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 August 31st, 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 2

Lessons from the Omagh Bombing

On 15 August 1998, a car bomb exploded in the centre of the market town of Omagh, Northern Ireland, causing the deaths of 29 adults and children, along with two unborn twins.  Fifteen of the deceased were aged 17 years or younger.  A further 400 people were injured, 135 of whom were hospitalised.  Many children and young people sustained severe and life-changing physical injuries, including loss of limbs and of soft tissue, scarring, and disfigurement.

It was the largest single incident in the Troubles in Northern Ireland, and the scale of the casualties sent shockwaves across the island of Ireland and beyond.  The bombing occurred just 6 weeks after the Good Friday Belfast Agreement which had been endorsed in twin referenda in Northern Ireland and the Republic of Ireland.  The ensuing widespread hope for a better and more peaceful future magnified the shock and horror caused by the bomb.

When the Omagh bomb exploded, the immediate mobilisation of resources was necessarily focused on the physical injuries in the local hospital and an airlift of survivors for specialist treatment in hospitals outside the area.  The local Health & Social Care Trust recognised that both the immediate and long term mental health impacts of this mass casualty event required urgent consideration. Consequently, a team of experienced clinicians was brought together with the aim of addressing the psychosocial care needs of the hundreds of direct and indirect survivors of the bomb.  The success of the mental health response to the Omagh bombing represented a turning point, and the lessons learned have had a lasting impact (1).

 

Omagh bombing - the impact

The ripple effects of the atrocity in a small town (with a population of 26,000) surrounded by a dispersed rural community were immense.  Recognising that existing mental health services were at risk of becoming overwhelmed, the Omagh Community Trauma and Recovery Team (CTRT) was established and remained operational for 3 years.  It acted as a central point of access, and provided assessment and therapeutic services.  In addition, it provided community and educational initiatives and established links with key community support mechanisms, such as those provided by the clergy, schools, general practitioners, and community and voluntary sector groups.  In total, 2,000 bomb-related contacts were recorded by local general practitioners in the first 3 weeks after the tragedy.

During its first year the CTRT received 500 contacts, the majority of them during the initial 4 months.  There was a marginal increase in referrals at the time of the first anniversary of the explosion, and over the 3 years in which the CTRT operated there were 622 referrals in total.  In addition, in the year after the bombing, local voluntary organisations provided support and counselling services to around 400–500 people.  Crucially, the service was evidence based, outcomes focused, and research orientated from the outset.

The response was based on the best available evidence, but also helped to grow the evidence base through a series of studies that have improved our understanding of PTSD.  We thought it important to explore the varying impacts of the Omagh bombing both to assist in the immediate effort to help survivors, and in order to improve our understanding of the impact of mass casualty events for the future.

There were several distinct features of the tragedy that had the potential to contribute to its psychological impacts.  First, the number of children who were killed or injured, symbolized by the sight of children’s small white coffins, generated severe distress and profound grief.  Second, although most of the people who had died during the Troubles were male, the adults who were killed during the Omagh bombing were mostly female, including a pregnant mother of twins.  Third, the incident occurred during a period when expectations of violent incidents had diminished greatly.  Fourth, people were moved to a perceived place of safety as the two telephone warnings provided inaccurate details of the bomb’s location; consequently, the police mistakenly moved people into the area of greatest danger.  Fifth, the disaster was caused by human activity, a factor that has been shown to produce higher levels of distress than so-called natural disasters.  

 

Research into Mental Health

The team undertook studies examined the impact on adults, adolescents, children and healthcare staff.

The adult study (n = 3,123; age range 16–92 years) found that six variables linked to a newly developing cognitive model for PTSD accounted for 63% of the variance in PTSD scores – rumination, thought or emotion suppression, nowness of the memory (whether the memory retains a sense of the trauma still being in the present), a muddled memory, negative beliefs about oneself and the symptoms of PTSD, and beliefs about the world being an unsafe place (2).

A parallel study, which involved 2,335 adolescents aged 14–18 years, demonstrated that exposure alone is not a precise predictor of risk for developing PTSD.  Again the findings emphasised the importance of cognitive factors – what a person is thinking during the event (e.g., the thought ‘I am going to die’), negative beliefs about oneself, negative beliefs about PTSD symptoms (e.g., ‘I am losing my mind’), rumination, and nowness of the memory) (3).

The third study involved 1,945 children aged 8–13 years who were attending 13 schools in the district.  An important finding was that comorbid conditions, especially anxiety, had a moderating effect on factors previously reported to predict the emergence of PTSD, such as pre-trauma characteristics (e.g., gender, age) and exposure factors (e.g., whether one was present at the time of the bombing), in predicting probable PTSD.  This is an important finding, as when a child presents with high levels of anxiety after a traumatic incident the clinician should screen carefully for PTSD (4).

 

Research Inform clinical practice

Two clinical trials were informed by this research, and in both of them therapists were encouraged to target the key PTSD maintenance factors identified in the studies.  In the first trial, a consecutive series of 91 patients who had been exposed to the Omagh bombing and had PTSD were recruited to an open trial of trauma-focused cognitive behaviour therapy (CBT) There were no major exclusion criteria, and 53% had an additional Axis I disorder.  The pre-treatment to post-treatment effect size was 2.47, with a median number of eight sessions.  Comorbidity did not predict outcome, nor did lack of social support and status (civilian vs. emergency services personnel).  However, continuing physical health problems were associated with poorer outcomes (59% vs. 77% improvement) (5).

The second clinical study, was undertaken in a new regional centre that evolved from the CTRT, the Northern Ireland Centre for Trauma and Transformation (NICTT), which continued its clinical work and research programme while broadening its geographical reach to all of Northern Ireland (6).  In this second randomised controlled trial, 58 people with prolonged and severe PTSD were randomised to either immediate cognitive therapy or delayed cognitive therapy.  At the point of randomisation, the mean duration of the current episode of PTSD was 8.9 years (SD = 9.2), with a range of 3 months to 32 years. Subjects demonstrated significant comorbidity (72% had one or more additional Axis I disorders), 19% had been physically injured, and 81% had experienced multiple traumatic events (median 3, range 1–10 events).  Despite the complex nature of the presentations of these patients, at 12 weeks the immediate cognitive therapy treatment group scores were significantly lower than the waiting-list group scores on all measures for both completers and the intention-to-treat group (p < 0.001). The mean number of sessions was 7.8 (9.2 for completers).  The delayed treatment group had similar pre- to post-treatment gains.  Factors associated with less improvement were high levels of depressive symptoms and a longer time since the trauma.  Factors not associated with improvement were the presence of a comorbid disorder, the presence of enduring trauma-related physical health problems, whether the traumatic event was directly experienced or witnessed, and single versus multiple traumas.

The evidence accrued in this series of studies helped to inform the further development of the Trauma focused CBT for PTSD underlining the importance of linking research and clinical practice, including the exploration of themes evident at the population level to identify important target areas for clinicians.

Prior to the Omagh studies, the focus of therapy was often on pre-trauma (e.g., gender) and peri-trauma (e.g., type of exposure) factors, whereas these findings suggest that immediate post-trauma factors were more important predictors of which people would go on to develop symptoms of PTSD.  The results of the community studies were integrated into clinical practice in the CTRT, with assessment and therapy targeting key risk factors for chronic PTSD, including rumination about the trauma and its consequences, and perceived nowness of traumatic memories.  Fewer imaginal exposure sessions, which are often difficult to tolerate, were offered, responses to triggers were understood and modified, and more purposeful use of visits to the site of the trauma was utilised.  The result was improved clinical outcomes and more rapid improvement.

 

An Emerging Concept: Prolonged Grief Disorder

In 1998, approaches to assessing and treating complex or traumatic grief were not well developed.  Although most bereaved people recover from the initial intense emotions within weeks or months, some experience difficulties that persist, and they may not seek clinical help despite suffering significant social impairment.  Prolonged grief disorder (PGD) was introduced as a diagnostic category in the International Classification of Diseases 11th Revision (ICD-11 (7)), published by the World Health Organization, in 2012.  It was included as an update to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) in 2020 (8).

In the response to the Omagh bombing, several points quickly became clear in relation to bereavement.  First, both primary care and mental health staff were reluctant to pathologise grief, which resulted in a low rate of referral.  Second, in the absence of a clear differentiation between PGD and normal grief, when people were referred it was often to non-specialist teams, usually in the voluntary sector, and for generic grief counselling.  Emerging evidence at the time, and further research since, have reported little evidence of benefit from this kind of generic grief work [9].  Studying the phenomenology of complex or traumatic grief has provided a rationale for developing a cognitive approach for PGD based on the TF-CT model for PTSD (10, 11).

 

Organisational and Therapeutic Responses to Trauma

The lessons learned after the Omagh bombing have helped us to guide responses to mass casualty events and service developments elsewhere, including providing training, advice, and support.  The response to the bombing became a reference point for clinicians and health service managers responding to other large-scale attacks, including the 9/11 attacks in the USA, the Utoya Island mass shooting in Norway, the Manchester Arena bombing and the London Bridge attack in the UK, and, more recently, the war in Ukraine.  We now understand that after large-scale attacks a tailored and phased response is necessary.  There is greater awareness that psychosocial responses should be evidence based, and that non-evidence-based interventions, which might cause harm, should be avoided.

The response to the Omagh bombing has also informed the development of the Improving Access to Psychological Therapies (IAPT) programme in England, which is designed to provide evidence-based psychological therapies at a population level – for example, through the incorporation of session-by session self-report outcome measures (12).

 

The Long-Term Impact of the Omagh Bombing in Northern Ireland

We can state with confidence that mental health services in Northern Ireland and worldwide have learned from the response to the Omagh bombing.  Now, decades after the worst years of violence, we can be hopeful of improved outcomes for survivors of conflict in Northern Ireland and elsewhere, even long after the initial traumatic event.

The Good Friday (Belfast) Agreement pledged that ‘we must never forget those who have died or been injured, and their families’.  The tragedy of the Omagh bombing reinforced the impetus for peace and the acknowledged necessity for adequately addressing the long-term consequences of violence.  The Stormont House Agreement of 2014 committed government to create a comprehensive, regionalised, and evidence-based trauma network for Northern Ireland.  The Regional Trauma Network was created, involving statutory, community, and voluntary sector organisations.  Its organisational and clinical approaches are directly informed by the experience of Omagh.  The knowledge accumulated also helped to inform the clinical aspects of the implementation of the Troubles Permanent Disablement Payment Scheme which provides payments to survivors of the Troubles who are physically or psychologically injured.

We will discuss these items in more detail in future blogs.

 

PLEASE NOTE

This blog is derived from our book chapter:

Mulholland, Ciaran; Duffy, Michael (2024)  Case study 1: the Omagh Bomb, the mental health response, and the lessons learned. Major incidents, pandemics and mental health: the psychosocial aspects of health emergencies, incidents, disasters and disease outbreaks. ed. / Richard Williams; Verity Kemp; Keith Porter; Tim Healing; John Drury. Cambridge University Press, 2024. p. 252-256.

 

References

1. Bolton D. Conflict, Peace and Mental Health: Addressing the Consequences of Conflict and Trauma in Northern Ireland. Manchester University Press, 2017.
2. Duffy M, Bolton D, Gillespie K, Ehlers A, Clark DM. A community study of the psychological effects of the Omagh car bomb on adults. PLoS One 2013; 8: e76618.
3. Duffy M, McDermott M, Percy A, Ehlers A, Clark DM, Fitzgerald M, et al. The effects of the Omagh bomb on adolescent mental health: a school-based study. BMC Psychiatry 2015; 15: 18.
4. McDermott M, Duffy M, Percy A, Fitzgerald M, Cole C. A school based study of psychological disturbance in children following the Omagh bomb. Child Adolesc Psychiatry Ment Health 2013; 7: 36.
5. Gillespie K, Duffy M, Hackmann A, Clark DM. Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Behav Res Ther 2002; 40: 345–57.
6. Duffy, M., Gillespie K, Clark DM. 2007, Posttraumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: Randomized controlled trial: British Medical Journal. 334, p. 147-150
7. World Health Organization (2012). ICD-11 Beta: Mental and Behavioural Disorders. Geneva, Switzerland: WHO
8. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC, USA: APA
9. Litterer DA, Hoyt WT (1999). Effectiveness of grief therapy: A meta analysis. Journal of Counselling Psychology, 46, pp. 370-380.
10. Duffy M, Wild J. A cognitive approach to persistent complex bereavement disorder (PCBD). Cogn Behav Ther 2017; 10: E16.
11. Duffy M, Wild, J. Living with loss: a cognitive approach to complicated and traumatic grief. Behav Cogn Psychother 2023. Available from: https://doi.org/10 .1017/S1352465822000674.
12. Clark DM (2018) Realising the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT Program. Annual Review Clinical Psychol. 14: 159–183. doi:10.1146/annurev-clinpsy-050817-084833.

 

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.