Promoting mental health in Northern Ireland ...

Promoting mental health in Northern Ireland: addressing division, inequality and stigma Key words: mental health; Northern Ireland; trauma; inequality; stigma

This article provides an overview of the literature on the impact of ‘the Troubles’ on mental health in Nor thern Ireland. It identifies three main phases of professional and policy response from concerns about the effects of the violence in the early 1970s, through many years of collective denial and neglect, until acknowledgment, following the Good Friday Agreement in 1998 (Northern Ireland Office, 1998), of high levels of trauma and unmet need. The issues of inequality and stigma are also considered and it is argued that peace is necessary but insufficient for promoting mental health. The development of mental health services in Northern Ireland and the relatively recent focus on promoting mental health are also outlined and examined. It is suggested that attempts to address the needs arising as a result of ‘the Troubles’ and more general mental health promotion strategies have, to some extent, developed in parallel and that it may be important to integrate these effor ts. The relative under-development of mental health services, the comprehensive Bamford Review (2005; 2006) and the positive approach of the Public Health Agency mean that, even in the current economic climate, there are great opportunities for progress. Routine screening, in primary care and mental health services for trauma, including Troubles-related trauma, is recommended to identify and address these issues on an individual level. It is also argued, however, that more substantial political change is needed to effectively address societal division, inequality and stigma to the benefit of all.

EVALUATION Gavin Davidson Lecturer in Social Work Queen’s University Belfast, UK Gerard Leavey Director of Compass – Centre for Mental Health Research and Policy, Northern Ireland Association of Mental Health and Honorary Professor in Community Mental Health, University of Ulster, UK Correspondence to: Gavin Davidson School of Sociology, Social Policy and Social Work Queen’s University Belfast Belfast BT7 1NN UK Email: [email protected]

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n 1819, William Todd, Secretary to the Asylum Commission, wrote that ‘lunatics abound more in Ulster than in any other part of Ireland’ (quoted in Prior, 1994). It has been suggested that this perception may have been created, or reinforced, by the higher levels of adversity and the inadequacies of mental health services in that region (McClelland, 1988). It could be argued that, for Northern Ireland, these issues continue to be important and this article will explore these and other factors relevant to promoting the mental health of its population of approximately 1.7 million people. Northern Ireland was established in 1921, as a result of the Government of Ireland Act 1920 (HM Government, 1920), and political division and conflict are significant, ongoing issues. This is demonstrated journal of public mental health vol 9 • issue 4 © Pier Professional Ltd, 2010

through high levels of segregation in housing and education, between Protestants and Catholics, but was most dramatically and destructively expressed through the violence, usually referred to as ‘the Troubles’, which dominated the jurisdiction from 1969 until the Belfast or Good Friday Agreement (hereafter, the Agreement) in 1998 (Northern Ireland Office, 1998; Muldoon, 2004). Over 3,700 people have been killed and over 40,000 injured as a result of ‘the Troubles’ and sectarian attacks and murders have continued, although at a much lower level, since the ceasefires of the mid-1990s (Odena, 2009). In this article, the literature on the impact of ‘the Troubles’ on mental health will be reviewed. The impact of inequality and stigma in Northern Ireland will also be explored. The development 10.5042/jpmh.2010.0698

Promoting mental health in Northern Ireland: addressing division, inequality and stigma

of mental health services will then be outlined before the main developments in promoting mental health are discussed. It is argued that, while considerable progress has been made, the central issues to public mental health in Northern Ireland of division, inequality and stigma have not been sufficiently addressed and some recommendations for possible ways forward are proposed. A broad understanding of mental health promotion is used that encompasses: the promotion of the mental health and well-being of the whole population; the prevention of mental health problems in at-risk groups; and health promotion for people with mental health problems (Bamford Review of Mental Health and Learning Disability, 2006). However, the main focus is on population-based approaches. The rationale for considering mental health promotion is established most convincingly by the social and economic costs of mental health problems. In Northern Ireland, these costs (which include direct care as well as lost productivity and quality of life) were estimated to be nearly £3 billion in 2002/03 (Northern Ireland Association for Mental Health & Sainsbury Centre for Mental Health, 2004). Mental health promotion has the potential to reduce these costs, minimise risks to all aspects of health, enhance protective factors and improve mental health throughout the life course (Leavey et al, 2009). The impact of ‘the Troubles’ on mental health in Northern Ireland Several phases or perspectives can be identified in the literature addressing the mental health impact of ‘the Troubles’. The first was evident in newspaper reports in the early 1970s when the direct and immediate negative impact of exposure to trauma was highlighted. This is exemplified by an article from The Guardian on 23 August 1971 (quoted in Prior, 1994), which reported: ‘A serious wave of mental illness has developed in Belfast as a result of last week’s rioting and continued tension. Doctors are reporting influxes of patients with mental breakdowns … one doctor in the Shankill Road area ... said he had prescribed more tranquillising drugs in the past five days than he usually does in a year… A spokesman for Purdysburn Mental Hospital estimated that since the riots, admissions had increased by 25 per cent.’ In this first phase, the view that the violence had a direct and negative impact on mental health, makes intuitive sense but was challenged, to some

extent, by the second perspective that suggested that there was little or no increase in mental health problems. This view emerged in research that was conducted, mainly by psychiatrists, during the conflict. An early example was Lyons (1971; 1972) who identified a reduced incidence of depression and suicide in the early years of ‘the Troubles’ and suggested that rioting and violence were offering opportunities to externalise aggression so that it had a positive impact on mental health. This research has been heavily criticised (eg. Heskin, 1980) but, until the process in the 1990s leading to the Agreement, the perspective that there was little impact on mental health appears to have been the dominant one in the research literature. Cairns and Wilson (1984) reinforced this view but suggested another explanation. They surveyed a community sample and concluded that the ‘majority of people in Northern Ireland deal effectively with stress generated by the political violence, but do so by denying the existence of this violence around them’ (Cairns & Wilson, 1984). Curran (1988) provided a more in-depth analysis of possible factors that may have explained the lack of an identified increase in the use of mental health services. These included: non-reporting; migration of those affected; denial and habituation; that there may be a latency period after exposure to trauma; catharsis, which reinforces Lyons’ theory of the mental health benefits of rioting; that those with ‘neurotic symptoms’ may improve when faced with external stress, partly as they may falsely attribute their difficulties to those external events; and that the conflict may improve social cohesion and identity within the different communities. The third phase began to develop in the late 1980s, with the suggestion that there were high levels of undetected mental health problems, especially post-traumatic stress disorder (PTSD) (eg. Loughrey et al, 1988), related to ‘the Troubles’. This view, which to some extent is a return to the first phase, has now become the dominant view but did not gain great momentum until the start of the process of transition to peace in the mid-1990s that led to the Agreement in 1998. Prior to the Agreement, there had certainly been many statutory and community-based efforts to improve community relations and to support people affected by the violence. In so doing, it promoted mental health but these initiatives were fragmented and under-resourced. The Agreement formally acknowledged the importance of addressing the impact of ‘the Troubles’ and made an explicit commitment to meet the associated needs. It stated that: journal of public mental health vol 9 • issue 4 © Pier Professional Ltd, 2010

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‘It is essential to acknowledge and address the suffering of the victims of violence as a necessary element of reconciliation… The provision of services that are supportive and sensitive to the needs of victims will also be a critical element… This will require the allocation of sufficient resources, including statutory funding as necessary to meet the needs of victims and to provide for community-based support programmes.’ The reduction in violence following the ceasefires and the political progress that culminated in the Agreement appears to have enabled the identification of the impact of the previous decades of violence and allowed consideration of how this impact could be more comprehensively addressed. There were two key reports, both completed in 1998, which addressed these issues. The first was Living with the Trauma of the Troubles (Social Services Inspectorate, 1998), which began by acknowledging that: ‘Although the current civil unrest in Northern Ireland has lasted for most of the past 30 years, it is only relatively recently that the long-term social and psychological effects of the traumatic events experienced by many have begun to be recognised.’ It provided a range of recommendations about how specific service provision should be developed to address Troubles-related trauma. The second report in 1998 was the Report of the Victims Commissioner (Bloomfield, 1998) called We Will Remember Them. As well as highlighting those who had died, been bereaved, injured and their carers, it suggested that: ‘There is, in a sense, some substance in the argument that no-one living in Northern Ireland through this most unhappy period of its history will have escaped some degree of damage.’ It also raised the possibility of the establishment of a body similar to the South African Truth and Reconciliation Commission. It seems unlikely to have been a coincidence that it was also in 1998 that the Health Promotion Agency was commissioned to lead the development of the first draft strategy for promoting mental and emotional health in Northern Ireland (Department of Health, Social Services and Public Safety (DHSSPS), 2000). This will be considered in more depth in the section that considers the range of public mental health initiatives in Northern Ireland.

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There have been a number of other research studies that have enabled a more detailed understanding of the mental health impact of the violence. Northern Ireland’s Troubles: The human costs (Fay et al, 1999) mapped all the deaths and highlighted that these were not evenly distributed across place or time. Over half of the deaths occurred between 1971 and 1976 and the main geographical concentrations were in Belfast and Mid Ulster. They also reported that there were more fatal incidents in socially deprived areas. These findings were reinforced by Muldoon and colleagues (2005) who also reported the uneven distribution of impact. They found that 12% of their community sample met the criteria for post traumatic stress disorder (PTSD) and that this was also related to socio-economic status. Dorahy (2006) has made the important point that conventional treatment for PTSD may not be sufficient in Northern Ireland as the nature of Troubles-related trauma and the sociopolitical, ethno-cultural context may require a range of different responses. Tomlinson (2007) in his report, The Trouble with Suicide concluded that: ‘The evidence that experience of the conflict is associated with poorer mental health is strong. Population-based surveys show several things. First, those who experienced most violence have significantly higher rates of depression than those with little or no experience. People whose areas had been heavily affected by violence had very high rates of depression. Another point is that, as the transition to peace progressed, people were more willing to report these associations.’ He also discusses the dramatic rise in suicides completed by young men in North and West Belfast since 1998, although cautions against overly simplistic explanations for these developments, such as a post-conflict reduction in social cohesion, as there appear to be important factors around how suicides have been recorded. Harland (2008) also considered the importance of gender in examining the impact of the Troubles and highlights the ‘complex phenomenon related to being young and male in a society emerging from a period of prolonged violence. While young men are caught up in the transition from conflict to peace they have not been equipped with the skills to manage this change’. Ferry and colleagues (2008) conducted the first epidemiological study in Northern Ireland investigating the number of people exposed


to trauma associated with the conflict and the numbers who have been negatively affected as a result. Two-thirds of people in their study reported having experienced at least one traumatic event and half of these events were conflict-related. They also found high levels of PTSD. Most recently, Leavey and colleagues (2009) have also highlighted the evidence that there may be up to 30% higher levels of mental health problems in Northern Ireland compared to the rest of the UK and that the high levels of violence and deprivation appear to be important factors in this. The Royal College of Psychiatrists (2010) have also reported that the per capita spend on anti-depressants in Northern Ireland is twice what it is in England. It could be argued that these high levels of PTSD and medication use reflect an increasing medicalisation of everyday life (Stein et al, 2007). This may be a factor, but the comparison with the rest of the UK suggests that ‘the Troubles’ do seem to have had a specific and important impact on mental health. Other possible contributing factors include inequality and stigma and these are considered next. Inequality and stigma in Northern Ireland The impact of violence and sectarian division are key issues in considering public mental health in Northern Ireland but it is important not to neglect other overlapping factors that may have had a less dramatic, but perhaps equally damaging, impact on the population’s health and well-being. There are many possible determinants of mental health problems but the focus in this section will be on the role of inequality and stigma. Peace is necessary but not sufficient to promote mental health, as Albee (2003) has argued, successfully promoting mental health requires social justice. In Northern Ireland, concerns about inequality have tended to concentrate on sectarian discrimination rather than social class disparities. As mentioned above, the impact of the Troubles, as well as other social determinants of health, have not been evenly distributed (DHSSPS, 2004). This has led to very progressive equality legislation (although the nine protected categories do not include income) and a high level of awareness of human rights issues but, despite efforts to target social need, the impact of poverty and socioeconomic inequality on mental health have not been effectively addressed. The importance of doing so has been summarised by Friedli (2009): ‘It is abundantly clear that the chronic stress of struggling with material disadvantage is intensified

to a very considerable degree by doing so in more unequal societies. An extensive body of research confirms the relationship between inequality and poorer outcomes, a relationship which is evident at every position on the social hierarchy.’ Northern Ireland has the highest levels of poverty and the lowest rate of economic activity in the UK (Northern Ireland Assembly, 2002) and, in terms of income distribution, has been found to be one of the most unequal societies in the developed world (Hillyard et al, 2003; Farrell et al, 2008). The Social Exclusion Unit (2004) reported that: ‘Stigma and discrimination against people with mental health problems is pervasive throughout society. Despite a number of campaigns there has been no significant change in attitudes. Fewer than four in ten employers say they would recruit someone with a mental health problem. Many people fear disclosing their condition, even to family and friends.’ Even within health and social services, stigma and discrimination are additional barriers to accessing support, social inclusion and stressors on mental health; for example one general practitioner in Northern Ireland stated that ‘they [‘neurotic patients’] take up far too much of our time and energy – people complaining, miserable, depressed, neurotically whining about how unhappy they are, pouring out all their problems in the surgery and dumping them on my doorstep. It would be really unbearable if I was actually listening to them” (quoted in Byrne, 2000). In Northern Ireland, Rethink, a voluntary organisation, reported that over half of their service users and carers reported that stigma was the biggest obstacle that they faced when dealing with their mental health problems (Rethink, 2009). The Health Promotion Agency (2006) have also considered attitudes to mental health problems in Northern Ireland. They compared Northern Ireland with Scotland and found that: ‘Overall, it seems that we in Northern Ireland are more positive when it comes to understanding the rights of someone with a mental health problem. However, we are less likely than people in Scotland to disclose that we have a mental health problem. In addition, fewer of us in Northern Ireland see the public as caring and sympathetic to those with mental journal of public mental health vol 9 • issue 4 © Pier Professional Ltd, 2010

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health problems, and fewer of us believe those with a mental health problem are likely to recover.’ The relative contribution of division, inequality and stigma to mental health problems in Northern Ireland is difficult to estimate, but it seems reasonable to argue that all of these factors need to be addressed. Before discussing how this may be more effectively achieved, the development of mental health services will be outlined and the more recent developments in promoting public mental health will be examined. The development of mental health services in Northern Ireland In 1817, Ireland was the first country in the Western world to introduce legislation to provide a system of public asylums. Perhaps in response to Mr Todd’s observations of high prevalence, the first district asylum in Ireland was built in Armagh in 1825 (Campbell & Manktelow, 1998). Then, ‘during the nineteenth century an enthusiastic policy of asylum building throughout Ireland produced a total of thirty-six asylums. What happened in Ireland mirrored the British experience where excessive resources were used in the provision and massive expansion of mental hospitals and numbers of available mental hospital beds’ (Campbell & Manktelow, 1998). By 1921, in Northern Ireland, there were six district asylums or psychiatric hospitals. The number of inpatient psychiatric beds in Northern Ireland peaked in 1961 at 6,486 (Prior, 1994). Mental health policy then generally followed England and Wales in recommending the transition from institutional to community care for people with mental health problems. Although the number of beds has reduced dramatically, progress in deinstitutionalisation has been relatively slow and all six psychiatric hospitals are still open (DHSSPS, 2009). In 2002–2003 approximately half (57%) of all mental health funding in Northern Ireland was spent on hospital care (Bamford Review of Mental Health and Learning Disability, 2005) and the percentage of the health and social services budget for mental health was 9.3% compared to 11.8% in England (Bamford Review of Mental Health and Learning Disability, 2006; Friedli & Parsonage, 2007). There has been some progress over recent years towards greater prioritisation of mental health and the development of community alternatives to traditional hospital care (DHSSPS, 2009), but the full implementation of positive policy has been frustrating slow.

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Another unusual aspect of mental health services in Northern Ireland is that health and social services have been integrated since 1973 and managed by Health and Social Services Boards, as established by the Health and Personal Social Services (NI) Order 1972 (HM Government, 1972). This was partly motivated by a desire to modernise services, but also by concerns about sectarian discrimination in the provision of services by locally elected councils. The integrated service may then have enabled health and social care professionals to work together more closely, but it also insulated them from local political and community accountability and may have contributed to the ongoing dominance of the medical model in mental health services (Campbell & McLaughlin, 2000; Reilly et al, 2007). Prior to 1972, Pinkerton and Campbell (2002) have suggested that health and social services were not well prepared to meet the needs created by the wider political developments and their responses were relatively unco-ordinated and chaotic. They argue that from 1972 until the 1990s, health and social services developed a more technocratic, neutral and detached role. This was partly due to the structural and organisational changes already mentioned, but not getting directly involved in political issues seems to also have been accepted, by most mental health workers, as necessary to stay safe. It is interesting to consider this response as a form of collective dissociation, a separating off of an area of life that was felt to be too risky or potentially painful to openly discuss and integrate. This approach, however, was partly responsible for the mental health issues arising out of the violence not being either identified or addressed (Campbell & Healey, 1999; Pinkerton & Campbell, 2002). As the research conducted during the 1970s and 1980s suggests, there appears to have been a collective need to either believe that the ongoing trauma was not impacting significantly on people’s mental health or, even if this was suspected, not to raise it. Another factor may have been that the power of the medical profession in Northern Ireland was not as challenged by the introduction of managerialism as it was in other parts of the UK. It is interesting to consider why this was the case and it may in part have been due to the wider conservative ethos that developed in a relatively unaccountable, top-heavy public sector working in the context of political conflict and inertia. The dominance of the traditional medical model may have inhibited the development of public mental health initiatives informed by a wider, more social understanding


of mental health. It is only since the reduction in violence, the introduction of devolution and greater accountability that significant developments and changes in mental health care are being discussed and introduced. Developments in promoting mental health The first draft strategy for promoting mental and emotional health in Northern Ireland, Minding our Health, was produced by the DHSSPS for consultation in 2000. This was an important first step towards a more co-ordinated approach to public mental health and it identified the range of existing relevant policies and services. It also reviewed the international research on effectiveness in mental health promotion and, based on this, made a number of recommendations for developments in early years, education, young people, the workplace, the community and voluntary sector, health and social services, the media and suicide prevention. Although ‘the Troubles’, inequality and stigma were all considered in setting the context, the focus of the recommendations was on conventional approaches to mental health promotion and the need for a regional implementation group to take an agreed strategy and action plan forward. The strategy and action plan was not published by the DHSSPS until 2003 but in the intervening years there was an increased policy focus on addressing the impact of ‘the Troubles’. In 2000, the Victims Unit, Office of the First Minister and Deputy First Minister (OFMDFM) was established and in 2002 it published Reshape, Rebuild, Achieve, which was the first strategy to attempt to comprehensively address the needs of those affected by ‘the Troubles’. Its vision was for:

how the traumatic events of ‘the Troubles’ could be recorded and remembered in ways that would facilitate individuals and the society to recover. It acknowledged the ongoing commemoration and remembering work and proposed a range of ways this could be further facilitated. It also suggested that ‘consideration should be given to the establishment of an appropriate and unique truth recovery process’ (Healing through Remembering Project, 2002). As mentioned earlier, the Promoting Mental Health: Strategy and action plan 2003–2008 was published by the DHSSPS in 2003. Its broad aims were to improve people’s mental health, prevent and reduce mental illness, raise awareness of the determinants of mental health and further develop training for those involved. It included recognition that mental health promotion is relevant to the whole population and needs to work at different levels by strengthening individuals, communities and by reducing social exclusion and inequalities. Interestingly the action plan began with the statement that: ‘Mental and emotional wellbeing is influenced by many factors including childhood experiences, life events, individual ability to cope, social networks, and wider social and economic circumstances. Many of these factors lie outside the control of the health and social services, and indeed of Government.’

‘A society where the suffering of all victims is recognised; a community that acknowledges the pain of the past and learns lessons for the future; and an administration that provides, in conjunction with others, support and services in a proactive and sensitive manner to meet the needs of victims.’

None of the 30 action points specifically addressed socio-economic inequality or ‘the Troubles’ but did include plans for an information campaign to reduce stigma. This was implemented by the Health Promotion Agency (which was incorporated into the new Public Health Agency in 2009) through the Minding your Head campaigns in 2007, 2008 and 2009, which did address the general population but also specifically targeted men aged 16–24 (Health Promotion Agency, 2009). In 2005, the OFMDFM published A Shared Future, which built on Reshape, Rebuild, Achieve but was focused on promoting good relations for everyone in Northern Ireland. It acknowledged that:

This did recommend that the needs of victims should be specifically considered in mental health policy and promotion but the main focus was not on public mental health or population-based interventions. The Healing through Remembering Project, which also reported in 2002, had originally developed through consideration of whether the work of the Truth and Reconciliation Commission in South Africa could provide any direction for Northern Ireland. It considered

‘Northern Ireland remains deeply divided, despite measurable progress. Patterns of division and a culture of violence have become ingrained through fear, mistrust and in many cases, a weary acceptance of patterns of living that have developed over many years in response to conflict and the role of paramilitaries... [and that] Division in Northern Ireland is costly in terms of both social and public resources. There is, unquestionably, an economic imperative to tackle these costs.’ journal of public mental health vol 9 • issue 4 © Pier Professional Ltd, 2010

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It recommended a cross-departmental Good Relations Panel to attempt to build in efforts to tackle division across all aspects of government and this first met in 2007. In 2006, the Victims and Survivors (Northern Ireland) Order 2006 (amended in 2008) led to the setting up of the Victims and Survivors Commission with the remit to promote the interests of those affected by the violence and to oversee the effectiveness of the services that they receive. Although these were positive developments, they represent further examples of the parallel approach to separately addressing division, especially the impact of ‘the Troubles’, and mental health promotion. In 2006, the OFMDFM published its antipoverty and social inclusion strategy called Lifetime Opportunities. This again acknowledged the need to address community division, health inequalities and social exclusion, but was not clear about the detail of how this would be achieved. Between 2002 and 2007 in Northern Ireland, there was a comprehensive review of mental health and learning disability legislation, policy and practice (later named the Bamford Review after the chairman, David Bamford). Although its review of mental health promotion (Bamford Review of Mental Health and Learning Disability, 2006) provided recommendations that were relatively limited, it did however recommend the establishment of a Regional Mental Health Promotion Directorate. This was partly due to the widely held view that the current DHSSPS (2003) Promoting Mental Health: Strategy and action plan 2003–2008 was ineffectual due to ‘inadequate resources; lack of ministerial direction; lack of guidance, authority and accountability to promote cross-sectoral collaboration, and importantly, lack of co-ordination’ (Bamford Review, 2006; p82). It also recommended that a separate suicide prevention strategy was needed and should be implemented and later in 2006 the DHSSPS launched Protect Life – The Northern Ireland suicide prevention strategy. The Bamford Action Plan 2009–2011 (DHSSPS, 2006), in response to the Bamford Review, retained responsibility for mental health promotion within health and social services and identified the new Public Health Agency as the appropriate body to take the lead. In accordance with the Bamford Action Plan, the Public Health Agency is currently developing a new mental health promotion strategy and the suicide prevention strategy is also being updated. An interesting and progressive aspect of the Bamford Review is that a monitoring group, made up of service users, carers and their representatives,

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has been established to consider and respond to the implementation of the Review’s recommendations (DHSSPS, 2009), although it seems reasonable to anticipate that the current economic climate may restrict what can be achieved. Additionally, the Review recommended that there should not be separate mental health and mental capacity legislation, as in the other jurisdictions in the UK, but instead one law for everyone whose decision-making capacity is impaired, for whatever reason, including mental health problems. The DHSSPS is currently working on this new legislation, but it does have the potential to reduce some of the segregating and stigmatising aspects of the current mental health law. The complexities involved in addressing these issues were demonstrated by the responses to the Report of the Consultative Group on the Past in 2009 (Consultative Group on the Past, 2009). This group was established by the Secretary of State to consult and make recommendations about how to best address the legacy of ‘the Troubles’. This built on Reshape, Rebuild, Achieve (OFMDFM, 2002) and suggested a range of possible ways in which people’s trauma and suffering should be recognised and remembered. It suggested that: ‘Truth is crucial to the prospect of reconciliation. Genuine conversations, to establish, and as far as possible agree, what that truth is, should take place between those involved in the conflict, while recognising that complete truth is unattainable.’ Unfortunately, most of the responses to this broadranging and challenging report concentrated on a recommendation that the nearest relatives of people who had died should receive £12,000 and this provoked considerable controversy and anger. The OFMDFM (2009) Strategy for Victims and Survivors that followed this report, made no mention of compensation and set out the government’s plans that include the establishment of a separate Victims and Survivors Service and further consideration of ways ‘to deal with the “past” as an essential element of transition’. The final development in promoting mental health in Northern Ireland that will be considered here is A Flourishing Society, a report commissioned by the DHSSPS and produced by the Northern Ireland Association for Mental Health (NIAMH) (Leavey et al, 2009). For the first time, it reviewed the range of current mental health promotion initiatives and overlapping strategies and attempted to provide a more integrated way forward. It found that ‘there are extensive mental health promotion


activities across NI but these efforts appear fragmented and inconsistent. It is extremely difficult to quantify these activities or any degree of success these have’, and recommended that ‘a single, coherent wellbeing strategy would be a major step towards achieving greater effectiveness in the development of a healthy, resilient and flourishing population’. It suggested that stigma may be more effectively addressed by making mental health issues a central, integrated and openly discussed aspect of society rather than specific, isolated anti-stigma campaigns. It also reinforced the need to address inequalities by targeting resources and providing greater support to those in the most deprived areas. Conclusion This article has attempted to provide a review of the impact of ‘the Troubles’ and the associated societal divisions, inequality and stigma in Northern Ireland, the traditional service response and the more recent development in mental health promotion policy and initiatives. There does seem to be a need, as identified by the Bamford Review (2006) and Leavey and colleagues (2009) to bring together the diverse and at times separate efforts to address these issues. The societal and service responses to the mental health impact of the violence and how these have changed over time are very interesting and these seem to continue to be considered separately from more general or population-based considerations of mental health. There is ongoing debate about how to best address the legacy of the violence and whether very formal structures, such as the equivalent of a Truth and Reconciliation Commission, are needed or would be effective, remains uncertain. If conventional responses to PTSD at the individual level can be transferred to the community and societal levels then some means of integrating these experiences would seem crucial to recovery and hopefully the Victims and Survivors Commission will enable this to happen. The main theme that has repeatedly been identified though is that the mental health needs that have arisen due to violence and division need to be integrated into the wider public mental health policy and practice. It is perhaps necessary due to the level of controversy raised by the issues involved that they have been considered in a parallel and largely separate way but an important indicator of progress would be their eventual integration into general mental health promotion and services. One means of doing this could be the introduction of routine screening and training in primary care and mental health services

for identifying and responding to trauma. The need for trauma screening in relation to childhood abuse and neglect has been convincingly established in the research literature (Read et al, 2008) and, in response to the specific needs of Northern Ireland, it would seem reasonable to add brief screening for Troubles-related trauma. Without routine questions on these forms of trauma the needs arising from them may not be identified and the services offered may be inappropriate. Effectively addressing inequality requires more substantial political change. The current approaches appear to focus on providing targeted support, mainly child care, in deprived areas. The implications of the growing body of research on the impact of inequality on everyone (Friedli, 2009) suggests that more comprehensive redistributive interventions may be both necessary and of benefit to everyone’s mental health. The open integration of trauma and growing acceptance of the interdependence of everyone’s mental health may also contribute to reducing stigma. The antistigma campaigns in Northern Ireland have raised some of the issues and the proposed new legislation introduces the possibility of Northern Ireland leading the world by fully integrating mental health into an anti-discriminatory capacity legislative framework. There does seem to be a clear need to provide further population-based interventions that directly address and integrate the mental health needs of Northern Ireland. A major obstacle to these issues being appropriately addressed in Northern Ireland is that they are perceived, accurately, to be political issues but, in this context, this brings an additional level of complexity. Politics in Northern Ireland continue to largely reflect the division of the past but there is a strong case for effectively addressing these issues as they have the potential to be of health and economic benefit for everyone. Regardless of views on the past, the role of the state or the responsibilities of society, to actively address division, inequality and stigma in Northern Ireland is in everyone’s interest. References Albee GW (2003) The contributions of society, culture, and social class to emotional disorder. In: TP Gullotta & M Bloom (Eds) (2003) Encyclopaedia of Primary Prevention and Health Promotion. New York: Kluwer Academic/Plenum Publishers. Bamford Review of Mental Health and Learning Disability (2005) A Strategic Framework for Adult Mental Health Services. Belfast: Department of Health, Social Services and Public Safety. Bamford Review of Mental Health and Learning Disability (2006) Mental Health Improvement and Well-being: A personal, public and political issue. Belfast: Department of Health, Social Services and Public Safety.


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Bloomfield K (1998) We Will Remember Them: Report of the Northern Ireland Victims Commissioner. Belfast: Stationery Office. Byrne P (2000) Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment 6 (1) 65–72. Cairns E & Wilson R (1984) The impact of political violence on mild psychiatric morbidity in Northern Ireland. British Journal of Psychiatry 145 (6) 631–635. Campbell J & Healey A (1999) ‘Whatever you say, say something’: the education, training and practice of mental health social workers in Northern Ireland. Social Work Education 18 (4) 389–400. Campbell J & McLaughlin J (2000) The ‘joined up’ management of adult health and social care services in Northern Ireland: lessons for the rest of the UK? Managing Community Care 8 (5) 6–13. Campbell J & Manktelow R (Eds) (1998) Mental Health Social Work in Ireland: Comparative issues in policy and practice. Aldershot: Ashgate Publishing. Consultative Group on the Past (2009) Report of the Consultative Group on the Past. Northern Ireland: Consultative Group on the Past. Curran PS (1988) Psychiatric aspects of terrorist violence: Northern Ireland 1969–1987. British Journal of Psychiatry 153 (4) 470–475. Department of Health, Social Services and Public Safety (2000) Minding our Health. A draft strategy for promoting mental and emotional health in Northern Ireland. Belfast: Department of Health Social Services and Public Safety. Department of Health, Social Services and Public Safety (2003) Promoting Mental Health: Strategy and action plan 2003–2008. Belfast: Department of Health Social Services and Public Safety. Department of Health, Social Services and Public Safety (2004) Equality and Inequalities in Health and Social Care in Northern Ireland: A statistical overview. Belfast: Department of Health, Social Services and Public Safety. Department of Health, Social Services and Public Safety (2006) Protect Life: A Shared Vision. The Northern Ireland Suicide Prevention Strategy and Action Plan 2006–2011. Belfast: Department of Health Social Services and Public Safety. Department of Health, Social Services and Public Safety (2009) Delivering the Bamford Vision: The Response of the Northern Ireland Executive to the Bamford Review of Mental Health and Learning Disability Action Plan 2009–2011. Belfast: Department of Health Social Services and Public Safety. Dorahy MJ (2006) Cautions on the overgeneralised application of the NICE and CREST recommendations for the treatment of PTSD: a reflection from practice in Belfast, Northern Ireland. Clinical Psychology and Psychotherapy 13 (5) 313–323. Farrell C, McAvoy H, Wilde J & Combat Poverty Agency (2008) Tackling Health Inequalities: An all-Ireland approach to social determinants. Dublin: Combat Poverty Agency. Fay MT, Morrissey M & Smyth M (1999) Northern Ireland’s Troubles: The human costs. London: Pluto Press. Ferry F, Bolton D, Bunting B, Devine B, McCann S & Murphy S (2008) Trauma, Health and Conflict in Northern Ireland: A study of the epidemiology of trauma-related disorder and qualitative investigation of the impact of trauma on the individual. Omagh: The Northern Ireland Centre for Trauma and Transformation. Friedli L (2009) Mental Health, Resilience and Inequalities. Copenhagen: World Health Organization Regional Office for Europe. Friedli L & Parsonage M (2007) Mental Health Promotion: Building an economic case. Belfast: Northern Ireland Association for Mental Health. Harland K (2008) Masculinity and Mental Health. Belfast: Health Promotion Agency. Healing through Remembering Project (2002) The Report of the Healing through Remembering Project. Belfast: Healing through Remembering Project.

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Health Promotion Agency (2006) Public Attitudes, Perceptions, and Understanding of Mental Health in Northern Ireland. Belfast: Health Promotion Agency. Health Promotion Agency (2009) A Healthy Legacy: 20 years of the Health Promotion Agency for Northern Ireland. Belfast: Health Promotion Agency. Heskin K (1980) Northern Ireland: A psychological analysis. Dublin: Gill and MacMillan. Hillyard P, Kelly G, McLaughlin E, Patsios D & Tomlinson M (2003) Bare Necessities: Poverty and social exclusion in Northern Ireland. Belfast: Democratic Dialogue. HM Government (1920) Government of Ireland Act 1920. London: OPSI. HM Government (1972) Health and Personal Social Services (NI) Order 1972. London: OPSI. HM Government (2006) Victims and Survivors (Northern Ireland) Order 2006. London: OPSI. Leavey G, Galway K, Rondon J & Logan G (2009) A Flourishing Society: Aspirations for emotional health and wellbeing in Northern Ireland. Belfast: Northern Ireland Association for Mental Health. Loughrey GC, Bell P, Kee M, Roddy RJ & Curran PS (1988) Posttraumatic stress disorder and civil violence in Northern Ireland. British Journal of Psychiatry 153 (4) 554–560. Lyons HA (1971) Psychiatric sequelae of the Belfast riots. British Journal of Psychiatry 118 (544) 265–273. Lyons HA (1972) Depressive illness and aggression in Belfast. British Medical Journal 1 (5796) 342–344. McClelland RJ (1988) The madhouse and mad doctors of Ulster. The Ulster Medical Journal 57 (2) 101–120. Muldoon OT (2004) Children of the Troubles: the impact of political violence in Northern Ireland. Journal of Social Issues 60 (3) 453–468. Muldoon OT, Schmid K, Downes C, Kremer J & Trew K (2005) The Legacy of the Troubles: Experience of the Troubles, mental health and social attitudes. Belfast: Queen’s University Belfast. Northern Ireland Assembly (2002) Measuring Poverty and Social Exclusion in Northern Ireland. Belfast: Northern Ireland Assembly Research and Library Services. Northern Ireland Association for Mental Health & Sainsbury Centre for Mental Health (2004) Counting the Cost: The economic and social costs of mental illness in Northern Ireland. Belfast: Northern Ireland Association for Mental Health. Northern Ireland Office (1998) The Agreement. Belfast: Northern Ireland Office. Odena O (2009) Practitioners’ views on cross-community music education projects in Northern Ireland: alienation, socio-economic factors and educational potential. British Educational Research Journal 36 (1) 83–105. Office of the First Minister and Deputy First Minister (2002) Reshape, Rebuild, Achieve. Belfast: Office of the First Minister and Deputy First Minister. Office of the First Minister and Deputy First Minister (2005) A Shared Future: Policy and strategic framework for good relations in Northern Ireland. Belfast: Office of the First Minister and Deputy First Minister. Office of the First Minister and Deputy First Minister (2006) Lifetime Opportunities: Government’s anti-poverty and social inclusion strategy for Northern Ireland. Belfast: Office of the First Minister and Deputy First Minister. Office of the First Minister and Deputy First Minister (2009) Strategy for Victims and Survivors. Belfast: Office of the First Minister and Deputy First Minister.


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Mental Health Review Journal This Journal is committed to keeping professionals up to date with all aspects of mental health. It is an informative and stimulating source of current thinking and information on research, policy and its implementation into practice, to help people survive, recover from and prevent mental health problems. Published quarterly in partnership with The Institute of Mental Health, each issue features peer-reviewed articles, reflective critiques, expert perspectives and comment on areas of mental health care.

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