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

    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

    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

    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

    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

    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

    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

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