Northern Ireland Affairs Committee Consultation
“Addressing the Legacy of Northern Ireland's past: The UK Government's New Proposals”
31 May 2020
Professor Siobhan O'Neill
Professor Brandon Hamber
In 2018 the Government carried out a public consultation on ‘Addressing the Legacy of Northern Ireland’s Past’, which was a proposal based on the Stormont House Agreement. We, as psychologists with extensive experience with victims of political conflict both in Northern Ireland and abroad, responded to this consultation with a call to consider the impact of the legacy institutions on the mental health of people who engage with them, and others who hear about the outcomes (see Appendix A). The impact on those with existing trauma-related conditions and mental ill-health, and the potential for re-traumatisation needed to be considered more carefully. The summary of consultation responses also identified the potential of the institutions and the processes of engagement with the institutions to re-traumatise people and the need to provide appropriate mental health support to those engaging with the process. We endorse this as per our original submission (Appendix A).
The new proposals aim to address some of our concerns by reducing the number of institutions that victims and survivors will need to engage with. The reduction of the number of bodies reduces the complexity of the process. It minimises the risk that victims will be re-traumatised by having to engage with multiple institutions. However, the new proposals also emphasise the process of gathering information rather than justice. It is crucial to note that this will cause significant hurt to many for whom justice was required for meaning making, and who had awaited justice in order to process the trauma and recover. There is significant research to show that justice can be part of the healing process following political violence. Some victims will struggle and battle to ensure that their case meets the threshold for further action. Others will take the view that justice will never happen and they will need to process that and integrate it into their life story so that they can find peace of mind. The new framework may be interpreted as representing a broken promise and this will serve to erode trust in the public institutions, which was one of the key aims of the Stormont House Agreement and also the Good Friday Agreement. The loss of this opportunity for justice, or the hope of justice, may need to be grieved in the same way as other losses, to achieve acceptance and integration. It would be beneficial if support through this process was available if this comes to pass, although we firmly believe that justice remains an vital component of healing for many and should not be dispensed with lightly.
Two points in the framework are also relevant to the mental health implications of the new structures. The framework refers to doing more to help individuals and society to share and understand the tragic experiences of the past. This is again a helpful point. Rituals and ways of memorialising will be required to support the process of truth recovery and adaptation. These could be experienced as glorifying violence or favouring one perspective on the events of the past, and the principles of rights and equality should be respected. Many will resist any attempt to “move on” and this is a common feature of grief. Psychologically speaking giving up on justice for those whom you cared and were killed because it appears politically or practically expedient to do so is not an option. This may make sense pragmatically for policymakers but produces massive psychological challenges for those grieving loved ones or who feel the government, and other groups in society, have caused or exacerbated their hurt in the past. The ways in which the new structures are presented needs to be carefully considered so that they are less likely to be interpreted in this way. That said, the denial of justice will be psychologically wounding for many no matter how this is attempted to be justified.
Increasing the speed at which gathering information for families and moving at a faster pace to retrieve knowledge before it is lost, is very much to be welcomed. However, victims need more information on what they might expect and plans, with dates and deadlines that need to be adhered to. This will promote trust and promote stability, so that victims and survivors have a focus and know what they might expect in the time ahead. At the same time, psychologically speaking, closing off avenues for judicial redress, such as through courts now or even sometime into the future, will undermine the perception and acceptance of all new institutions – whether such redress is practically possible or not.
Our initial response (Appendix A) highlighted two further mental health risks of the legacy structures. The first was regarding the differing definitions of victimhood that are implicit within the remit of each of the institutions. This was also a common theme of the consultation responses. If justice avenues are curtained, or the HIR removed from the original SHA proposals, this will reduce the impact of this on one level but introduce new challenges on another. First, not addressing justice questions through the legacy institutions will not reduce the intensity of debates about who is seen as a more “worthy” victim in the eyes of government or not; such debates which will move into the political and public sphere and will remain psychologically taxing for survivors. Second, the ICIR addressed cases where there has been a death as a result of the Troubles, whereas the OHA took a broader definition of victimhood, potentially including “anyone who has been touched by the Troubles” would be able to share their memories and tell their stories and have these recorded in the Archive. The OHA serves to acknowledge the subjective nature of experiences related to the conflict, and truly “acknowledging the suffering of victims and survivors” as per the goals of the institutions. The wider definition of the OHA may complement the narrow criteria of the other proposed institutions. However, there remains a need to provide definitions and boundaries on the OHA and eligibility will need to be established, and even if fairly wide criteria are used in the OHA it will not be able to meet survivor needs for truth-recovery.
The narrower definition of eligibility in the ICIR means that people and families with other types of experiences are excluded. The result of this remains that losing a relative could be seen as “worthy” of truth-recovery but being profoundly tortured or disabled by the conflict is only “worthy” of acknowledgement or storytelling in the OHA. Financial and practical limits might be needed to run the different institutions, but the consequences of including or excluding individuals from the information retrieval process will have mental health consequences thus demanding a duty of care or altering what different institutions focus upon. The second difficulty was that individuals and families may need to approach more than one institution, and navigate a system that could turn out to be bureaucratic, complex, mechanistic and “cold”. Whilst one body will be in place there remains two goals, one of truth recovery and the other of relating individual experiences. Even if one over-arching institution is setup, it will still require information on the structure of the institution and its components to be effectively communicated to survivors as well as those that support them. There remains a risk that victims may end up telling their stories to different components of the process as proposed. Survivors may also have to figure out the role of a new mental health service attached to such structures as we originally recommended (see below), and Victims and Survivors Support Service at the same time.
In conclusion, in our original response we emphasised the need for a victim and survivor centred, trauma-informed approach and set out a series of recommendations on how this might be achieved. This are contained in Appendix A, but for reference we summarise them here:
We believe these recommendations remain pertinent to the new proposed framework, especially as they will bring new mental health challenges if implemented as proposed.
Response to the “Addressing the Legacy of Northern Ireland’s Past” Consultation, 4 October 2018 by Professor Siobhan O'Neill, Professor of Mental Health Sciences, Ulster University & Professor Brandon Hamber, The John Hume and Thomas P. O'Neill Chair in Peace, Ulster University
The Research on Trauma and the Troubles
Ulster University research shows that whilst around 71.5% of the population have minimal levels of mental illness, the mental health difficulties of at least half of the remaining 28.5% (approx. 213,000 adults) appear to be directly related to the Troubles. These figures are based on robust data, using strict psychiatric criteria for mental illness, and they illustrate how the conflict was a significant and distinctive stressor in the life of the community in Northern Ireland for over 40 years (Bolton, 2017; McLafferty et al., 2016; O'Neill et al., 2015). This study showed that 39% of the population experienced a traumatic event that was related to the Troubles. Such events included bombings, shootings, and witnessing killings and mutilations. Troubles related trauma was also shown, in these studies, to increase the likelihood of suicidal behaviour (O'Neill et al., 2014) and this fits with theoretical psychological understandings of suicide which demonstrate the impact of violence and habituation to pain and death, on the person's capability to act in response to suicidal thoughts. Sadly, this is also borne out in the population's rates of suicide deaths which, 16 per 100,000 are the highest in the UK. Our male suicide rate is double that of England. The suicide rate has doubled since the Good Friday Agreement, and whilst there are many contributory factors, the fraught nature of the peace process, the legacy of poverty and despair in the areas most affected, has resulted in the most deprived areas having rates that are up to three times those of the last deprived areas (Bunting et al., 2018).
The research demonstrated the depth and scale of the mental health needs of the NI population, however progress on meeting those needs and providing the evidence-based treatments for complex trauma-related illnesses has been slow. In the meantime, the consequences are manifest in the form of social unrest and high rates of prescribed medication (Benson et al., 2018). Mental illness stifles healing and empathy. Psychological therapies can help individuals make meaning from their experiences, which not only reduces their suffering, but also allows them to place the experience in context, to foster recovery. Such processes at both a personal, and community level promote peacebuilding, and create the environment for peace. We know, from other research conducted by staff at Ulster University, that for victims and survivors of trauma, the issues of truth, justice, accepting responsibility, compensation and official acknowledgement are part of this "meaning making" and are interwoven with healing (Hamber, 2009). In fact, healing, often promoted by addressing wider victim issues such as truth and justice, in such circumstances may provide the conditions for post traumatic growth (Joseph, 2015). The opposite is also true, that failing to address the wider needs of survivors (such as a desire for justice or truth) can have negative psychological consequences into the long term (Hamber, 2009).
The proposed legacy institutions will therefore have a profound impact on the mental health of the individuals who engage with them, those who for whatever reason choose not to, and those with existing trauma-related conditions and mental illness who either participate, or hear about them from the media and other sources. It is vital that the mental health of those affected is protected through this process.
In this document we base our definitions of trauma and mental illness, and therefore "victimhood", on the psychiatric criteria for mental illness. However, it is important to acknowledge the contested nature of this term and the difficulties associated with the use of narratives of "deserving" and "undeserving" victims, which can in fact, serve to exacerbate suffering and illness among those who have been affected by very real injustices. The term "survivor' may be viewed as more appropriate, and in fact reflects the fact that the majority of those affected by the years of violence have not had significant long-term mental illness. There are numerous examples of post traumatic growth, where people have flourished as a result of their experiences. However significant proportions of those affected by multiple horrors, and adverse childhood experiences will no doubt have serious and chronic mental illness (in NI 4.3% of the population, McLafferty et al., 2016). It is this group that the institutions aim to target and it is incumbent upon them to ensure that the vulnerable people who engage with the institutions have an opportunity to obtain treatments and are not subjected to further harm. In addition, for those without a diagnosed condition, the process will prove extremely stressful and although most have coped over time with what happened, the social and psychological impact of the conflict has been profound (Bolton, 2017; McLafferty et al., 2016; O'Neill et al., 2014).
Among the key goals of the institutions are the promotion of reconciliation and the acknowledgement of the suffering of victims and survivors. However, it is startling in this regard that the needs of survivors, particularly in relation to psychological support, receives scant consideration in the consultation document. In this response we therefore consider the potential impact of the legacy structures and their processes, on the mental health of the people who engage with them, the staff, and on the population in general.
We put forward six key recommendations to mitigate against harm and maximise the potential of the institutions to promote recovery and healing.
Mental health risks of the proposed legacy institutions
The consultation document proposes four new legacy institutions, each addressing the needs of victims and survivors as defined in different ways. Three of the institutions, the Historical Investigations Unit (HIU), the Independent Commission on Information Retrieval (ICIR) and the Oral History Archive (OHA) will deal with the needs of specific groups of victims. There are two challenges with this structure from a mental health perspective, that are not addressed in the current proposals. The first is regarding the differing definitions of victimhood that are implicit within the remit of each of the institutions.
The HIU and ICIR address cases where there has been a death as a result of the Troubles, whereas the OHA takes a broader definition of victimhood, potentially including "anyone who has been touched by the Troubles would be able to share their memories and tell their stories and have these recorded in the Archive. This would include victims and survivors, but also former soldiers and police officers, members of the emergency services, former paramilitaries, and anyone who lived through this difficult period in Northern Ireland's history".
The OHA may be regarded as serving to acknowledge the subjective nature of experiences related to the conflict, and truly "acknowledging the suffering of victims and survivors" as per the goals of the institutions. There is the possibility that the wider definition of the OHA may complement the narrow criteria of the other proposed institutions. However, there will more than likely need to be definitions and boundaries imposed on the OHA and eligibility will need to be established, and even if fairly wide criteria are used in the OHA it will not be able to meet some survivor needs such as justice or truth-recovery. In contrast, the adoption of a narrower definition of eligibility in the HUI and ICIR means that people and families with other types of experiences will be excluded. The result of this for victims, whether established in law or not, could be that losing a relative could be seen as "worthy" of investigation and truth-recovery (with the potential benefits of truth and possibly even justice) in the HIU and ICIR, but being profoundly tortured or disabled by the conflict is only "worthy" of acknowledgement or storytelling in the OHA. The latter of course could in some cases be validating for individuals, but for others it could have a psychological impact in which their subjective suffering is minimised in their eyes by the nature of the institutions. Acknowledgement and validation are important to "meaning making" and will promote recovery, but it has to be noted that the inclusion criteria for the HUI and ICIR has the potential to cause hurt and further harm. We acknowledge that financial and practical limits might be needed to run the different institutions, but the real consequences of including or excluding individuals goes beyond legal and pragmatic questions, and will have mental health consequences thus demanding a duty of care.
The second difficulty with the structures is the possibility that individuals and families may now need to approach one or more institutions, and navigate a system that could turn out to be bureaucratic, complex, mechanistic and "cold". There is little information on how the structures relate to one another and there is the real risk that victims may end up telling their stories to three different bodies, as well as victims having to figure out the role of a new mental health service and Victims and Survivors Support Service at the same time.
There is reference to the fact that support will be provided under each of the institutions (with the exception of the IRG) but this is not discussed in any uniform way in the proposed documents. For example, it is noted that HIU would have "a dedicated family support function to assist families through the process"; ICIR will ensure "families would be supported and the ICIR would keep them informed of progress"; the OHA will make potential contributors aware of "support arrangements available for victims/survivors and appropriate support bodies". In addition to this the "Stormont House Agreement outlined a Commitment from the Northern Ireland Executive to provide access to an advocacy counsellor who would assist victims and survivors to engage with the legacy institutions". In short, there is no standardised approach to support and the broadly autonomous nature of the proposed institutions might result in very different support mechanisms being put in place with different and unequal outcomes. Any support provided needs to meet the needs of victims, many of whom will have had negative experiences in accessing services in the past, which serve to create further pain and distress. In other processes around the world poor administrative treatment of victims and haphazard support has been found to have profoundly negative impacts (Hamber, 2009).
Currently the mental health support to those who engage with the institutions is likely to come from the Victims and Survivors Service who have in place 23 Advocacy and Support Workers and 25 Mental Health and Wellbeing case workers. In addition, the institutions plan to work with the Regional Trauma Network to ensure that people who engage with the service receive timely and effective treatments. Participants may also engage wish to engage with the statutory and non-statutory mental health services, including the suicide prevention helpline, Lifeline, as well as wider community-based support and trauma services. But it is not clear how the support spoken about in the consultation document will relate to or interface with these existing supports, or if these will be resourced.
It is therefore important that a process of demand profiling and impact assessment is undertaken prior to the commencement of the work of the institutions so that likely need is established, based on the current research evidence about the numbers affected. The Victims and Survivors Service, Regional Trauma Network and statutory and non-statutory sector need to be adequately resourced to deliver services and treatments on this basis. In addition to this the institutions need to be assessed from the perspective of the survivor navigating through them, and it is to this we now turn.
A victim and survivor centred, trauma-informed approach
The US substance abuse and services administration (SAMSHA, 2018) define a trauma-informed approach as an approach that:
We recommend that the legacy institutions adopt these principles in their engagement with victims and survivors, and the Northern Ireland population as a whole.
Three of the proposed institutions deal with narratives about what happened, which may be described as personal experiences and interpretations, facts, stories, or truths. However, each institution delivers different outcomes, and as such, the structures may be perceived from a psychological level to place a value on the importance of one method (and its attached narrative) over another. Furthermore, although hearing multiple versions of "truth" can be helpful, processes of truth recovery also have the potential for further personal destabilisation (Hamber, 2009). New information and revelations, regardless of which institution they fall under, have the capacity to exacerbate the mental health symptoms associated with trauma exposure and PTSD, and impede healing and recovery. For example, in other processes around the world, truth recovery can often mean previously untold stories emerging (say of betrayal) which can create new dynamics and challenges. To address such complex situations a range of supports will be necessary operating at different levels.
At a practical level, four broad categories or types of interventions that could improve the psychosocial well-being of those in the midst of humanitarian and political emergencies have been identified (IASC, 2007), and we would argue thinking of support in the legacy process could be considered in a similar way (see Figure 1). Needs listed at the bottom of the pyramid require the most investment and resources, and those identified thereafter may need progressively less resources, although all layers are important, require implementation concurrently (IASC, 2007) and are inter-related. Some areas of need might also be acute and demand specific treatments or interventions.
Figure 1 IASC (2007) Intervention pyramid for mental health and psychosocial support, diagram from Hamber (2015)
The most extensive task aimed to ensure psychosocial well-being, according to the IASC Guidelines is to (re)establish security, ensure adequate governance and services that address basic physical needs (food, water, basic health care, control of communicable diseases, etc.). This is beyond the remit of the proposed institutions, although a sensitivity to the fact that mental health is continually impacted upon by social conditions such as living in poverty or areas with serious social problems should underpin any intervention.
Secondly, it should be recognized that for many victims (and the population at large) key community and family support is essential to well-being, and often the first port of call in times of distress.
Thirdly, non-specialised supports (these can include emotional and livelihood support) for the still smaller number of people who additionally require more focused individual, family or group interventions by trained and supervised workers should be ensured.
There are many different types of intervention implicit in the community, support and non-specialised levels outlined above. Less clinical and community-driven approaches include activities such as group sharing of problems, befriending, community dialogue, healing rituals, art projects, theatre initiatives, interpersonal skills development, training on issues such as legal support, advocacy and mediation. Many community groups, and local structures, in Northern Ireland have provided these supports over the years. They should continue to be resourced to offer these supports throughout the legacy process and to complement specialized services.
Finally, the specialised services of psychologists, psychiatrists or other trained individuals should be offered to people with severe mental disorders whenever their needs exceed the capacities of existing primary/general health services (Bolton, 2017; IASC, 2007).
In terms of specialised services it is important to consider the mental health impact of trauma, and the features of post-traumatic stress disorder (PTSD) in particular. This understanding is critical to a trauma-informed approach. Exposure to types of traumas associated with the Northern Ireland Troubles can lead to specific clusters of mental health symptoms, and PTSD. The effects of trauma exposure are not only borne by those who have experienced the trauma, but also by those who work with them and witness their testimonies (Bolton, 2017).
PTSD is characterised by three clusters of symptoms:
• Horrifying flashbacks and nightmares of a particular event, where it is as if that person was re-experiencing the event;
• Avoidance and numbing, where the person suppresses even positive emotional responses, to avoid any reminder of the event and to avoid "triggering" a flashback or intrusive memory;
• Hypervigilance; a heightened stress reactivity that impedes day to day functioning.
In the Northern Ireland study of health and stress we found that in 2008 8.8% of the population had met the criteria for PTSD (Bunting et al., 2013). PTSD is treatable, but this requires specialist "trauma-focused" therapies, which serve to "re-programme" the interactions between the person's memories of the event and their stress response systems (NICE recommends trauma focused Cognitive Behavioural Therapy, NICE, 2018). In addition to PTSD, trauma exposure was associated with a wide range of other mental illnesses many of which were also severe and enduring. In 2008 only one in five had received treatment that they perceived to be effective (Bunting et al., 2015). There is therefore huge concern about the level and impact of this unmet need, and the institutions need to consider this when implementing the proposals.
Many people with trauma related mental illnesses avoid reminders of the events that led to their illness. This is particularly the case for people with PTSD, as any reminder may trigger flashbacks, and in effect consolidate the illness. People who share their experiences and who receive inappropriate responses, or who ask for help and do not receive treatment that is effective, frequently report a worsening of symptoms. Worryingly, inappropriate responses to requests for help for mental illness can worsen the sense of hopelessness and despair that is associated with suicidal thoughts. One of the main goals of the legacy institutions is to encourage disclosure, therefore the implications for mental health and trauma need to be carefully considered and the effects mitigated against. A deliberate trauma-informed approach that offers support throughout and after the process is necessary.
But any direct traumatic responses cannot be addressed completely outside the wider social and political context. The legacy institutions will generate "new" information, as disclosed to the institutions of the legacy, or available as a result of the oral history archive. Perceptions about the value placed on that information, in terms of the extent of suffering and the need for compensation can impact upon the "meaning making" that fosters recovery. However, equally whilst truth can be powerful and transformative, it can also exacerbate pain and suffering, and prompt further unhelpful rumination. Truth, justice, and recovery processes can serve to validate and prioritise some perspectives over others. The processes must therefore be delivered cautiously and monitored carefully. When people share testimonies that even their nearest and dearest may be unaware of they can become vulnerable. The testimonials are precious and the ways in which they can be made public and used, or in fact exploited by others needs to be managed carefully. The same can be said of testimonies collected in the OHA. We note with deep concern that "there would be a procedure for the disposal of records where the Deputy Keeper has decided collected records should not form or should cease to form part of the OHA". In terms of testimony destroying a victim's testimony, no matter the reason, could have very deep and lasting impact for the individual. Again, any such process of record destruction from a psychological perspective needs to be deeply considered, if not removed from the remit of the OHA.
By defining the boundaries of victimhood in terms of who can speak to what institution, or deeming certain information irrelevant, may be perceived to be making judgements about a person's suffering, that is at best insensitive and at worst, itself traumatizing. By diminishing the very real suffering caused by the trauma of physical injury, witnessing death or serious injury (all of which are included in psychiatric definitions of trauma) we risk causing additional harm. Such harm needs to be mitigated at the top of the pyramid outlined above by offering adequate and professional support through, and at the other levels ensuring that social, legal, welfare and community support is also forthcoming and resourced, most likely through assessing needs and making appropriate referrals.
We make six specific recommendations:
• Benson, T., Corry, C., O'Neill, S., Murphy, S., Bunting, B. (2018). Use of prescription medication by individuals who died by suicide in Northern Ireland. Arch Suicide Res, 22, 1, 139-152.
• Bolton, D. (2017). Conflict, peace and mental health: Addressing the consequences of conflict and trauma in Northern Ireland. Manchester: Manchester University Press.
• Bunting, B.P., Ferry, F.R., Murphy, S.D., O'Neill, S.M., Bolton, D. (2013). Trauma associated with civil conflict and posttraumatic stress disorder: evidence from the Northern Ireland study of health and stress. J Trauma Stress, 26, 134–141.
• Bunting, B., Corry, C., O'Neill, S., Moore, A. (2018). Death by suicide at the Ward level in Northern Ireland. Psychol Med, 48(8), 1375-1380.
• Hamber, B. (2009). Transforming Societies After Political Violence: Truth, Reconciliation and Mental Health. New York: Springer.
• Hamber, B. (2015). Dealing with Painful Memories and Violent Pasts: Towards a Framework for Contextual Understanding. In B. Austin & M. Fischer (Eds.), Berghof Dialogue Series 11. Berlin: Berghof Centre.
• Inter-Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Retrieved from: http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf
• Joseph, S. (2015). A person-centred perspective on working with people who have experienced psychological trauma and helping them move forward toward posttraumatic growth. Person-Centered and Experiential Psychotherapies, 14(3), 178-190
• McLafferty, M., Armour, C., O'Neill, S., Murphy, S., Ferry, F., Bunting B. (2016). Suicidality and profiles of childhood adversities, conflict related trauma and psychopathology in the Northern Ireland population. J Affect Disord, 200, 97-102.
• NICE (2018). Guidance: the treatment of PTSD. Retrieved from: https://www.nice.org.uk/guidance/cg26/chapter/1-Guidance#the-treatment-of-ptsd
• O'Neill, S., Ferry, F., Murphy, S.D., et al. (2014). Patterns of suicidal ideation and behaviour in Northern Ireland and associations with conflict related trauma. PLoSOne, https://doi.org/10.1371/journal.pone.0091532
• O'Neill, S., Armour, C., Bolton, B. et al., (2015). Towards a Better Future: The Transgenerational Impact of the Troubles on Mental Health. Belfast, CVSNI. Retrieved from: https://www.cvsni.org/media/1171/towards-a-better-future-march-2015.pdf
• SAMHSA (2018). Trauma-Informed Approach and Trauma-Specific Interventions. Retrieved from: https://www.samhsa.gov/nctic/trauma-interventions
 Hamber, B. (2009). Transforming Societies after Political Violence: Truth, Reconciliation, and Mental Health. New York: Springer.