Legacy of war

Northern Ireland’s Troubles left their mark on the
province’s community not just in terms of physical injuries
and deaths. Sally Gillen looks at the
mental health problems stemming from the conflict and at steps
being taken to tackle them

There was a time when Michael Duffy would arrive home at night,
lock the door and stay put until morning. But that was in the 1980s
when the former social worker lived in Belfast, at the heart of
Northern Ireland’s Troubles.

Violence between Protestants and Catholics was a daily reality. In
the 30 years of Troubles – before the ceasefire in 1997
– more than 3,600 people died and another 40,000 were
injured.1

Peace may have been a long time coming but inevitably 30 years of
unrest have left their mark, not least on the mental health of
those living in the province. A report by the Sainsbury Centre for
Mental Health and the Northern Ireland Association for Mental
Health (Niamh), published in June, revealed a 25 per cent higher
prevalence of mental illness in Northern Ireland compared with
England.

It is impossible to calculate the extent to which the Troubles are
responsible for this staggering disparity. As well as an unstable
and bloody history, Northern Ireland has a host of other
socio-economic problems that have contributed to the high levels of
mental illness.
Poverty and deprivation also blight the country, and industries
such as farming – a traditional employer in the largely rural
province – have been badly affected in recent years.

Graham Logan, service manager at Niamh, says the legacy of the
Troubles is undoubtedly connected to the high number of mental
health problems. But he is keen not to simplify the causes, adding
he would not want to overstate the Troubles’ impact.
Nevertheless, he believes the Department of Health’s current
review of mental health and learning difficulty services in the
Northern Ireland, due to be published next April, is “long
overdue”.

Unlike England, Northern Ireland has no national service framework
for mental health and Logan hopes the review will set one up.
Outreach services, crisis resolution teams and a range of provision
created through the NSF would be enormously helpful, and Logan
wants to see more of an emphasis on preventive work.

With the bill for mental health services totalling £3bn,
according to the Sainsbury report – a sum that includes the
cost of care, lost working days as well as the cost of pain and
disability – the review must provide urgent solutions to
tackling the large number of people with mental health problems if
the costs are not to spiral further. In the five years to 2003, the
money allocated to dealing with mental health problems rose by
£36m to £150.8m, according to Department of Health
figures.

Research published in the Journal of Epidemiology and Community
Health in June 2003 found that, of nearly 1,700 people interviewed
aged 16-24, more than 20 per cent said the Troubles had affected
their lives “quite a lot” or “a lot”.

Some people, though, are unaware their mental health has been
affected. Duffy now works at the Northern Ireland Centre for Trauma
and Transformation, which opened in 2002. It has dealt with 200
referrals from people of all walks of life and is staffed by a
range of professionals, including social workers and psychiatrists,
to help victims aged 16 and over.

He says: “Some of the people we see have been traumatised
since the 1970s and are suffering from chronic post-traumatic
stress disorder (PTSD) and a range of other conditions. Some will
claim that they have not been affected by the Troubles even though
their levels of functioning may have been badly damaged.
“

Links between mental health problems such as anxiety and depression
– common symptoms of trauma – have rarely been made in
the past by the individuals concerned or by professionals such as
GPs and social workers.

Consequently, says Duffy, there have been high levels of
misdiagnosis of symptoms, and someone who may have PTSD may instead
have been diagnosed with depression. Not only does this mean it is
impossible to judge whether the problem may be connected to the
Troubles but it may also have been mistreated, partly because of an
unwillingness to acknowledge the effects of armed conflict.

“There has been a huge process of denial that went on for
years. Individuals, communities and people at senior level in
public sector agencies have failed to recognise the impact the
Troubles were having until recently,” says Duffy.

“At various stages of the conflict one group’s
allegiance would be a lot stronger and it was important to people
not to show they were being affected. It was a case of having a
stiff upper lip and not showing your group to be less
resilient.”

Now that the bombs are no longer going off, many more people are
facing up to what is a painful past and seeking help. But peace
brings its own problems. Post-ceasefire suicide rates have risen,
particularly among young males, and new services are springing up
to cope with a rise in referrals.

Stigma attached to mental health problems may also, however,
prevent people seeking help. Logan says: “Northern Ireland is
quite a religious part of the world. Within that there can be an
assumption by some – certainly not all – that if you
have a faith you should not be suffering, that if you are a
Christian you should not be depressed.”

For this reason he believes that in addition to promoting mental
health awareness through the education system, churches should be
approached.

Duffy says: “Social workers have a valuable role in helping
to put communities back together. They were often the only point of
contact for some very vulnerable people during the Troubles.
However, social workers have been guilty in the past, as have other
professionals, of not speaking about it.”

But as Bernie Kelly, a former team leader in a Belfast social work
department, points out, social workers in the city, which
experienced 40 per cent of the deaths, were as influenced by the
unrest as much as anyone, and were often prevented from doing their
jobs by road blocks. They were also threatened.

Kelly is now a trauma co-ordinator at the North and West Belfast
Health and Social Services Trust, which serves the parts of the
city most badly affected by violence. Of the 40 per cent of
Troubles-related deaths in Belfast, 70 per cent were in north and
west Belfast. Confidential counselling and therapeutic services
provided by a neighbouring trust are now being offered to social
work staff, among others.

Take-up of help has been high, and increased during the Holy Cross
primary school dispute in Belfast in 2001 when loyalists surrounded
its gates for five months and abused Catholic girls and their
parents as they entered and left. Social work offices were near the
school, and staff were at times caught up in the fray.

In October, a trauma centre will be opened for people living in the
north and west. There is one other centre for families and children
in the city, but Kelly says people were too frightened to travel
from their part of the town to use it.

Despite the ceasefire, segregation remains. “We have a
ceasefire but we do not have reconciled communities, which is
crucial to a more permanent peace. A lot of the dynamics that
maintained the conflict remain simmering under the surface,”
says Duffy.

A government paper, A Shared Future on Improving Community
Relations In Northern Ireland, published in January 2004 and based
on a consultation with more than 500 people and organisations,
found that 40 per cent supported the existing segregation.

This is an area where social workers can play a part. Duffy says:
“Social workers have an important role in the post-conflict
era in terms of helping groups break down divisions.”

But there are positive signs that the profession, along with
others, is slowly coming to acknowledge the significance of the
Troubles. The inclusion of dedicated training on the issues within
the social work curriculum testifies to this.

“For the first time in 30-odd years the Troubles are on the
social work curriculum as a subject in their own right. How
incredible is that?” asks Duffy.

People in all kinds of situations who have suffered and might be
recognising, now the war is over, that they have some symptoms of
PTSD, might be struck by this quote from the famous anti-war film
All Quiet on the Western Front, says Duffy.

“And this I know: all these things that now, while we are
still in the war, sink down in us like a stone, after the war shall
waken again, and then shall begin the disentanglement of life and
death.” CC

1 MT Fay, M Morrisey, M Smyth, Cost of the Troubles, Institute of
Conflict Research, 1999