EMDR Therapy Quarterly

Introduction

It is widely documented that policing carries psychological risks (Mind, 2015; The Police Federation of England and Wales, 2016; Miller et al., 2018.) In 2020 in England and Wales, 10,000 police officers were off work due to stress, depression, anxiety and post-traumatic stress disorder and 80% of police officers admitted to struggling with their mental wellbeing (The Police Federation of England and Wales, 2021a). In the same year, in Scotland 70% of Scottish officers had their rest days cancelled due to work demand and around a third regularly went to work despite feeling mentally unwell – on average 19 times in six months (Campeau et al., 2021). The Police Service in Northern Ireland lost 21,702 working days due to psychological illness between April and December 2021. Sadly, UK police suicide prevalence is thought to be 2-3 times that of the public (Dixon, 2021).

These statistics can be explained by the fact that, in addition to usual life stressors, an officer could see 400-600 traumatic events during an average career, contrasted with the three to four serious events typically thought to be experienced by civilians (John Sutherland speaking to The Police Federation, 2021b). This accumulation of stress and trauma can take its toll, causing a dripping tap effect of individual experiences resulting in catastrophic cumulative impact, with comparable levels of traumatic illness to the military (Irizar et al., 2021).

Research also shows that, as well as over 90% of officers being trauma-exposed, prevalence of post- traumatic stress disorder (PTSD) within the police is around 20% and many more officers (55%) feel that they do not have the opportunity to process difficult experiences before moving on to the next. This is a significant precursor to impairment from trauma impact. (Miller et al., 2018; Brewin et al,. 2022). Despite this, there are very limited trauma services bespoke to the needs of police officers, seemingly comparatively fewer than in the military, particularly under the military covenant.

How police officers access help

Most occupational health departments offer access to employee assist programmes (EAP) which facilitate six sessions of generic talking therapy. Some police forces have additional professional support (such as a dedicated force psychologist or therapist) but these can be limited in accessibility, requiring referral from human resources, or line management (and thus disclosure). What is more, the therapist-officer ratio means that there can often be extensive waiting lists.

Officers can seek help via the NHS, however complex PTSD (CPTSD – arising from multiple events and having wider effects) is often out of the remit of primary care talking therapy services; yet, due to individuals’ typical high level of self-functioning, many do not meet secondary care criteria.

Barriers to treatment

Critically, the main barrier to treatment is the reticence to seek support (Bell & Eski, 2016). Stigma and self-stigma is well documented (Bell, Palmer-Conn, & Kealey, 2021: Newell et al., 2021) and there can be other occupational limitations, such as being taken off frontline duties, that deter affected officers from seeking support. “Weakness” (or the appearance thereof) is highly undesirable in this ‘helper population’. Furthermore, occupational health support is not considered confidential and officers’ professional experiences of services; supporting public in distress or unsuccessful S136 requests (emergency police powers to detain and place someone, thought to be psychiatrically unwell, to a place of safety) all act as barriers to treatment (Newell et al., 2021).

There are logistical barriers too. One of the biggest stressors for police is the lack of staffing and the resultant impact on the remaining team. Workload and unsociable/long working hours and shifts compromise the ability to engage with mainstream services. Even if help was to be sought, policing commitments render consistent attendance to that support almost impossible.

Adding to this is the prevailing cynicism towards psychological therapies (Bell & Palmer-Conn, 2018; Woody, 2005). This is multifaceted. There can be latent distrust of external providers regarding the utility and efficacy of treatment (Bell & Palmer-Conn, 2018; Woody, 2005). There is also reticence and inability to disclose policing material to non-police related services; either due to highly sensitive and confidential material or not wanting to ‘burden’ the psychological professional with higher than average traumatic or graphic information (Woody, 2005: Wester et al., 2010). The clinician is also under scrutiny, there is a general distrust and therefore a ‘testing period’ ensues. Officers question ‘is this person up to talking to me about these things; can this individual cope with this information; and are they credibly qualified?’ (Kirschman, Kamena, & Fay, 2015).

With an inherent lack of help options available: doubt in impartiality and confidentiality and a concern among help-seekers that acknowledging difficulty might have an adverse effect on one’s career (Bell & Palmer Conn, 2018: Turner & Jenkins, 2018), it is evident that external services are on the back foot when it comes to offering police-aware or ‘safe’ CPTSD intervention (Kirschman et al., 2015; Woody, 2005).

Other independent and police-aware settings are in demand and charities such as Police Care UK and the Police Treatment Centres (PTC) receive a regular stream of support requests from veteran and serving officers and are usually operating close, at, or even beyond capacity. These organisations, being operationally ‘neutral’, but respected by those in the policing family, offer timely, safe and evidence-based support that appears to fulfil the needs (and quell the anxieties) raised here. An independent review of the PTC’s psychological wellbeing provision undertaken by Robert Gordon University, Aberdeen in 2019, revealed that the service was both effective in its treatment of anxiety and depression but also was accepted and highly regarded by police officers (Alexander et al., 2020). Police Care UK has seen a significant increase in therapy requests over recent years – 2020/21 saw 5367 therapy hours delivered (an increase of nearly 900% on the previous year) as word spread and continues to do so, the majority being for trauma presentations (Police Care UK, 2021).

What is needed

Police officers do seek help but under certain conditions. This suggests that, like the military, further bespoke services are warranted to meet growing need. Mild to moderate mental health disorders are already catered for by existing police force, PTC and Police Care UK services. CPTSD, however, has no dedicated service provision despite the fact that one in five officers (at any one time) can be affected by this (Miller et al., 2018).

Treatments for PTSD/CPTSD according to the NICE guidance (NG116) are trauma-focused therapies such as trauma-focused cognitive behavioural therapy (tfCBT), prolonged exposure (PE) or eye movement desensitisation and reprocessing (EMDR). These therapies require significant specialist additional training and are more specific than the generic counselling offered to first line officers. Traditionally, 8-16 sessions would be considered depending on presenting need. Yet often, career-accumulated trauma can require moderate to longer term therapy for which (military aside) there are very few options. We speculated that if a bespoke service existed, affected officers may seek help sooner, lessening their treatment needs. Effective psychoeducation on how to spot the signs of being psychologically affected by the job is very much needed: 72% of UK officers and staff with clinical levels of trauma disorder reported they were unaware of their clinically-relevant symptoms (Miller et al., 2018).

EMDR, PE and tfCBT (and combinations of these three therapies) have all been condensed and researched in intensive programmes. Ehlers et al. (2014) intensive tfCBT trial on single-event trauma/PTSD condenses treatment into a seven-day non-residential intervention and yielded comparable results to those experiencing weekly therapy for three months. The findings for all intensive approaches show faster symptom reduction, quicker return to work and life quality (Ehlers et al., 2014; Woolliscroft, 2021). Similar positive results have been documented for the intense EMDR counterpart especially for those with CPTSD, which is notoriously difficult to treat within current provisions (Van Woudenberg et al., 2018; Hurley, 2018). In summary, intense EMDR delivered over 2×4 days has been shown to deliver the same effects as 16-18 sessions of weekly EMDR therapy and these positive changes have remained at one year follow up (Hurley, 2018).

PSYTREC, set up in 2015 by Prof. Ad de Jongh, is a specialist trauma clinic in the Netherlands. It has pioneered this model, treating around 150 people per month with an 87% reduction in CPTSD diagnosis in 2020 (Voorendonk et al., 2020; Woolliscroft, 2021). Other interesting findings for this approach include its attrition (3% drop out from therapy which is low – Woolliscroft, 2021) and safety; despite accepting those with severe presentations, significant comorbidities and suicidal ideation, risks have not increased (Voorendonk et al., 2020; Bongaerts, van Minnen, & de Jhong, 2017; van Woudenberg et al., 2018; Woolliscroft, 2021). Comparable results have been found at the Altrecht Academic Anxiety Centre’s intensive CPTSD service lead by Dr Suzy Matthijssen. These intensive programmes, unlike conventional trauma treatment, skip the stabilisation stages of therapy (undertaken to minimise risk and enhance coping) leading from assessment straight into intense processing with no adverse effects reported. Therapy itself is stabilisation. Intensive EMDR has also shown to be effective within active military operations; intervention being delivered in theatre (warfare) five days post-event for four consecutive days with an immediate return to frontline, yielding sustained treatment effect at 18 months (Wessen & Gould, 2009). This suggests that EMDR is helpful whilst in active service, and does not need preparatory work or break from duties.

The adoption of the intense trauma treatment approach, drawing on a dual trauma-focused therapy approach as modelled by PSYTREC is therefore of significant interest with this population. It is NICE-compliant, suitable for PTSD and CPTSD alike, suitable for those with adverse childhood experiences (ACES) as well as adult trauma, suitable and effective on comorbid presentations, measurable, and provides sustained change and a faster recovery than traditional weekly therapies. Importantly, this approach is radically different to typical weekly therapy, filling a gap and making it an attractive addition to all other provisions available to police within the UK. Importantly, it also compliments existing and effective resources provided by The Police Care UK and The Police Treatment Centres joint working collaboration.

Service provision

With consideration to the above, Police Care UK evaluated an intensive trauma service (ITS) which was tailored to the needs of police officers. A small cohort (n=18) of serving police officers was treated. Each intake (n= 6) engaged in a 2×4.5 day residential providing two therapy sessions per day, imaginal exposure and EMDR. Like the Dutch models, the therapy was pre-or proceeded by physical activity (suitable for individual capabilities) and daily psychoeducational sessions. The physical activities sought to offer positive distraction and/or prevent rumination, offer grounding and team cohesion between sessions, whilst the talking therapy actively treated the troublesome memories. The psychoeducation covered trauma information but also post-traumatic effects and preparation for potential return to duties.

ITS, hosted by the Police Treatment Centres has extensive facilities and is highly experienced in the delivery of residential treatment for police officers. Police Care UK’s identified clinicians were highly experienced in uniformed trauma, with their lead clinical therapist (trained in this specific approach by Dr Suzy Matthijssen) delivering the psycho-therapeutic components on site. Akin to the PSYTREC research, data was captured using trauma measures the Life Events Checklist for DSM 5 (LEC-5), The PTSD Checklist for DMS 5 (PCL-5), The International Trauma Questionnaire (ITQ), The Clinician Administered PTSD scale for DSM 5 (CAPS-5) and the Patient Health Questionnaire (PHQ 9) and qualitative feedback.

In addition, of interest was also the lived experiences of the participants, namely: how did the intense two-week treatment impact them? What changes were there in their quality of life? Were they able to return to work or resume their usual duties? The impact on the occupational wellbeing of these serving officers could provide a valuable insight into how such individuals may be supported in the future.  Eligibility criteria are shown in Table 1.

Inclusion criteria	Exclusion criteria
Identifiable level of CPTSD (psychometrics or pre-existing diagnosis)	Psychosis
Low suicide risk	Moderate-severe suicide or self-harm risk
Low-moderate self-harm risk	Significant/high dose sedating medications (benzodiazepines, analgesics, etc.)
Adequate daily functioning	Inability to undertake regular moderate physical activity (cardiac rehab, pregnancy etc.)
Ability to be in a police setting	Inability to commit to residential requirement
Motivated to change/engage in all aspects of the programme	Unsupported by police force
Previous therapy experience (irrespective of outcome)	Subject to ill-health retirement processes
Support from police force to release for treatment and facilitate follow up	Subject to disciplinary/criminal justice procedures
	Experiencing life events (bereavements etc) at a level that would compromise engagement

Methods

To engage police forces, information about the ITS was circulated via the chief constables of all UK forces. Those interested attended online briefings to discuss the collaboration between the treatment team and occupational health units (OHU), referral potential and candidate suitability.

Occupational health leads would discuss the project with potential participants and, where consenting, refer them for further assessment by the ITS team. Assessments comprised C/PTSD psychometrics, presenting need, risk, history taking and assessment of motivation. If officers were eligible and willing, further preparation ahead of attending such as drawing up treatment plans, welcome calls with the whole team and sending information packs took place. The residential programme was structured with trauma therapy and sport timetabled twice daily along with psychoeducational sessions and other activities.  Therapy sessions were 90 minutes long and following the PSYTREC ethos, processing started from the first session. Later in the residential, in-vivo activities were introduced. These were optional and mainly for those wanting to return to trauma-facing roles or in line with their own therapy goals.  

On the last morning, each candidate repeated psychometrics and provided narrative feedback. They met individually with the clinical lead regarding their handover back to their respective occupational health departments. Follow-ups were conducted at one, three and six months and there was ongoing contact with occupational health at these points. This collaboration was to aid any difficulties phasing back into a working environment.

Outcome measures

This evaluation drew on five psychometrics LEC, CAPS, PCL-5, ITQ, PHQ-9. To be eligible, candidates had to score positive on all five. Due to the design of each measure, there were slight variations in their use. Table 2 shows when each was used. To be considered ‘below diagnostic threshold’, candidates had to be below clinical significance on all measures.

	Intake assessment	Post intervention	1 month	3months	6months
LEC 5	✔️	X	X	X	X
PCL-5	✔️	✔️ (2 week version)	✔️	✔️	✔️
ITQ	✔️	✔️	✔️	✔️	✔️
CAPS-5	✔️	X	✔️	✔️	✔️
PHQ 9	✔️	✔️	✔️	✔️	✔️

Narrative feedback was in the form of a feedback form circulated on their latter days of residential and open questions around their individual progress at follow-ups.

Ethical Considerations

Due to the intensive nature of the programme, coupled with being away from home, there was extensive discussion around its suitability with each person. Candidates with ongoing life pressures: recent bereavements, difficulties arranging childcare, significant life events, inability to be in a police environment, were excluded from the programme. Generally, these were highlighted pre-OHU referral and provided for within the police force’s duty of care, however if this was later identified the applicant was signposted to alternatives and/or encouraged to pause their application. Two applicants deferred their residential dates for example and attended once their life events had resolved.

Also excluded were those undergoing any form of professional standard investigation or medical retirement process (exploring or started). This was due to the often very stressful effects of these processes, adding to this with highly intensive therapy would be unethical. Additionally, medical retirement requires all treatment options to have been exhausted and unsuccessful. Accepting an individual hoping for medical retirement into intensive treatment poses a challenge as the applicant will require a negative treatment outcome. There were, however, a few officers who were extremely motivated and wished to avoid being retired; none were in any actual process but feared it being introduced if they did not address their traumas.

Equally those presenting with unmanaged risk, alcohol misuse, physical health barriers were not suitable for this intervention or setting and were encouraged to engage with other services. Individual referrals were similarly not accepted as, without the option of OHU input, the transition back into a working environment where trauma is omnipresent could pose challenges for the officer.

Police Care UK is in a fortuitous position of being able to offer alternative support (peer support, weekly therapy, signposting to other police charities and channels) so where applications were unsuitable, but needs were identified, we were able to either provide other options or liaise with their occupational health units to ensure the officer, and their families had access to the necessary support.

Results and discussion

As planned, all 18 candidates attended and completed the three intakes in June, September and November 2022.  The project is still gathering data; completion due by June 2023. The reviews comprise quantitative data (psychometrics) and qualitative data (narratives around their quality of life, career and other changes).

Each candidate fully immersed themselves into the two-week provision and all reported positive changes, often within the first week. For some this was the benefit of a routine and healthy lifestyle but also for some a reduction in nightmares, flashbacks and emotional dysregulation. Many also reported positive feedback from their family members after the middle weekend and/or some changes in trigger stimuli and ability to tolerate their previously identified sensitivities. There were no risk events, adverse reactions to treatment or treatment drop out.

Return to work findings

As of the last review, 93% of attendees have returned to work, many to their usual roles or other trauma-facing or frontline roles. Some have been redeployed to other substantive posts, whilst this is a change it is important to note that trauma is omnipresent within policing so the exposure may differ but is not absent.

In many cases officers returned to work, from sickness leave almost immediately following their interventions and felt this was positive.

In comparison before treatment

• 50% of attendees had been off sick longer term (ranging from 6 months to 2 years).
• 30% were on adjusted duties within the working environment but away from frontline exposure.
• 20% were working from home on other projects/admin type functions.

Learnings from the intakes, especially after the June programme highlighted the impact occupational health has on return from treatment. Those where this work dovetailed better between the charity and workplace have made more progress than those who were less involved. ITS has been shown to ‘reset’ the officer, forces however need to look at how they phase these individuals back in line with their identified treatment outcomes. Many of the officers were understandably nervous around ‘being thrown in at the deep end’ if they weren’t correctly supported. An identified period of support has prevented this in most cases. There have been four cases where forces have introduced difficult stimuli too early, but any setbacks have been temporary and required minimal support.

Psychometric outcomes

To achieve ‘loss of diagnosis’ status, participants must score sub-clinically on the chosen psychometrics.  Further statistical analysis, upon data completion, will be able to break this data down further and reveal the impacts across and between scorings. Overall, across all cohorts those under the diagnostic threshold are running at 87% (March 2023). A couple of participants had multiple diagnoses pre-attendance, treating the trauma component has helped their ongoing care focus on the remaining difficulties.

Narrative Themes

Although data collection is ongoing, some emergent themes have been identified.

Policing identity

Many officers report a reconnection with their policing identity and/or increase in self-confidence in role “I actually feel like a useful officer again”.

Some have moved departments and found their previous (trauma-inducing) roles have provided a greater depth to their work “I can teach why that is important…..”

Several participants are being more open around the impacts of policing trauma to their peers, their experiences and promoting wellbeing within their forces.

Personal life

Every attendee has had their own subjective positive change too: tolerating a previous challenge easily “I’ve returned to certain places and not been triggered, it’s weird”; “I went to watch the rugby in a packed stadium, and enjoyed it”; “I am able to take my kids out places I couldn’t before”; “I don’t lose my temper at home like I did”; “I’ve booked a holiday…and we’re going to fly!”; “I actually ‘did’ Christmas; wrapped presents and helped. I’ve not done that in years”.

Even for candidates with lesser progress, they report an increase in tolerance and wellbeing outside of policing. The impact on families living with a PTSD or CPTSD affected officer can be far reaching and improvements here are not to be underestimated. The force has a duty of care to consider quality of life outside of employment and not overly focus on returning to work but seek to remedy harm caused by the roles they hold/held.

Self-determination

ITS is not a magic cure; some participants are still working on habituation plans with input from occupation health. For some, ITS addressed some memories and facilitated them engaging in ‘regular’ (weekly) therapy where this was ineffective previously.

Whilst therapy can have varied effects for many reasons, those participants who gave ITS their maximum, gained the most. The most severely CPTSD-affected often made the most recovery; many becoming asymptomatic and sustaining this. These individuals displayed the most resolve consistently and full transparency regarding any private life adversity. They also often cited absence of/limited access to trauma treatment and/or long-standing mental health problems, being at capacity of coping and highly welcoming of support.

Police-aware therapists

Many, if not all attendees commented on “feeling heard”, “held” and “accepted”. Public perception of policing can be mixed and current media portrayal only depicts the worst of policing.

“For me personally, when I first came to the centre and met your team, I unconsciously used my standard ’police head’ defensive thinking strategy – lots of observation, scan the room, watch the person closely and listen carefully to what they are saying to try and figure out their motives, intent, soundness of mind etc. Once I figured out that the threat level was low and this person is actually trying to help me, I was able to start to open up.”

Furthermore, policing has specialist departments and uses many acronyms; participants felt they were able to speak freely, without stopping to explain which was less interruptive.

The setting

The Police Treatment Centre’s facilities and professionalism of staff across the centre meant that their provision was ideal for this type of therapeutic input and extremely well received by the participants. Every officer found the physical exercise very complimentary to the pacing of the intensive therapy and the gym team very approachable and understanding.

Being in a police-aware setting has been positive; attendees felt comfortable, able to ‘be’ officers (in a world where identifying as such can incur hostility), able to draw on peer experience and ‘held’ by the tranquil facilities. For the therapy team, being in a police setting was useful in having other professionals available who understood the target population. It also gave access to police-related stimuli for the in vivo experiments.

Due to the neutrality of the treatment setting and provider, all of the officers disclosed trauma material that was personal and/or not part of their professional records. For many this was pertinent to their later recovery; the ITS approach requires full understanding of an individuals’ trauma profile and compilation of a cohesive treatment plan.

The value of intensive therapy

Intensive therapy was overwhelmingly welcomed by every participant. In contrast to weekly/regular therapy it was deemed “very hard work” but impactive.

“I have had 20+ counselling sessions with ZERO improvement. All of them have been spaced apart and I haven’t felt ‘heard’. Coming so far from home away from my comfort zone has aided my ability to open up and see it as an opportunity to ‘reset’ and go all in. Intensive treatment has allowed me to remember things instantly there and then and mention them, almost like a ‘clean sweep’”

“My personal experience of CPTSD is that once a week (therapy) only really serves in ‘keeping the wolf from the door’, at best. By the time I reached out for help I was already in a whirlwind of distress. Over the years I have seen first-hand how former colleagues have been broken by this condition and have been medically retired, or who have gone off the rails and been sacked, or have resigned, or worse. In my opinion no amount of traditional talking therapy (once a week) would have made a meaningful difference to where I was mentally and physically.”

“The Police Care UK programme is a short, effective means of addressing a colossally destructive condition which allowed me to get back on track and got me back to being productive and happy at work.”

Intensive therapy programmes are also very structured in design, which was commented on by the majority of attendees in helping them feel contained and being predictable; both of these being imperative when working with chronic dysregulation.

“… everything on the programme happened according to schedule, when I reflect on it now this added to the sense of safety as the days went by. I also appreciate that there may well have been a lot of rushing about in the background that the participants and I were completely oblivious to.”

The intensive treatment approach – therapist’s perspective

Working in this way has been highly informative. The intensive therapy approaches are distinctly different to traditional UK therapy delivery. This service provision adopted therapist rotation within and between each intake. Two EMDR consultants were involved in all three intakes alongside the clinical lead, joined by three others on different months. The clinical lead operationalised the model, undertook the assessments, treatment planning, preparation, reviews and liaison with the force referrers. Clinical supervision was provided by Dr Justin Havens and wider support via Prof. Ad de Jongh and Dr Suzy Matthijssen.

Feedback from the assessment process was that officers felt the ITS assessment process was safe, contained and non-triggering. This process focuses more on present day effects of the traumatic events and not disclosure or discussion of memories until the confirmation of acceptance on the programme.

In addition to rotation, the sessions are intensive; there is no initial safety netting in this approach with processing starting in session one. Admittedly this felt unfamiliar for us all but was highly positive in use and may also reflect the functioning and determination of the policing population to regain their health. We also observed tangible session augmentation, generalising effects of processing and that the team were able to get a far deeper level of therapeutic traction even early in the programme. The twice-daily therapy seemed to increase the level of adaptive information processing (AIP); it was not uncommon that participants reported positive change between sessions and as the week(s) progressed found that other pre-identified target memories were no longer sensitive ahead of treatment schedule.

The team were able to increase the intensity of sessions for all participants in the second treatment week in line with the increased resilience of the officers. For many this also included police-trauma-specific behavioural in-vivo experiments to prepare for their return to work.

The use of in vivo exposure in the Netherlands model is widespread. In this evaluation we drew on this later in the programme for those who were keen to verify their processing or practice facing triggers ahead of returning to work or for those with triggers that greatly impaired daily life. The experiments were sometimes specific to individuals; noises, handling raw meat, answering the telephone as if in a police station, rail stations. The in vivo could also involve a combination of triggers as a group exercise; where officers had to wear uniform/kit, deliver CPR on adult and child mannequins, handle ‘blood’, and other police-related olfactory and auditory stimuli. This was done in full discussion and collaboration with the attendees and therapists and not mandatory. Those who partook stated this was a key part of their ITS experience.

Summary

Police Care UK’s service evaluation of this intensive trauma provision supports the work already done in the Netherlands; but this is essentially a new way of working, designed by Police Care UK to meet the unique needs of UK police officers.  Whilst the results have been largely positive, a few candidates have required ongoing support and/or have low-level symptoms/pre-dating alternative diagnoses, it is therefore not a ‘magic wand’ but can facilitate distinct improvement for complex cases. For those who are willing to dedicate their all to treatment, the results can be far-reaching and therapists may need to consider how to promote and balance this positive risk taking.

Due to the positive reception of the programme and initial results, the evaluation is being extended. We are providing six residentials between May 2023 and March 2024 to further our findings and more specifically explore the health economics of this approach.

This evaluation has provided some promising results. It supports working in a condensed format to augment treatment impact, whilst shortening treatment duration and mitigating external life influences; not having to juggle work or family commitments conjointly. For police specifically, this treatment format, delivered in a respected police-friendly environment with police-informed practitioners, is unique to current resourcing and meets a distinct, unmet need.  

Policing is a ‘job like no other’ and therefore deserving of support like no other.

I can sleep. No flashbacks. Very calm and confident. Listen to sirens without panic. Answer phones.
Conduct CPR without panic. Motivated. Fitter. A total transformation from who I was.

Acknowledgments

David Keane and Rae Young were integral to the success of this work and I would like to thank them for their contribution, consistent expertise and above all willingness to do something very different.

Rachel Rogers is the Lead Clinical Therapist at Police Care UK.