Conflict, peace and mental health: Addressing the consequences of conflict and trauma in Northern Ireland

By David Bolton

What are the human consequences of conflict and what are the appropriate service responses? This book seeks to provide an answer to these important questions, drawing on over twenty-five years of work by the author in Northern Ireland and elsewhere. Focusing on the work undertaken following the Omagh bombing, the book describes how needs were assessed and understood, how evidence-based services were put in place, and the training and education programmes that were developed to assist first those communities affected by the bombing and later the wider population affected by the years of conflict. The author places the mental-health needs of affected communities at the heart of the political and peace processes that follow. This is a practical book and will be of particular interest to those planning for and responding to conflict-related disasters, policy makers, service commissioners and providers, politicians, civil servants and peace makers.

• Language: English
• Publisher: Manchester University Press
• Release date: Jun 20, 2017
• ISBN: 9781526116406

David Bolton

David Bolton worked in a broad variety of occupations before settling into a career as a lecturer on English as a foreign language. He has written a number of textbooks for foreign students, published around the world, as well as a local history book on Bristol, where he lives.

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Conflict, peace and mental health

Conflict, peace and mental health

Addressing the consequences of conflict and trauma in Northern Ireland

DAVID BOLTON

Manchester University Press

Copyright © David Bolton 2017

The right of David Bolton to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.

Published by Manchester University Press

Altrincham Street, Manchester M1 7JA

www.manchesteruniversitypress.co.uk

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

ISBN 978 0 7190 9099 8 hardback

First published 2017

The publisher has no responsibility for the persistence or accuracy of URLs for any external or thirdparty internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Typeset in 10.5/12.5 Adobe Garamond by

Servis Filmsetting Ltd, Stockport, Cheshire

Dedicated to the people of Enniskillen and the people of Omagh, who held together in times that might otherwise have driven them apart.

Contents

List of figures and tables

List of abbreviations and glossary

Acknowledgements

Timeline

Introduction

1  The Omagh bombing and the community’s response

2  The Omagh Community Trauma and Recovery Team

3  Assessing the mental health impact of the Omagh bombing

4  The mental health impact of the Troubles, 1969–1999

5  The mental health impact of the Troubles, 2000–2015

6  The Northern Ireland Centre for Trauma and Transformation: a comprehensive trauma centre

7  The development of a trauma-focused therapy programme

8  Trauma-focused skills training for practitioners

9  Research, advocacy and policy support

10  Planning for and responding to the mental health impact of conflict

Postscript: the rupture of loss and trauma

Bibliography

Index

Figures and tables

Figures

1  Illustration of the pattern of referrals to the Omagh Community Trauma and Recovery Team, over two-and-a-half years, from August 1998.

2  Illustration of the PDS and GHQ caseness levels for adults, for each type of exposure to the Omagh Bombing (Duffy et al., 2013).

3  Illustration of the mean PTSD and stress scores of staff involved in the response to the Omagh bombing, compared with scores for those who were not involved (Luce et al., 2003).

4  Number of self-help groups formed in Northern Ireland in relation to the Belfast Agreement (From Dillenburger et al., 2006).

5  A needs-led and trauma-focused public health framework for service development and building workforce capability in communities affected by long-term stressors.

6  The prevalence of lifetime mental health disorders in the Northern Ireland Study of Health and Stress across three trauma categories (Bunting et al., 2012).

7  Overview of possible measures to promote the capabilities of community members and key services to address the immediate and long-term impact of major traumatic stressors on individuals, families and communities.

Tables

1  Framework for considering the impact of community tragedies (Bolton, 1999).

2  Overview of the NICTT’s integrated trauma-focused workforce development framework.

3  An example of a competence framework developed by the NICTT, outlining core competences of workers operating in key parts of a trauma stepped-care system.

Abbreviations and glossary

Acknowledgements

What follows reflects the concerns and efforts of many, not just one person. I wish to record and acknowledge the contribution to this work of those who have suffered loss, injury and trauma over the course of nearly thirty years and whom I have met along the way. On nearly every page, a child, a parent, an adult or a family came to mind as I wrote. Their loss, suffering, realities, insights and hopes, their sometimes arresting view of things, pervade the thoughts and purposes behind this book. Likewise, I wish to record and acknowledge the contributions of the hundreds of individuals whose lives touched mine and whose efforts brought consolation, support and healing to those who have suffered – from the passing act of neighbourly kindness that made all the difference, to the life given over to this work. I remember especially the humanitarian efforts of manager, practitioner and administrator colleagues whose compassion, skill and professionalism I was privileged to witness at first hand on many occasions. Similarly, across Northern Ireland, throughout the Troubles, many individuals, services and communities provided what support they could – often in the most difficult of circumstances. My experience has been that in the deepest adversity the best of humanity can be found. The collective generosity of those who suffered and the efforts of those who sought to help them stand over and against the worst that we can do to each other. Beauty, instead of ashes.

Services such as those developed in Omagh following the bombing and later in the work of the Northern Ireland Centre for Trauma and Transformation (NICTT) could not have been established or sustained without the support of funders. Many funders and donors – public, charitable, private and personal – have contributed to the body of work described in the following pages. I gratefully acknowledge the contribution of: the Sperrin Lakeland Trust; the Northern Ireland Office (NIO), the Omagh Fund, the European Union’s PEACE II and Interreg funds and Cooperating and Working Together (CAWT), the UK’s Big Lottery Fund, Northern Ireland’s Executive Office (formerly the Office of the First Minister and Deputy First Minister), the Lupina Foundation, The Atlantic Philanthropies, Northern Ireland’s Department of Health (formerly the Department of Health, Social Services and Public Safety), the Community Relations Council and other funders. Appreciation also to the Special European Union Programme Body (SEUPB), which managed the European Union’s Programme for Peace and Reconcilliation, for its interest in the research and work of the NICTT. The support interest and encouragement of those individuals in funding bodies, who were motivated by their concern for those in need and their desire to see good things happen, is not forgotten.

When so many have played a part, thanking and acknowledging are fraught with the problem of adequately reflecting whose contribution should be acknowledged. So, mindful of the support and friendship of many, there are some I would like to thank in particular for their companionship and collegiality along the way. First, from the earlier days, I think of my boss at the time, Freda Carson, who along with two local teachers Kate Doherty and Toni Johnston with courage, concern, intuitive caring and commitment, did so much to bring support to children, adults and families affected by the Enniskillen bombing (Doherty, 1991). In 1989, following the Kegworth aircrash, Marion Gibson and I worked together representing Northern Ireland’s Health and Social Services in the East Midlands, England. Marion has contributed much to the development of practice in the wake of disasters, in Northern Ireland and elsewhere. Then, from our work in the aftermath of the Omagh bombing, I remember in particular, Hugh Mills, chief executive, and Richard Scott, chairman, of the local public health and social care services agency, the Sperrin Lakeland Health and Social Care Trust, whose intuitive and enabling leadership at a time of great crisis for our organisation, made good things happen – including the establishment of the Omagh Community Trauma and Recovery Team. I recall the tireless work of fellow directors, senior managers, practitioners and administration colleagues as we sought to bring order out of the chaos of the immediate aftermath and in the long term ensure services were available to the community. I remember vividly those I worked alongside in the hours and days following the bombing, colleagues from my own organisation – the Sperrin Lakeland Trust – and those from other organisations and places who volunteered to work alongside us. I recall too the wider community of those who worked to bring help and support, including members of the public, neighbours and friends, colleagues from local not-for-profit agencies, the clergy and leaders from local churches and faith communities, the family liaison officers from the local police service, and the staff at Omagh Leisure Centre, who made a significant contribution to the practical care of those who needed it. And there was the important work of colleagues who kept services going for those who had not been affected by the bombing, yet still required medical, nursing, social care and other services.

From the early days of our work in Omagh following the bombing in 1998, Kate Gillespie, consultant psychiatrist and accomplished cognitive therapist, contributed greatly to the development of the trauma therapy service, and through her skill and commitment helped so many along the way. Michael Duffy, experienced social worker and skilled cognitive therapist who, with a detailed knowledge of Omagh and the wider community, energetically coordinated the work of the Omagh Team for over three years and who likewise did much to help people through his therapeutic work. Kate and Michael later contributed centrally to the development of the NICTT and in particular the provision of its therapy, research and education services. Key to progress was the commitment of many practitioners, including Sean Collins and colleagues from various disciplines who, following the bombing in 1998, formed the early team and in some cases contributed over many years, including with the NICTT. James Baxter and Michael Skuce, Omagh’s senior police officers, Eddie Morton, Eddie Giboney and their colleagues worked closely with us to coordinate the support for individuals and families affected directly by the bombing. Maura McDermott, child and adolescent consultant psychiatrist, led the development of services for children and young people caught up in the explosion and was central to the study which assessed their needs in the aftermath. Clive Burges, occupational health consultant, played a key role in the development of services to support the staff of the local hospitals and community services who had responded to the bombing and was instrumental in the important study of staff needs in the years following the bombing. I remember too administration colleagues, especially the late James Johnston, Daphne Armstrong, Anne Donaghy and Esther Stewart and their colleagues, without whom we would have been lost and who brought much to the services of which they were an essential part. Colleagues in the local mental health services played a key role in supporting the local community and in volunteering for the trauma Team over the course of its lifetime. I recall the tireless contributions of the Reverend Robert Herron and Father Kevin Mullan who with other faith leaders contributed so much to the stability of the Omagh community, and whose liturgical and pastoral responses, along with their insights and support, helped us in the development of services. Joe Martin, chief executive of the local education authority, Jack Walls who was assigned to liaise between the schools and the Team, their colleagues, and local school principals and teachers, were key to establishing a relationship between the pivotal work of schools in support of children and the work of the Omagh Community Trauma and Recovery Team. The officers and politicians at Omagh District Council contributed much to the response and recovery of the local community, and I recall in particular the leadership of John McKinney, chief executive, the staff at the Leisure Centre under the leadership of Phillip Faithful, and the creative and enabling contribution of Frank Sweeney. The editors and staff of the two local newspapers, the Tyrone Constitution and the Ulster Herald, played such an important role in telling the wider world about the impact of the bombing and provided valuable information and support for local people.

Several academics contributed to the development of the strategic direction of services and to the understanding of the impact of the bombing on the community. David Clark, professor of psychiatry, Ann Hackmann, Freda McManus, Anke Ehlers and their colleagues at Oxford University were instrumental in the therapeutic approach at the heart of the therapy programme. With local services, they undertook the needs-assessment of adults within a year of the bombing, upon which later developments were founded. Similarly, Jenny Firth-Cozens of the University of Northumbria, and her colleagues Anna Luce and Simon Midgley helped us understand the impact of the bombing on health and social care staff and thereafter greatly influenced the development of staff care services. Andy Percy and the late Patrick McCrystal from Queens University Belfast, along with Michael Fitzgerald from Trinity College Dublin, collaborated with local practitioners to undertake the important needs-assessments of children and adolescents, which again influenced the development of services.

When the decision was taken some years after the Omagh bombing to establish the NICTT, it required the formation of a governing trust. The steadfast contribution of the trustees was central to the work of the Centre. I am profoundly grateful to the tireless leadership, wisdom and support of the chairman, Fabian Monds, who was originally from Omagh, with a background as an entrepreneur and leading academic. I also pay tribute to the other trustees, Brian Patterson (business leader), David McKittrick (journalist and writer, and co-author of an iconic chronicle of the deaths in the Troubles, Lost Lives), Paul Seawright (professor of photography and esteemed photographer of the Troubles), Roy McClelland (professor of mental health and co-chair and author of a major review of mental health needs and services in Northern Ireland – the Bamford Report – DHSSPS, 2007), Sacha, Duchess of Abercorn (from the Omagh area, practitioner in transformation and founder of The Pushkin Trust focusing on the developmental and educational potential of children), and Sinead McLaughlin (a primary school principal from Buncrana, Co. Donegal). They brought presence, along with highly relevant skills and experiences to their task. Together they have made a remarkable contribution of public service in the interests of those who have been adversely affected by the Troubles. They have provided the platform upon which services could be developed, in which pivotal research was undertaken, training developed and from which other communities in far away places that were affected by conflict, could be helped.

Others played pivotal roles in the development and work of the Centre. I recall the passionate concern of Sean O’Dwyer, chairman of the the Omagh Fund, whose encouragement, along with the support of the Fund’s trustees and officer, Brian Oliphant, enabled the Centre to take hold in the imagination of those who sought to support adults, children and families affected by the bombing. The Fund’s long view of and concern for the needs of those affected psychologically by the bombing was highly influential in shaping the work undertaken in response to the bombing, and later by the NICTT. My thanks to Hugh Mills, chief executive of the Sperrin Lakeland Trust, John McKinney, chief executive of Omagh District Council, Tom Frawley, chief executive of the Western Health and Social Services Board (the Sperrin Lakeland Trust’s service commissioner) and John O’Neill and colleagues at Venture International, who were instrumental in early progress on the development of the Centre. And thanks also for the considerable support in the early days following the bombing in Omagh and in the years that followed, of John McFaul and Des Browne, Parliamentary Under-Secretaries of State (both of whom were subsequently appointed life peers in the UK House of Lords) and their colleagues at the NIO, with William Stevenson and Mary Lemon, civil servants at the NIO’s Victims Liaison Unit in Belfast, for their interest, advice and support and for making funding available at a critical time. My thanks also to John Clarke at the Victims Unit (OFMDFM) for his interest and support especially in relation to the training and education work of NICTT.

My thanks to all our other colleagues at the NICTT, including Eileen MacMackin, Ruth Liggett, Tracey McCrossan, Gemma Rankin and other administration colleagues, whose contribution was at the heart of its work. Besides those already mentioned, the Centre’s therapy team included Geraldine Kerr, who was the first point of contact for many who sought our help, and therapists Susan McGandy, John McLaren and Paul Quinn. In the later years, Brendan Armstrong, cognitive therapist and clinical director at the Centre brought much to the further development of its therapy and education services. Maria Kee, psychiatrist and cognitive therapist, brought innovative approaches to the delivery of training thereby helping many in non-clinical settings, and individuals and families affected by traumatic experiences. Our partnership with Brendan Bunting, principal investigator and professor of research psychology at the Ulster University, with Finola Ferry the lead researcher, Siobhan O’Neill and Sam Murphy, led to an extensive body of research over ten years, which examined the population impact of the Troubles and which came to form the definitive epidemiological assessment of the impact of the Troubles. The partnership was enabled by the Research and Development Division of Northern Ireland’s Public Health Agency, with the interest and support of its former Director, Bernie Hannigan. Key research was funded by Peter Warrian and Margret Hovenec’s Lupina Foundation which established an early interest in the work of the Centre and who, through a sustained relationship of interest and financial support, were also able to contribute to the Centre’s work in support of other conflict-affected communities. Barney Devine who, as business manager of the Centre, not only believed passionately in the mission of the Centre but from his years in education, and in peace and reconciliation work in Northern Ireland, saw how addressing the mental health impact of the Troubles was a critical concern for peace-makers. For his enduring support and friendship, I am most grateful.

The book has been made possible by the encouragement, practical and kind support of the chairman and trustees of the NICTT Trust, by the Department of Foreign Affairs and Trade in Dublin, and with the help and assistance of the staff at Manchester University Press, to whom I express my appreciation. My thanks to Rachel Evans, copy-editor, for her careful and gracious handling of the text, and to Dominic Carroll, for his comprehensive index. My thanks also to those writers and researchers who willingly provided copies of research reports and papers, and who answered queries. I am thankful to David McKittrick and Hugh Mills for their careful proofreading of the text, and to them, David Clark, Barney Devine, Kate Doherty, Michael Duffy, Kate Gillespie, Robert Herron, Roy McClelland, Fabian Monds, Eddie Morton, Kevin Mullan, Sean O’Dwyer, Brian Oliphant and Richard Scott, for their observations and suggestions. I am grateful to Paul Seawright whose picture Steps is on the front cover, one of several we were privileged to have on the NICTT corporate literature over the years.

Finally, my wife Helen, our daughters – and in adulthood their growing families – have been an enduring source of strength, support and encouragement over the years. They have shared closely in some of the events described herein. This book is in many ways an account of their journey also. To Helen, Julie, Leah and Alison – my utmost respect and deepest appreciation.

Through this book I hope that something of the efforts of this cast of many will reach people we will never meet and places we will never visit, but with whom we share and express our concern, support and hope.

David Bolton, Enniskillen

January 2017

Timeline

With thanks to McKittrick and McVea (2012).

Introduction

Two days after a car bomb exploded in the town of Omagh in Northern Ireland on 15 August 1998, the British Secretary of State for Northern Ireland, the late Dr Marjorie Mowlam M.P., visited the town. In the context of a terrible atrocity her visit was both ceremonial and highly focused on the real risk the bombing posed for the recent peace agreement (the Belfast or Good Friday Agreement), which marked the culmination of talks between most of Northern Ireland’s political parties and the British and Irish Governments. The Agreement, finalised on 10 April 1998, had raised hopes of a historic political settlement to the Troubles – the years of civil conflict in Northern Ireland that had commenced in 1969.

On the morning of Dr Mowlam’s visit to Omagh, I was one of a small group of health and social care practitioners who had been involved in responding to the bombing, from shortly after the bomb exploded. When she arrived at the temporary trauma centre that had been hurriedly set up that morning, she wanted to hear about the consequences of the bombing for those directly affected and for the wider community. What I recall most clearly from our conversation were two incisive questions posed by the Secretary of State. What would the human impact of the bombing be? And what needed to be done to address that impact?

It has taken over fifteen years to provide competent answers to these important questions and it is from the experience of struggling with them