Professional life

Despite the history of civil violence and disorder there has never been a shortage of (albeit largely local) admirably qualified candidates for both junior and senior psychiatric posts. Psychiatric hospital and community facilities in the province are generous compared to those in Great Britain and we have been spared the savage pruning in services and the directions professional life has taken in other parts of the UK. The moves to general hospital units and community psychiatry have been less precipitous and more planned than in Great Britain, as local services and the planners have waited to observe the benefit/loss ratio of mainland experiments.

Doctors generally are well thought of in the province and have not had to endure the threats to which other professional groups and individuals have been subjected. None the less, almost every major hospital campus has been sometime visited by violence.

Our colleagues in accident and emergency medicine, orthopaedics, neurosurgery, plastic and general surgery have developed an expertise in the management of emergencies matched, sadly, only by our forensic scientists and pathologists. Similarly, in psychiatry each of us has gathered the experience of dealing with victims of violence, learned best classification systems of psychological reactions to trauma and developed treatment techniques to best apply in different and individual circumstances.

History

The different phases of what the Provisional IRA call “the Long War” and citizens colloquially call “the Troubles” brought different psychological effects or issues. Throughout the late 1960s and early 1970s there was widespread public disorder and street rioting, with neighbourhood pogroms and intimidation and a rapidly escalating murder rate. Sectarian gangs readily found innocent targets in the opposing community, since people are easily identified and political assumptions made about them merely from their address, name or school background. There was much fear and people, of necessity, scurried to the comparative safety of the ghettos, at the expense of increasing sectarianism and with growing reliance on the paramilitary organisations forming within. The Republican movement launched a bombing campaign against civic targets, bringing terror and mayhem to town centres and fear to the citizenry. They were matched in their savagery by Loyalist paramilitary retaliation.

The entry of the British army initially as broker between the two communities and the 1972 proroguing of the failed local Stormont Parliament provided each paramilitary organisation with fresh reason for renewed barbarity. The death rates for that period (Table 1) reflect the changing phases of the conflict over the 30 years. Internment failed as a military strategy, as did a series of political initiatives and strategies. More selective targeting of the security forces and members of opposing organisations and the switch of the bombing campaign to mainland Britain led to a reduction in the local murder rate and to what a Home Secretary, Reginal Maudling, infamously described as an “acceptable level of violence” (see Curran, 1988).

In more recent years the apparent acceptance by the paramilitary organisations of the futility of violence, their cease-fires and their tentative move towards politics, combined with public weariness of the Long War, have led to new hopes and initiatives. However, we have a communal legacy to come to terms with: 3740 dead, thousands bereaved, countless thousands injured and many embittered and unforgiving survivors. Many former paramilitarists have switched to frank criminality and establishing drug empires, while the political objection of Republicans to the state police force allows them to adopt a role in ‘restorative justice’, physically punishing, expelling and banishing those they judge as socially deviant.

Impact on services

We have previously commented on the apparently limited impact of the Troubles on conventional psychiatric services (Reference CurranCurran, 1988). The Mater Infirmorum Hospital serves the catchment area of North and West Belfast, containing half the population of the city of Belfast. It is an area of very high social deprivation, unemployment, housing and population density and social pathology. The region is characterised by a series of culturally polarised housing estates and politically opposed communities, each area boasting flags, bunting, murals and painted kerbstones, as much to claim its territorial and cultural loyalty as to annoy and provoke the opposition. The interfaces are the new battlegrounds for internecine community insult and attack. Yet, in an internal audit of the Mater Infirmorum Hospital's general (National Health Service) (NHS) psychiatric practice we found only 6% of our referrals and admissions had as their precipitants any violence-related issues. Some 94% of our clinical practice is the same as that of colleagues elsewhere in the British Isles. And yet, in our densely populated, if geographically small, catchment area of perhaps no more than 10 square miles, there have occurred one-third of all the deaths, one-third of all the injuries and one-third of all the incidents of criminal and terrorist violence in the whole province over 30 years.

This figure of 6% has a resonance elsewhere. Lyons (1974) followed-up 100 individual victims of various bomb explosions and found that only 4% required psychiatric admission. Sims, in a smaller study of victims of the Birmingham bomb, found that 5% required psychiatric help (see Curran, 1988). In a large survey of 499 criminal injury litigants who had each been victim of a variety of acts of terrorist and criminal violence, we found that 4.5% required psychiatric in-patient admission, while 11% graduated to NHS out-patient services (Reference Kee, Bell and LoughreyKee et al, 1987). In our most recent survey of 2191 victims, 2% were admitted and 13% referred to either psychiatric out-patients, community psychiatric nurses or counselling services (further details available from the author upon request).

Just because someone experiences or witnesses an act of violence does not mean that he or she will inevitably develop psychiatric morbidity. Indeed, we have previously described (Reference Kee, Bell and LoughreyKee et al, 1987) how 6% of victims had insufficient clinical evidence to warrant any diagnosis, while a further 7% had mere acute reactions to stress lasting no more than days. The classifications applied in the 1987 study (Box 1) used ICD–9 (World Health Organization, 1978), which did not allow for a diagnosis of post-traumatic stress disorder (PTSD). The results are shown in Table 2. However, examining the same cohort of 499 victims under DSM–III–R (American Psychiatric Association, 1987) we determined that 23% had a diagnosis of PTSD (Reference Kee, Bell and LoughreyKee et al, 1987), a proportion in keeping with the 20–30% quoted in a recent paper by Adshead (2000).

In community surveys, Cairns & Wilson (1989) reveal that the population deals effectively with the stress of continuing political violence, possibly by denial (Reference Cairns and WilsonCairns & Wilson, 1984). They also found that coping is more related to a person's perception and appraisal of violence than its actual level.

Throughout the province, in both urban and rural practice, our in-patient admission rates, out-patient attendance rates and psychotropic drug prescription rates are broadly comparable to similar districts in Great Britain. Our people who commit parasuicidal acts seem to do so by reason of the same litany of life's vicissitudes as anywhere else. Interestingly, our completed suicide rate halved when the Troubles first broke out in 1969 and remained low for the next few years, when the homicide rate was high (Table 1). This reflects international experience in several arenas of war over 100 years and invokes Durkheim's (1897) observation that there is an inverse relationship between homicide and suicide rates. However, since 1975 we have experienced exactly the same rise in male, and especially young male, suicide rates as has been noted elsewhere in Europe. In psychological post-mortem studies and observations we have not noted any correlation between the community violence and the personal circumstances of the victims of completed suicide and we assume the reasons for the high suicide rate are similar to those in other jurisdictions.

And yet this society has mutilated and ravaged itself for 30 years, visited quite indescribable acts of barbarity on its neighbours and created even more sectarianism and polarisation than previously existed. Every doctor has had patients who have been physically and emotionally wounded and who have witnessed direct acts of violence or the indirect sequelae of violence. Many thousands of people have been the primary victims of violence and every psychiatrist has examined and nursed and shared the pain of people intimidated, abused, bereaved, tortured or maimed. But the services have not been swamped, except on occasions by the sheer numbers involved, such as after the Omagh and Enniskillen bombs. We, the citizenry and the professionals alike, seemed to have learned to cope, whether by some individual psychological process or by using the plethora of voluntary, self-help support organisations that have blossomed over the years.

Currently, in the new dispensation of political hope, there is debate and speculation as to the need for a formal peace and reconciliation forum, such as happened in South Africa. Some argue that the public opportunity for individuals' cathartic expression of their feelings would prove therapeutic for the individuals and reparative for the public, but many others consider that such a forum would be exploited by the anti-agreement faction and used to express further bitterness and foment sectarian attitudes.

Why is there no apparent increase in psychopathology?

We have previously speculated (Reference CurranCurran, 1988) on the range of explanations for the fact that our services have not been overtaken by the enormity of individual and community emotional pain that it is assumed must have arisen because of the violence (Box 2). Possibly individuals do not report to the caring agencies, on the assumption that little or nothing can be done for emotional pain rooted in the reality of their circumstances. Perhaps, over the years, the emotionally wounded and hurt have selectively emigrated and are no longer part of local epidemiology. Some believe that taking part in violence, being involved in politics or being a member of a paramilitary organisation, having an emphatic political view and expressing feelings including anger, are all cathartic and psychologically healthy. Many people with neurotic disorders who otherwise would have visited our psychiatric clinics in peaceful times may falsely attribute their symptoms not to personal intrapsychic conflicts, but to the harsh and violent real world around them and do not present to us. Psychologically, perhaps the citizens, including doctors and psychiatrists, lawyers and police personnel, have all become habituated to the reality and the concomitants of violence and become case-hardened. Certainly, as doctors who have directly examined thousands of victims, we are aware of this, although we are unsure whether it is denial or habituation that we employ to self-protect against the horror within the histories we have gathered. In a recent paper, Turner (2000) discussed the issue of vicarious traumatisation of therapists and listed hopelessness, omnipotence, punishment and avoidance as the countertransference feelings they experience.

We have also argued previously (Reference CurranCurran, 1988) that increased social cohesion within sub-populations may partly explain the phenomenon of the apparently modest impact of the Troubles on our local health services. Over the years, self-selecting communities have come together for protection. They may gather in the increasingly subcultural homogeneous working-class estates, albeit at the expense of increased sectarianism and rule by paramilitary organisations posing as defence forces united against a common enemy, real or supposed. They may form social, occupational, recreational or class groups. They may even set up victim groups. Whatever the socially binding group each of us has determined for ourselves over the 30 years, it may serve as a psychologically useful device when all around us others have wished, visited or threatened us with evil and malice. We imagine that, just as in the Second World War Londoners gathered ‘underneath the arches’ of the underground gained individual strength from the camaraderie, and just as the Franco-Prussian people bonded closer in nationhood during their earlier wars, so also have the various sub-populations of Northern Irish society gained strength and mutual support from whatever their source of social cohesion between 1969 and 1999.

Children of the Troubles

The experience of our colleagues in child and adolescent psychiatry has been broadly similar. Most diagnostic and treatment issues in child psychiatry are the same as they are elsewhere in the UK, and particularly in Belfast reflect emotional problems associated with inner-city life. On the occasions of major bombings or shooting massacres, such as Shankhill, Greysteel and Loughinisland, there was an increase in referrals of affected children and their families, approximating to 10% of the workload at those times. In some areas outreach specialist clinics were set up to cope with those sudden increased demands. Lynch (quoted in Daly, 1999) found that although many of the experiences undergone in such incidents mirrored those of children involved in other stressful events, prolonged exposure to the conflict and frequent reminders, such as media reporting and increased security force presence, exacerbated children's symptomatology. These children included those who had witnessed a shooting, often of a family member, had been involved in a bombing, with or without physical injury, and had been held captive or hostage. The majority suffered PTSD. In many cases school performance deteriorated. Preschool children, for whom diagnosis is difficult, often exhibited behavioural problems such as disobedience, disruptiveness, overactivity and distractibility, as well as positive symptoms of PTSD (e.g. sleep and distorted dream disturbance). Symptoms of anxiety and depression were common in all ages and several experienced grief reactions following loss of relatives. In many cases parents were unable to offer support to their children because they also were suffering from the effects of the trauma and loss. For some families, mistrust of the security forces and/or fear of the paramilitaries were additional stressors.

While studies of clinic attenders have found that many children directly exposed to violent incidents are likely to be severely affected, for children in the community not directly exposed the situation is less clear. A school-based community study currently underway may help clarify this. Fifteen months after the Omagh bombing of August 1998, 4500 children aged between 8 and 18 years completed screening questionnaires designed to assess symptoms of traumatic stress and anxiety. Preliminary results suggest considerable disturbance for a significant minority of children.

The psychological impact of horrific paramilitary beatings that some children and adolescents have endured has yet to be studied.

Treatments in psychotraumatology

Treatments for PTSD (including debriefing) have been reviewed in several publications (Reference Foa, Steketee and RothbaumFoa et al, 1989; Reference ShapiroShapiro, 1989; Reference Van der Kolk, McFarlane and Weisaethvan der Kolk et al, 1996; Reference Wessely, Rose and BissonWessely et al, 1998; Reference Mayou, Ehlers and HobbsMayou et al, 2000; Reference TurnerTurner, 2000). Here we present just one model of psychological intervention, offerred by van der Hart et al (1989). They provide a useful therapeutic skeleton (after Pierre Janet, see Box 3) listing the five phases of treating PTSD.

Conclusions

Many individuals in Northern Ireland over the past 30 years have been physically and psychologically traumatised and have suffered, often grievously. The existing health services have coped in helping those who presented to them. The rest of the (primarily not traumatised) population has apparently coped without psychiatric intervention, by whatever psychological resources, since there is little evidence of a major impact on NHS facilities. Curiously, we have noted in more recent years, when the violence has reduced somewhat, a rising trend in people seeking acknowledgement of victimhood. Society and the Government are currently addressing this.

Our experience is that the best result for an individual victim is attained by a combination of psychopharmacology and cognitive and behavioural therapies, but to be successful this must be delivered in the context of public empathy and society's acknowledgement that the victim has suffered.

Multiple choice questions

1. 1. Traumatic memories:

   1. a are highly emotionally charged

   2. b fit easily within existing declarative schemata

   3. c need to be converted to semantic memory during therapy

   4. d are flexible and readily accommodate new information

   5. e are stored in iconic form.

2. 2. Fewer people than anticipated attend psychiatric services because of:

   1. a the selective emigration of the traumatised

   2. b the cathartic effect of involvement in violence

   3. c denial

   4. d non-reporting of symptoms

   5. e habituation to violence.

3. 3. PTSD in preschool children may be accompanied by:

   1. a disobedience

   2. b drug misuse

   3. c overactivity

   4. d disruptiveness

   5. e distractibility.

4. 4. As regards treatments for PTSD:

   1. a selective serotonin reuptake inhibitors are of benefit in the acute phase

   2. b critical incident stress debriefing has been shown to have long-term benefits

   3. c psychodynamic therapy is widely used in Northern Ireland

   4. d eye movement desensitisation and reprocessing is a ‘stand-alone’ therapy

   5. e cognitive–behavioural therapy is a key component in its management in Northern Ireland.

5. 5. Janet's treatment phases for PTSD include:

   1. a disintegration of the traumatic memory

   2. b restructuring of traumatic personal schemata

   3. c deconditioning of traumatic memories and responses

   4. d trauma narrative development

   5. e stabilisation.