The Stormont House Agreement (SHA) will be 10 years old on 23 December 2024. Many aspects of the Agreement have not been fully or even partially implemented but there are two important exceptions, both relating to the mental and physical health of persons affected by the “Troubles”/”conflict”.

Today the Regional Trauma Network (RTN) established under this Agreement, which involves both the Health and Social Care Trusts and the community and voluntary sector groups which are focused on providing care and support for victims and survivors of the “Troubles”/”conflict”, is operational and developing its services, interventions, and training and research programmes.

The Troubles Permanent Disablement Payment Scheme (TPDPS) has been operational since 31 August 2001, and has now received more than 10,000 applications.

These initiatives, outlined in successive clauses of the SHA, were built on an understanding of the mental health impact of the Troubles, not just on individuals, but on communities and society.  There is much to be learnt from an interweaving of this clinical understanding with political and legal considerations.

Mitchell Institute Fellows: Legacy, Dr Ciaran Mulholland and Dr Michael Duffy will explore these issues in this blog series on PTSD and Politics: Lessons from the ‘Troubles’, in the hope that this will be helpful and meaningful, for practitioners, policy makers and academics, both in Ireland, North and South, and in other places.

 

Part One

Ten Years Since the Stormont House Agreement: Delivering for Victims and Survivors?

The Stormont House Agreement (SHA) is ten years old.  Two important proposals, both relating to the health of persons affected by the “Troubles/”conflict” were outlined, very briefly, in successive clauses of the Agreement alongside a pledge to provide care and support for victims and survivors in a more general sense.

The Executive will take steps to ensure that Victims and Survivors have access to high quality services, respecting the principles of choice and need. The needs of victims who do not live in Northern Ireland should also be recognised.

The Commission for Victims and Survivors’ recommendation for a comprehensive Mental Trauma Service will be implemented. This will operate within the NHS but will work closely with the Victims and Survivors Service (VSS), and other organisations and groups who work directly with victims and survivors.

Further work will be undertaken to seek an acceptable way forward on the proposal for a pension for severely physically injured victims in Northern Ireland.

Victims and survivors will be given access to advocate-counsellor assistance if they wish.

(Stormont House Agreement, 2014 – paragraphs 27-29)

These commitments, made in the context of the Agreement’s discussion around dealing with ‘The Past’, refers to recommendations informed by a Comprehensive Needs Assessment published by the Commission for Victims and Survivors (CVS) in 2012.  In this research, the CVS identified mental health as the key priority for victims and survivors and recommended the development of a trauma-focused coordinated service network lead by the Department of Health (DOH) in partnership with the Executive Office (TEO).

These ideas grew from years of previous deliberations and discussions and were based upon the experience and acquired knowledge of individuals and groups across all sectors.  There was increasing recognition that whilst the violence had stimulated advances in surgical and anaesthetic care, progress in mental health care had been less impressive.  This had to change.  If Belfast could lead the world in surgical care, why not too in mental health care?  Understanding the past will help us set the context for developments since the SHA was signed.

 

Surgical Treatments: Belfast Leads the World

When violence erupted onto the streets in August 1969 its epicentre was only a few hundred yards from the Royal Victoria Hospital (RVH).  Mr William Rutherford, an A & E doctor in the hospital, had returned to Northern Ireland after many years as a medical missionary in India, where he had witnessed at first hand the upheavals which accompanied the British withdrawal and the partition of the subcontinent between India and Pakistan.  In 1969, he developed the hospital’s Disaster Plan, which was designed to ensure fluid mobilisation of staff and equipment in times of crisis. “The Disaster Plan imposed order on what would otherwise have been chaotic situations”’ and was instrumental in ensuring the survival of many victims who would otherwise have died from their injuries (see Clarke, The Royal Victoria Hospital, p 184).  In the first few years of the Troubles ‘disaster situations’ were declared in the hospital on 15 occasions.  The Plan was later adopted by hospitals across the UK (Rutherford, 1975).  

Several significant surgical advances resulted from the ingenuity of Northern Ireland's medical profession.  It was realised early on that many bomb victims were developing “blast lung” (when trauma to the chest causes the lungs to fill with blood and other fluids, commonly resulting in death).  Bob Gray, Denis Coppell, and other Royal Victoria Hospital anaesthetists developed Positive End Expiratory Pressure (PEEP) which acted to keep the lungs slightly inflated at the end of a breath to prevent collapse (Richard Clarke’s history of The Royal Victoria Hospital in Belfast covers this and other relevant developments).  This technique is now widely used around the world.

High velocity bullet wounds to the head often result in large skull defects and Mr Derek Gordon, a neurosurgeon at the RVH and Gordon Blair, of the School of Dentistry, developed titanium cranioplasty to address this issue.  Titanium was moulded by explosives, permitting the production of a very fine, extremely strong metal.  This approach proved extremely effective and, following a seminal 1974 British Medical Journal paper, was taken up worldwide (Gordon and Blair, 1975).

The 'Belfast Fixator' (an external fixation device for limb fractures), created by orthopaedic consultant John Templeton and local engineers James Mackie and Sons in the 1970s, allowed for the treatment of muscular or vascular complications to proceed, whilst repair of the fracture and skin tissue continued (see Standard et al, 2011).  Vascular surgeon Aires Baros D'Sa (see obituary, 2007) introduced intraluminal shunts for devascularising limb injuries (the “Belfast Technique”) to allow early restoration of blood flow to the affected limb.  As a result of these innovations the number of amputations in Belfast hospitals fell dramatically over the course of several years. 

All these innovations have influenced battlefield medicine and have saved many lives in other zones of conflict.

 

Mental Health Treatments: High Rates of Prescribing

The physical impact of violence is all too evident, the psychological impact less so.  In the context of mass upheavals affecting most of the population mental health impacts are of course to be expected but there is also ample evidence that increased social cohesion in embattled communities acted as a powerful protective factor for many, who looked to their family, friendship group, local community or church.

There is certainly some evidence of a generalised population effect and Northern Ireland does appear to have higher rates of mental health problems than England, Scotland, Wales and the Republic of Ireland.  One survey suggests rates of common mental health problems such as anxiety and depression (based on the General Health Questionnaire) are 25% higher than in Great Britian but other surveys have not confirmed this (there are major differences in methodology between studies and definitive research is yet to be completed).  There is some evidence of higher rates of psychotic illnesses and addiction problems, and for a high rate of PTSD, but the exact rates relative to other conflict zones is uncertain.

Whatever the population effects, many of the individuals who were most directly affected by the violence developed diagnosable and treatable mental health disorders including post-traumatic stress disorder and prolonged grief disorder.  These conditions were not adequately treated in the past, but for obvious and understandable reasons.  

In the 1970s and 1980s mental health services remained underdeveloped, and general practitioners carried the bulk of the workload.  One consequence was a reliance on medication: by 1976 the local Belfast Telegraph newspaper was carrying the headline “Ulster-The Tranquillized Province” (Belfast Telegraph, June 15th, 1976) and reported a “three to four” times increase in amount of “tranquillizers” prescribed since 1969.  In the 1970s “benzodiazepine tranquillizer prescribing was consistently 20-30% higher than in the rest of the UK…” and the highest rates were in North and West Belfast, the areas of worst violence.  Today Northern Ireland has “…one of the world's highest prescription rates for anti-depressants…” which “far exceed…those of England and Wales - and were also higher than levels found in 23 countries featured in a global study which included Canada, Australia, Portugal, Denmark and Sweden” (see Irish Times, 17 November 2014).

 

Where to Next?

Simplistic conclusions should be avoided, but it seems reasonable to consider it probable that difficulties accessing psychological therapies results in over-prescribing.  A systemic approach was necessary to at last address the consequences of trauma on the mental health of individuals who had suffered most during the Troubles.  The mental health response to the Omagh bombing was to represent a turning point, and the lessons learned would have lasting impact.

 

References

• Adam Standard, Karim Brohi and Nigel Tai, ‘Vascular Injury in the United Kingdom’, Perspectives in Vascular Surgery and Endovascular Therapy, 2011, 23, 27–33
• Barros D’Sa L and Blair P. Aires Agnelo Barnabé Barros D’Sa Obituary, British Medical Journal, 2007, 334, 804.
• Belfast Telegraph (June 15th, 1976) “Ulster-The Tranquillized Province”
• Clarke, R (1997) The Royal Victoria Hospital, Belfast: A History 1797-1997.  Blackstaff Press, Belfast.
• Gordon, DS and Blair GAS Titanium Cranioplasty British Medical Journal, 1974, 2, 478-481
• Irish Times (November 17th, 2014) “Concern over high antidepressant use in North.  Research questions view poverty and legacy of Troubles fully explain high prescription levels”
• Rutherford WH, ‘Surgery of Violence II: Disaster Procedures’, British Medical Journal, 1975, 1, 443-45.

 

Michael Duffy is a Consultant Cognitive Psychotherapist and Senior Lecturer/Director of the Specialist MSc (Trauma) in Cognitive Behavioural Therapy at Queen’s University Belfast.  He is an acknowledged expert in trauma related conditions such as PTSD, Complex PTSD and Prolonged Grief Disorder.  He is research & clinical advisor to the RTN, a member of the UK Trauma Council and member of Mental Health Advisory Panel of the National Emergencies Trust.

Ciaran Mulholland is a consultant psychiatrist with the Northern Health and Social Care Trust, and Senior Lecturer in the Centre for Medical Education at Queen’s University. Since 2015 he has been the Clinical Director of the RTN.  He has provided advice to the Northern Ireland Secretary of State, the Commission for Victims and Survivors, The Executive Office, Department of Health, Department of Justice, the Victims Payments Board Office, and the Veterans Commissioner, on mental health issues including the implementation of the Troubles Permanent Disablement Payment Scheme.

The featured image has been used courtesy of a Creative Commons license.