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Perspectives and Possibilities:
Mental Health in post-Agreement
Northern Ireland
Elizabeth Gallagher, Brandon Hamber and Elaine Joy
Mental health is considered one of the most important issues in the post-conflict
reconstruction period.1Northern Ireland is no exception is this regard. There
are numerous studies that show that the 30-year conflict has had an impact on
the general and mental health of children and adults in Northern Ireland2,
although the poorer sections of the community were most affected. The
Consultative Group on the Past (2009) notes that working class and border
areas, in particular, experienced victimisation, ranging from economic and
social deprivation to the oppressive presence of military and paramilitary forces.
It is estimated that one in six people in Northern Ireland will suffer from a
medically defined mental illness at some stage in their lives.3 In comparison to
the UK average mental health needs in Northern Ireland are 25% higher.4As a
result of the conflict young people in Northern Ireland face a higher risk of
mental ill health in comparison to young people in both England and Scotland.5
But how does society at large understand what the impact of the conflict
has been? How do professionals and policymakers understand this legacy and
what needs to be done?
In recent years, the work of victims/survivor groups supporting those
affected by the political conflict has been instrumental in highlighting the
ongoing impact of the conflict and the need for sustained interventions.
However, this article contends that this has also, at least in part, resulted in the
mental health impact of the conflict being wrongly seen as only a “victims”
issue. Although it is vital to offer support services to victims, we argue, this
focus has missed the wider impact of conflict on society and also belies a larger
debate within the mental health profession about how to conceptualise mental
health problems, i.e. as a definable and diagnosable psychopathology or a wider
social problem.
Reference: Gallagher, E., Hamber , B., & Joy, E. (2012). Perspectives and Possibilities: Mental Health in post-Agreement Northern
Ireland. Shared Space: A research journal on peace, conflict and community relations in Northern Ireland, 13(March), pp.63-78.
64 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
These issues, among others, were the focus of a discussion at the 2011-2012
Forum for Cities in Transition conference where a panel discussion on “Conflict
and Mental Health” took place.6This article will highlight some of the issues
raised in panel, as well as the wider literature and research focused on
understanding mental health in transitional and post-conflict societies. As noted
above, it will unpack debates about how best to understand and address the
current mental health challenges on Northern Ireland.
Legacy
When one considers that roughly two-thirds of Northern Ireland’s adult
population have had one or more experiences of trauma, and that the Troubles
accounted for half of these experiences7, it is fairly remarkable that the society
has, at least to a degree, moved significantly forward politically in the last two
decades. Some communities which were devastated by conflict have gone on
to be reconstructed socially and economically, and although many victims of
the conflict remain on the margins of society, others now hold significant
positions in government, civil society and the statutory sector. All this has led
some to postulate that people are more resilient to conflict than is often thought.
Experts on the “Conflict and Mental Health” Panel challenged this view and
that the people of Northern Ireland were and are generally resilient to trauma
associated with conflict. For the first ten or fifteen years, clinical observations
highlighted the resilience of the people of Northern Ireland, and in particular,
women and young people, without considering how trauma can manifest
adversely in the long-term.8John Alderdice notes:
Whilst it may seem that people are resilient — and indeed in some
circumstances they are — one should not misunderstand that and believe
that there are no serious long-term and frequently trans-generational
sequelae.
David Bolton shares the view that Northern Ireland’s initial neglect of
mental health issues was often predicated on the presumption of resilience, and
that experiences of trauma in Northern Ireland are, in fact, much more prevalent
than first believed.9Bolton uses the results of an epidemiological study of the
conflict in Northern Ireland carried out by the Centre for Trauma and
Transformation as evidence for his view.10 The study found that fifteen percent
of individuals who had experienced trauma developed Post-Traumatic Stress
Disorder (PTSD), one-third of whom did not recover without access to trauma-
focused therapeutic interventions.11 Thus, Bolton asserts:
65
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
There is a lesson to be learned from Northern Ireland and the lesson is:
don’t leave it as late as we did. If you’re dealing with societal conflict, one
of the steps that need to be taken is to begin to put in place effective, trauma-
focused mental health services that can deal with the initial trauma but also
with the chronic trauma that will emerge in due course.
Muldoon and Downes (2007) also use PTSD as their yardstick. They argue
that the post-traumatic stress disorder is the most common mental health
problem resulting from years of war and conflict.12 The prevalence of PTSD in
post conflict societies is also thought to be normally higher than in societies
where conflict is still ongoing.13 Nevertheless, very little research on the
prevalence of PTSD in post conflict societies such as Northern Ireland is
available.14 Muldoon and Downes (2007) note that “those identified as having
probable PTSD represent a particularly vulnerable and disadvantaged group in
terms of financial, psychological and social capital”.15 Many of the people in
Northern Ireland with symptoms that may suggest PTSD do not see themselves
as victims of the conflict and instead of seeking professional help some self-
medicate and “treat” their symptoms with drugs and alcohol.16
But there is also a concern about narrowing the understanding of the impact
of the conflict to a limited construct such as PTSD.17 Focusing on symptoms
can reduce the focus on the social context that continues to create ongoing
mental health challenges. Focusing on “diagnosis” can divert attention to
individual symptoms instead of seeing the reconstruction of the social,
economic and cultural environment as the key parts of supporting positive
mental health in societies emerging from political violence.
The issue of suicide is a case in point, which is not simply a manifestation
of individual depression but integrally linked to the dynamics of the social
context and the political conflict in Northern Ireland. One of the main concerns
of “The Promoting Mental Health Strategy and Action Plan”18 is high level of
suicide among young males in the society. This has a gender dimension.
Violence and aggression remain deeply ingrained in the society and manifests
in violence particularly by men against others and themselves.19 Statistics from
the Northern Ireland’s Public Health Agency as quoted in The Guardian20 show
that between 1999 and 2008 suicide rates in Northern Ireland have risen by
64%. In 2010, 313 deaths from suicide have been registered showing a
significant increase on the previous year with a total of 260 suicide deaths
registered in 2009.21 The majority of suicide deaths in 2010 were males between
15-34 years old, a total of 240 male deaths as a result of suicide were registered
in comparison to 73 female deaths.22
66 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
One of the public debates in Northern Ireland about suicide is the degree to
which it is a legacy of the conflict, and the role of paramilitary groups in this
in particularly.23 It has been argued that post-Troubles suicides and suicidal
behaviour frequently occurred among young males who had not themselves
participated in the violence, but who resided in areas where there had been
chronic, long-term violence as a result of the conflict.24 Often, these young
men were the targets of intimidation, and physical and sexual abuse by
paramilitary and other figures in their communities. According to Smith, Fay,
Borough and Hamilton (2004) in Northern Ireland the mental health of young
men is particularly affected by the conflict as they are more likely to fall victim
to punishment beatings and intimidation by paramilitary groups in comparison
to females. Healey explains that in her experience as a mental health practitioner
in Northern Ireland, the mental health of young people in conflict is adversely
affected by such diverse circumstances as: coping with the death or
imprisonment of a parent(s); growing up with a parent(s) who has PTSD; living
in the shadow of a brother or sister killed during the Troubles; suffering from
domestic violence and various forms of physical and sexual abuse; and even
being forced to relocate as a result of political intimidation.
Members of the security forces and ex-paramilitaries also seem to be
vulnerable to suicide often exhibiting suicidal behaviour years after initial
conflict-related incidents and experiences.25 The nexus of long-term
unemployment, poverty, relationship breakdown, alcohol and substance abuse,
and at times the existential anxiety of the “terrible futility of the things” they
were involved in can result in mental health problems.26 Recent research has
also begun to suggest that the impact of the conflict can become more acute
with age with over 90% of ex-prisoners now being over 50 years old. A recent
survey of former politically motivated prisoners found that they were four times
more likely to be unemployed than others in Northern Ireland.27 Mental health
impacts were also present, i.e. 68.8% of respondents engaged in levels of
drinking that were hazardous and 32.6 % had received prescription medication
for depression in the last year.28 Given that at least 15,000 people were
incarcerated in Northern Ireland during the conflict, the effect on individuals
and the knock-on effect onto extended families cannot be underestimated.
Perspectives
Although, as was outlined above, the individual impact of conflict can be
devastating there is a tension in the psychology field about how best to
understand this and the concept of resiliency. Earlier in the article the notion of
resilience was challenged, but this should not be read as a total dismissal of the
concept of resiliency. Rather it is a challenge to how it has been used in
67
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
Northern Ireland particularly, where its use in the 1970s and 1980s was often
tantamount to the denial of the full mental health impact of the conflict. This,
for example, is evident in the fact that a policy focus on victims of the conflict
only developed post the 1998 Agreement. It has been argued that there was a
policy silence in the areas of health, social services, education and other
provisions for victims of the conflict.29 This was acknowledged by the British
government through Minister Des Browne in 2003 when he noted, “in all that
time [thirty years of conflict] there were no policies in relation to victims”. 30
Since 1998, there have been numerous victim policies set in place31, and in 2008
the establishment of the Commission for Victims and Survivors in Northern
Ireland. However, there is a danger of moving from one extreme to the next,
i.e. that there is no mental health legacy of the conflict to diagnosing everyone
as traumatised by the conflict. This can have the effect of pathologising
resiliencies that are there and denigrating local coping mechanisms.32
Resilience is the process of adapting well in the face of adversity, trauma,
tragedy, threats, it means, “bouncing back” from difficult experiences.33 Each
individual possess protective factors that serve to support them if they
experience a traumatic event, however, situations can affect these protective
factors and can either support or weaken their response to a traumatic event.34
According to Baker and Shalhoub-Kevorkian (1995) people in the same
household react differently to the same traumatic experience. Betancourt and
Khan (2008) argue that resiliency; psychological adjustment and mental health
in societies that have endured years of conflict should be seen as a dynamic
process instead of a personal trait. If we start to understand resilience as
something that can come not only from individuals, but from the social context
(e.g. community connections and cohesion, social protection) then how we can
rebuild resilience and strengthen coping becomes more apparent.
Gilligan (2006) has pointed out that war can have positive aspects, for
example community bonding, and that there are many social, political,
economic, and cultural factors which influence how or if individuals seek help.
Terms such as PTSD also run the risk of pathologising individuals, labelling
them as having a disorder and skewing power relations.35 It has also been argued
that using medicalised language changes how people begin to describe their
suffering, moving away from talking about the wider social and political context
and how it links to mental health, towards framing the impact of conflict as
primarily individualized PTSD as this is what gains medical and legal
attention.36
Many are now starting to reject an individualized mental health focus and there
is a growing view that other paradigms and institutions can contribute to our
68 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
understanding of mental health in transitional and post-conflict societies more
effectively.37 The mental health paradigm is but one lens with which to view
conflict and it is not apolitical.38 Not only do structural conditions (i.e.
segregation) impact upon the effective delivery of mental health services,
Breen-Smyth cautions that the primacy of the mental health paradigm may
actually be detrimental to victims/survivors. As in Northern Ireland, if research
cannot present sufficient statistical evidence of widespread, trauma-induced
psychopathologies as a result of exposure to conflict, policymakers can justify
delaying, or neglecting altogether, instituting mechanisms to effectively deal
with the past.39 Although some feel therapeutic models do not promote passivity
and patients can take control of their treatment40, others argue the mental health
paradigm inherently promotes inequitable power relationships between an
expert practitioner and an inexpert patient41. This constrains individual capacity
to identify his or her needs and claim ownership of the recovery process.42 As
a result, Breen-Smyth states, individual therapeutic interventions may be ill-
fitted to patients’ underlying needs:
It seems to me that it’s at our peril that we look at these things solely through
the lens of mental health. We also need to factor in the justice frameworks.
People are aggrieved, they have not seen justice, and if we put a pill in
somebody’s mouth when they are grieving and the lack in their lives is the
lack of justice and the lack of reconciliation, then we are storing up trouble
for our own futures and for our children’s futures. So, let’s use mental health
frameworks by all means, but let’s remember that they are only one pair of
glasses, and we have many more pairs of glasses at our disposal.
Hetherington concurs that justice is critically important to victims and
survivors, but that in Northern Ireland, justice is contested, generally meaning
law, order and security to unionists, but social justice and parity to nationalists,
rendering consensus virtually unachievable.43 That said, victims of political
conflict from all backgrounds are unlikely to divorce the questions of truth,
justice, labelling responsibility for violations, compensation and official
acknowledgement of what happened to them from the healing process.44
Although issues like justice are also not a panacea to dealing with the impact
of conflict45, research has highlighted that the legacy of conflict upon mental
health cannot be dealt with solely by considering individual psychopathologies
of those with direct or indirect experiences of conflict.46
Violence committed by paramilitary groups, for example, is a group
phenomenon and is not about individual psychopathologies.47 The fact that
Protestant, working-class young men are disaffected, lacking the educational
resources and employment opportunities of the Protestant middle-class, and
69
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
failing more recently to attain the same level of social advancement as
nationalists following the conflict, is a social problem not solely an individual
one but has massive mental health ramifications.48 Maureen Hetherington
argues that violence in Northern Ireland can only be understood in terms of a
collective, cultural phenomenon in which domestic violence, punishment
shootings and beatings for drug-related or anti-social behaviour and political
support for violence are tolerated with apathy or indifference.49 The faith
community, bystanders and politicians all have a role in changing Northern
Ireland’s culture of violence and that only through cultural change will victims
and survivors be allowed the space to share their experiences and ultimately to
heal.50
According to Tomlinson (2007) the conflict affected everything and the
society as a whole has been “traumatised” with brutalisation being common
and “resistance to change engrained and depression and anxiety widespread”.51
The impact and reverberations of the conflict are still being felt most acutely
by the direct victims and the bereaved, but whole communities also have a
collective experience of suffering making the problem personal, communal and
society-wide.52
Implications
The panel at the 2011-2012 Forum for Cities in Transition clearly articulated
the importance of establishing effective mental health strategies even in low-
level conflicts, such as in Northern Ireland. Compared with the Rwandan
genocide where 800,000 people were killed in just three months53, or with the
conflict in Bosnia and Herzegovina which claimed the lives of more than
100,000 individuals in three years54, it can be easy to dismiss the impact of the
3,600 people killed in the Troubles.55 Nevertheless, as evidenced by this article
and other research the impact of the conflict on mental health has been
pervasive and extends well beyond the devastating impact on those most
directly affected in terms of injuries or bereavement.56
A misguided notion of resilience has in the past in Northern Ireland resulted
in the full impact of the conflict being ignored until recently. Mistakenly seeing
resilience as universally inherent in individuals has hindered mental health
promotion in that it has affirmed the culturally defined idea that people are
strong enough to deal with their own problems and this has led to many people
self-medicating, taking part in risk-taking activities and various forms of
violence as a means of coping with their problems. In other words, the universal
presumption of resilience has led to a negative form of coping, which in turn,
70 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
has impacted negatively on the mental health of people affected by the conflict
in Northern Ireland.
It is only in the last fifteen years that the assumption of resilience to the
Northern Ireland conflict from a mental health perspective has been challenged.
It is now also contended that the failure of society to acknowledge the
complexity and pain of the past and deal with outstanding conflict-related issues
in Northern Ireland politically is, at least in part, about the neglect of the
massive impact the conflict has had on the society.57
The conflict has had particularly devastating consequences for the mental
health of victims, former combatants, children, and women. Further these
effects have been chronic and generally manifested only after a significant
passage of time. During the conflict people in Northern Ireland generally did
not receive adequate support to deal with their problems.58 Establishing effective
trauma-centred therapeutic interventions is one critical avenue by which to
address trauma and its often devastating sequelae.
However, therapeutic interventions are only a small part of what is needed.
For example, the disproportionate effects of trauma on young people, needs to
also be addressed through safeguarding and promoting the rights for children
and ensuring young people feel they have a secure future. Chronic
unemployment and bleak economic prospects cannot be divorced from the
mental health challenges faced by a range of people in the society. Links
between mental health and the social environment have been well documented,
with deprivation, poverty and low educational attainment being associated with
poor mental health.59 According to Muldoon and Downes (2007) in order to
better understand the impact of any specific incident in conflict situations
approaches need to consider previous traumatic experiences and socio-
economic background. Clearly there are linkages between trauma, anti-social
behaviour, crime, poverty, substance abuse, and suicide, and therefore there is
a need to define the relationship between mental health and justice both in the
criminal sense but also socially. At the same time, however, we need to ensure
that stigmatization of the working-class as responsible for the violence does
not take place as this can be traumatizing in itself, and it fails to see that the
conflict has permeated all aspects of life in Northern Ireland and is also
perpetuated by attitudes across the society.60
This sort of thinking means we need to stretch the boundaries of the mental
health field to encompass the spatial territory of politics, justice and socio-
economics if we are to truly understand how individuals have been adversely
affected by political conflict. In other words, the mental health impact of the
71
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
conflict needs to be mainstreamed across policies aimed at health, welfare,
education, justice and economic development among others. Beyond
considering innovative methods of incorporating discourses of mental health
and the conflict into other paradigms, this article has argued that mental health
should not be discussed simply in terms of individual psychopathologies, but
also in terms of shared conflict experiences across collectives and groups. This
requires community-orientated interventions aimed at whole communities as
part of the process of social reconstruction.61 These interventions should have
psychological, social, economic, cultural and environmental elements and be
aimed at ensuring human security in the broadest sense and seek to maximise
the capabilities of individuals to participate in the development of their own
lives and communities. Such a focus should also aim to build resilience by
building on existing coping mechanisms and capabilities often seen in
communities, which may be present in the community and social structure.
Barsalou (2005) posits that we should reinforce the sources of resilience within
our communities instead of psychopathologizing the process of social
reconstruction.
For strategies to be effective the whole family should be the focus of the support
in order to dampen trans-generational effects of the conflict.62 Even those
lacking direct experiences of the conflict such as young people can continue to
live with its legacy. Yet, if we focus only on the individual aspects of a young
person’s particular experience, we may disregard common narratives, shared
experiences and the social and political conditions that detrimentally affect their
mental health. Moreover, we would fail to see the implicit linkages between
the mental health of parents or community leaders, and the manifestation of
trauma in young people. Equally, by taking a narrow individual pathology
model, or only focusing on direct victims of the conflict, the experience of many
women who had to cope with enormous levels of family disruption, economic
hardship and abuse in the home linked to violent conflict-masculinities63, as
well as alcoholism often seen in impoverished communities, can be missed. In
other words, if we isolate our discussion of mental health to trauma caused by
the direct participation of men in armed conflict, we would ignore the shared
experience of women in the structural and physical violence associated with
that struggle and its aftermath.64
By discussing mental health solely in terms of individual psychopathologies,
we also forego the pursuit of strategies to address cultural attitudes to violence.
Support for violence and its pervasive nature post-Agreement cannot be reduced
to an individual’s particular state of mental health or pathology. Without
questioning the society-wide cultural framework that perpetuates and
legitimizes the pursuit of goals through violence, we not only limit alternative
72 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
courses of action, but restrict the space for victims and survivors to speak openly
about their experiences of conflict at the detriment of their mental health.
In summary, violence and dealing with its mental health legacy means we
need to understand violence in context and address it not only individually, but
socially and politically. Although, it is extremely important to focus on the
victims and survivors of the conflict, we need to simultaneously move beyond
this narrow focus and consider the wider society. There is of course a danger in
arguing everyone was affected by the conflict, i.e. we can fail to acknowledge
the differential impact of the conflict.65 However, if a genuinely contextual
approach to dealing with the legacy of conflict is adopted, then different social,
political, developmental and environmental interventions, as well as tailored
individual therapeutic approaches, would be the result.
73
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
Notes
1 World Health Organisation, 2002; Ghosh, Mohit and Murthy, 2004.
2 Deloitte, 2007.
3 Department of Health, Social services and Public Safety, 2003.
4 Department of Health, Social services and Public Safety, 2004.
5 Harland, 2009.
6 The second annual Forum for Cities in Transition was held from 23rd to 26th May,
2011 in the Guildhall in Derry/Londonderry. On the closing day of the conference,
participants met for a session on “Conflict and Mental Health” which was billed as
“a panel discussion on the need to deal with PTSD and other mental injuries caused
by conflict” (Forum for Cities in Transition, 2011). Chaired by Professor Brandon
Hamber, panelists included: Lord John Alderdice, House of Lords and Executive
Medical Director of South and East Belfast Health and Social Services Trust from
1993 to 1997; David Bolton, Director of the Northern Ireland Centre for Trauma
and Transformation in Omagh, Northern Ireland; Marie Breen-Smyth, Chair of
International Politics at the University of Surrey, England; Arlene Healey, Centre
Manager and Consultant Family Therapist at the Family Trauma Centre in Belfast,
Northern Ireland; and Maureen Hetherington, Coordinator of The Junction, a
community relations and peacebuilding centre.
7 Ferry, Bolton, Bunting, Devine, McCann and Murphy, 2008, p.22.
8 Alderdice, panel.
9 Bolton, panel.
10 Ibid.
11 Ferry et al, p.28.
12 Muldoon and Downes, 2007.
13 De Jong, Komproe and Van Ommeren, 2003.
14 De Girolamo and McFarlane, 1996; Muldoon and Downes, 2007.
15 Muldoon and Downes, 2007, p.148.
16 Bolton, panel.
17 Breen-Smyth, panel.
18 Department of Health, Social services and Public Safety, 2003.
19 Alderdice, panel.
20 O’Hara, 2011.
21 Northern Ireland Statistics and Research Agency, 2011.
22 Ibid.
23 Tomlinson, 2007.
24 Alderdice, panel.
25 Ibid.
26 Ibid.
27 Jamieson, Shirlow and Grounds, 2010.
28 Ibid.
29 Hamilton, Thomson and Smyth, 2002.
30 Irish Echo Online, 2003.
31 McDowell, 2007.
32 Bracken, 1998.
74 Shared Space: A research journal on peace, conflict
and community relations in Northern Ireland
33 APA Health Center, 2004.
34 Baker and Shalhoub-Kevorkian, 1999.
35 Lykes and Mersky, 2006.
36 See Beristain, 2006.
37 Breen-Smyth, panel.
38 Ibid.
39 Ibid.
40 Bolton, panel.
41 Breen-Smyth, panel.
42 Ibid.
43 Hetherington, panel.
44 Hamber, 2009.
45 Bolton, panel.
46 Hamber, 2009.
47 Alderdice, panel.
48 Ibid.
49 Hetherington, panel.
50 Ibid.
51 Tomlinson, 2007, p.109.
52 McAllister, 2008.
53 Verwimp, 2004, p.233.
54 Tabeau and Bijack, 2005, p.207.
55 Cairns and Darby, 1998; Smyth, 2001; Morrissey and Smith, 2002.
56 Fay, Morrisey, Smyth and Wong, 1999.
57 Consultative Group on the Past, 2009.
58 Ibid.
59 Department of Health, Social services and Public Safety, 2006.
60 Hetherington, panel.
61 Ghosh, Mohit and Murthy, 2004.
62 Thabit, Abed and Vostanis, 2001.
63 Hamber, 2007.
64 Hamber, Hillyard, Maguire, McWilliams, Robinson, Russell and Ward, 2006.
65 Morrissey and Smyth, 2002.
75
Perspectives and Possibilities: Mental Health in post-Agreement
Northern Ireland
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