF recorded that:

"The organisational culture or value system may be an impediment in dealing with stress-related illnesses in work, particularly in police forces.  This is usually because of the 'macho' image of the policeman which means that it is a sign of weakness to admit to strain.  Evidence of it is perceived by the rank-and-file to be damaging to promotion and possibly even a reason for scorn.  As a result much stress may go undetected since the skills in recognising it and being able to counsel on it have not been developed.

A serious obstacle to dealing with it effectively in most police forces is lack of professional knowledge in depth of police related illnesses and disorders." 

That report then included among other recommendations the suggestion that there should be short training modules for all ranks on the value and importance of health, fitness and lifestyle in coping with the pressures of police life and that training in basic stress management should be devised to be provided as a normal fully integrated part of training for all levels.

Alcohol

"Having read this Force Order I feel I must make some comments which are my personal views:-

In general I have considerable concern about the methods of using this video.  These have been expressed on a number of occasions, without effect. 

I feel that to simply publish a Force Order which states that the video will be viewed at all sub-divisional schools is not helpful when it is widely accepted that these schools are not very effective or active.  The whole tenor of the Order gives the impression of complete lack of commitment to the project by Senior levels in the Force. 

The video is in my view helpful but if used in an offhand manner or on the basis that 'this has to be shown', the video and its contents can easily became laughable.  I believe that one or a small number of people should be identified to show the video in a controlled way.  As it is, those tasked with showing the video have no background whatsoever given to them as to how to use the video and the material and indeed may see the video themselves for the first time with their men. 

I found it fascinating that I was asked by a member of your Department at what stage of the presentation I felt the leaflet should be distributed.  The following day I received the Force Order clearly showing that the decision had already been made.  Incidentally, I felt that the leaflet would best be distributed after the video.  The Force Order says before!

I do not believe that the objective is, or ever was, considered to be 'to educate the Force on the identification of alcohol related problems'.  If this is the objective, this was not my understanding as a member of the working party and the video manifestly does not meet this objective.

Comments are quite correctly made about a second (and in my view more important) video.  To date nothing to my knowledge has been done to even start this video or consider in any detail its production.

I cannot speak for Welfare Branch but my understanding was that it was made clear that they could not provide a representative at each viewing. 

In summary I am deeply saddened and concerned by this Force Order which I feel debases and nullifies the work which was put into the production of the video.  I can only repeat my views that it would be better not to release the video than to do it in this half-heartened and apparently ineffective way."

It is perhaps hard to imagine a more trenchant or scathing commentary.

"My involvement in the saga of the production of the video on alcohol related problems has been negligible and therefore I believe that I have been able to scan this file OBJECTIVELY.

There are several things which have an impact upon me.  The Chief Medical Advisor has been consistent throughout that the context in which any such video is shown is the key to getting the message across. 

Equally consistent throughout the file seems to be the disregard which has been shown to the advice of the Chief Medical Advisor. 

If the Force has seen fit to appoint a Chief Medical Advisor, why would it not listen to his advice? 

I understand that it is generally accepted in the training profession that video can only be effective when used in a controlled context by a trainer or other selected person who can authoritatively 'warm up' the audience to receive the video, and can pick up and develop the issue opened by the video.  In other words, I believe Dr Courtney has been right all along. 

I have grave doubts about how effective the showing of the video at sub-divisional schools will have been.

Phase 2

If I were to be asked how Phase 2 should be approached, I would say:-

.       do away with the Committee!

.         give the Chief Medical Advisor his proper place! Let him and the Video Production Unit get on with the job, giving them such support as they ask for."

Conclusions

{142] I am also satisfied that, in terms of bringing officers to the OHU as opposed to a educative function, Force Orders 14/88 and 16/95 could not have worked to their full potential in practice. Within a short time of promulgation this was appreciated by Dr Courtney and most reasonable commanders. To have enforced the Orders to the letter would have brought the system into disrepute, seriously weakened some of the stations and units and completely overwhelmed the resources of the OHU. In such circumstances it seems likely that, in addition to any problem caused by patchy availability and distribution, the adoption of ad hoc solutions in some areas may have contributed to a degree of misunderstanding and ambiguity over time. Margaret Bennett, a very experienced occupational health nurse who joined the OHU in 1992, explained the difficulty that some officers experienced after the 1994 ceasefire in accepting that non-terrorist events, such as serious road traffic accidents, were intended to fall within the ambit of the Force Order referral system. However the fact that they did not operate perfectly as designed does not mean to say that the adoption of these Orders was, in itself, negligent. They represented pragmatic attempts by reasonable individuals to deal with a situation in which there was little or no available guidance. In addition, despite the views of Dr Courtney, I think that, to some extent, they performed an effective educational function as a number of witnesses confirmed. In particular, Dr Slovak considered that they produced a double benefit in that, as well as being directives to managers, they served to raise the whole profile of the issue of traumatic stress and the services available. The Orders were kept under review, consistent with the other professional and clinical demands upon their services, by appropriately qualified experts in the persons of Dr Courtney, Dr Poole and Dr Reid. At one point in the course of his closing submissions counsel on behalf of the plaintiffs seemed to suggest that the draft Clinical Psychology Trauma Support System proposed by Dr Reid in March 2006 was a system that ought to have been adopted by the OHU shortly after it opened for business. I would reject any such suggestion. The proposal which, prima facie, appears to contain a number of positive suggestions is based upon very recent research and the introduction by the Royal Marines of the Trauma Risk Management system ("TRIM") in 2003. TRIM is a system that remains at the experimental stage and Dr Reid has asked Queen's University for a researcher to investigate its suitability for use by PSNI. It is currently the subject of an RCT being carried out by Professor Wessely's unit.

{145] It seems to me that a number of factors fall to be considered with regard to communication, training and education:

(1) Shortly after the creation of the OHU in 1986 the Defendant began to appreciate for the first time that exposure to traumatic incidents could cause chronic psychiatric disorders in officers without any pre-existing vulnerability or predisposition. The OHU was a new and confidential facility that was capable of providing support and some degree of treatment for such disorders. Referral might be by management or the individual concerned. In such circumstances while the numbers ultimately affected might be relatively small the risk was obvious, given the almost daily exposure to trauma, and it became important to take all reasonable steps to ensure that officers were aware of the facility and the opportunity to benefit from its services.

(2) In addition, not only did this new information require to be effectively disseminated and properly understood but it is also clear that the Defendant should have realised that attempts to do so were likely to be met with strong cultural resistance. The terms of reference and preliminary report of the CHMF in 1984 specifically identified the problem and paragraph 6.1.6 of the 1987 report foresaw that the support of senior management at all levels would be required. In practice the OHU was given a voice in training that reached about 4% of the force. After the OHU produced the draft of Force Order 14/88 Dr Courtney's concern that management training was required in view of the novelty of the procedure was rejected by B Department on the basis that the Force Order procedure itself was clear and did not need any supplementation. As the later Stress Working Party recognised while the information may have been available there was a need "to get it over to the men." The evidence established that, in practice, Force Orders alone were an unsatisfactory means of communicating with officers on the ground no doubt as a consequence of the demands made upon them by the continuing campaign of terrorism. While the procedure was designed to avoid exposure of individuals the means adopted, given that only a small minority were liable to be significantly affected, had the potential to bring the system into disrepute as an unnecessary form of interference by the "medics". The history of compliance with Force Orders 14/88 and 16/95 confirmed the existence of a significant area of discretion and that, despite the apparent clarity of the wording, management understanding of their duties remained at best ambiguous.

(3) It is difficult to see how the Defendant could completely rely upon the experience and common sense of officers as envisaged in the "know your men" concept to provide a reliably uniform response to a phenomenon the existence of which had not previously been appreciated. Dr Crowther confirmed that awareness is an important part of stress education and that recognition of the problem is not instinctive. While there can be little doubt about the quality of many senior officers and their ability and willingness to subscribe to the "know your men"principle, it would be unrealistic, bordering on the naïve, to assume that was universally the case in an organisation comprising many thousands of individuals. Mrs Margaret Bennett accepted that come SDCs were good at operating the referral system but others were not so good and, as Mr McQuillan candidly observed, some officers were very good, some were not so good and some were awful. Mr McClurg , an officer who has held several of the highest offices in the Police Federation and in whose name this litigation was commenced, referred to a perception that management ruled by threat and he gave as an example the concern among reserve officers that their contracts would not be renewed in the context of prolonged sickness. Mr McClurg conceded that, in practice, very few contracts were not renewed and that there was a sense that "bark was worse than bite" within the police management system. Nevertheless the letter in the 1989 edition of Police Beat to which the Defendant referred in relation to that topic provided support for the existence of a policy of "bark" in some quarters. Mr Alan Wright, a former chairman of the Federation, made a speech at the Federation conference in 1983 in which he referred to too many transfers taking place as a demonstration of authority rather than to enhance the life of individual officers or the operation or efficiency of the Force. ACC Sheridan pointed out that in earlier days it simply was not done to ask officers how they felt whereas, at present, it was a matter of routine. He accepted in cross examination that goodwill and intimacy alone were not enough and that training was necessary. ACC Toner had no difficulty in accepting the principle that stress awareness training for all ranks would have been of great benefit if it had been available in 1969. Former ACC White described training and education about stress and stress related illness as "patchy and incomplete" and observed that "..it was the blind leading the blind because if supervisors themselves weren't being trained then in a sense the advice and guidance that they were giving to people could have been somewhat suspect." It was accepted by the Defendant's witnesses that within the force there was a diversity of views with different emphases and that the approach to the policy on trauma and referral to the OHU was not systematic.

(4) On behalf of the Defendant Mr Hanna QC relied on the opinion of Professor Shalev that psycho-education was bad practice and a double edged sword in that while it might help to identify subjects at risk it also had the potential to over-sensitise and weaken an officer's protective shield. However in cross examination Professor Shalev accepted that in a paper published in 1989 he had advised that preventive intervention on the group level should include primary physicians and medics counselling commanders on the psychological impact of specific combat conditions. In that paper he identified a number of signs that might indicate the development of Combat Stress Reaction, as opposed to a normal reaction, and could be used to educate commanders on the battlefield. He made the distinction between psychological and psychopathological impact accepting that commanders were aware of and concerned about the former while the latter involved diagnosis and jargon that was essentially a matter for clinicians. He expressed the view that good commanders would know some of the signs but accepted that even a good commander might not know what they indicated unless he was taught. The task of the primary physician or medic was to counsel commanders as to the need to recognise such signs and, in appropriate cases, to refer individuals to them for assessment and/or treatment. Professor Shalev emphasised that his opposition was specifically directed towards any attempt to teach that a natural fear reaction might be the beginning of mental disorder. In that context, he would not accept Mr Irwin QC's proposition that soldiers should be informed about the possibility of flashbacks or "intrusive memories or nightmares" saying:

"I am not sure that we're not sensitising those who have those symptoms for a few days to look at them as something very special, I am not sure that we are reducing the stress rather than sensitising, I am not sure where this kind of education will lead to, either being more aware or less aware."

On the other hand Professor Pitman, who also gave evidence on behalf of the defendant, had no reservations about referring to both nightmares and unwanted intrusive daydreams when writing his letter to the Russell Landing Zone Association although I accept that was a group of veterans. In addition, as I have noted earlier, Dr Slovak, the occupational health expert referred to the clear and agreed benefits of the stress awareness package.

"In any preventative programme an awareness of the problem is fundamental. If this does not exist, it's extremely difficult to instigate preventative strategies. In the late 1980s traumatic incidents in the RUC were effectively taken for granted as an accepted part of duties. Incidents were commonplace and for many officers incidents were not thought of as being out of the ordinary. It was not well recognised that involvement in incidents could have a deleterious effect on health and therefore it was important to raise awareness in a realistic and reasonable way."

Such views were clearly shared by Dr Crowther and Dr Tracy Reid.

(6) It was never envisaged that police supervisors/managers would become sufficiently skilled to enable them to identify the subtle signs of mental disorder familiar to clinical psychologists or psychotherapists nor did the plaintiffs call any evidence to sustain such a proposition. Neither was it suggested that the force in general should be taught to expect mental disorder as a "normal" consequence of exposure to trauma. Supervisors could not be expected to conduct clinical examinations or to ask each officer exposed to trauma whether they had any "psychological problems" as one of the lead claimants seemed to expect. Provided that they otherwise gave the impression of being more than capable of fully discharging their duties, I am not persuaded that supervisors could be expected to routinely question officers who had been exposed to trauma about their domestic lives. It might well be otherwise if an officer spoke to his or her supervisor about relevant domestic difficulties, as the stress awareness pack and video recommended, or the supervisor directly received relevant information as in the case of Mr A. What was contemplated by the CHMF and the Training Research Unit under Inspector White was that practical, as opposed to academic, and appropriate training would be given to officers and various levels of management. Anticipating the concerns expressed by Professor Shalev the training modules were to be non-technical, informative, jargon free, optimistic and based upon a common sense approach with suitable adaptations for the type of officers to whom they were to be addressed. Without in any way detracting from the eminence and authority of the expert evidence, I think that it is important not to underestimate the range and depth of the expertise and practical experience, both of life in the RUC and in their own particular fields, represented by the membership of the CHMF. Given the need to pilot the modules it seems to me that implementation of the training could have commenced by late 1987/8. If so, it would have complemented the introduction of Force Order 14/88. It is not easy to understand why training should be delivered to approximately 4% of the Force but not to the remainder until approximately 6 years later, especially when it related to a significant risk to mental health the existence of which had not previously been appreciated by management. No reasoned decision could be traced for the course adopted by the Defendant in rejecting the CHMF recommendations and the only explanation for the failure to implement their proposals seems to have been that they were superseded by the PACE training programme. It is possible that relying solely upon the use of the Force Order system represented a saving in manpower and/or overtime which appears to have been a factor in the approach to the way in which the video relating to alcohol was introduced but it is not immediately apparent why, important though it may have been, training was made available to the whole force in relation to a legal practice and procedure but not in respect of a significant risk to the mental health of officers. No evidence of any reasoned consideration or decision making process was placed before the court and, in such circumstances the only reasonable inference to be drawn is that the training/education programme carefully developed under the supervision of the CHMF and approved by ACC of B Department was simply abandoned in favour of training for P.A.C.E. It would appear that Dr Courtney's advice both as a member of the CHMF and with regard to training in relation to Force Order 14/88 was rejected. Unfortunately it seems likely that attitudes expressed later by Superintendent Johnston rather than that of Superintendent Boyd probably held sway even at this stage. In my view the failure to adopt the precautions recommended by a reasonable and competent non-specialist occupational health doctor, a standard for which the Defendant has contended, represented a systemic failure on the part of the Defendant.

Treatment

"On the basis of current research it is recommended that SSRIs are the first line pharmacological treatment to be followed by MAOIS and TCAS. The psychological treatment(s) of choice are CBT and EMDR unless reasons exist for ruling them out. Other family and social interventions should be applied as appropriate in individual cases. The efficacy of treatment intervention should be monitored closely."

"Notwithstanding these methodological reservations, given the evidence that there is unlikely to be a clinical important effect on subsequent PTSD, we do not recommend that systematic, brief, single-session interventions focusing on the traumatic incident or provided individually to everyone who has been exposed to such an incident. However, we do recommend the good practice of providing general, practical and social support and guidance to anyone following a traumatic incident. Acknowledgment of the psychological impact of traumatic incidents should be part of health care and social service workers' responses to incidents. Support and guidance are likely to cover reassurance about immediate distress, information about the likely course of symptoms and practical and emotional support in the first month after the incident."

"What I looked for is what the consumer, what the patient had to say. We listen to these people a lot. We wanted to know how they felt, did they feel they were getting better and they did feel they were getting better on many occasions. …. A lot of people did feel better …….and did actually give us that information that they were feeling better, that they were able to cope better and they felt they would actually say they felt normal again ….. The majority of them thought that counselling should be offered to everyone.

A number of the lead cases confirmed the benefit of attendance at the OHU. For example, Mr Woods, a man who had even refused to admit being under stress when directly questioned about physical symptoms by his own GP was quite clear about the benefit that he obtained in terms of symptom reduction from his first few meetings with Donna Andrews. Subsequently he underwent EMDR with Dr Tracey Reid and, while the experience was undoubtedly tiring and difficult, the benefit to his quality of life was clear.