Learning from Northern Ireland Trauma and Suicide.

Mental health response to trauma and crisis has seen many different professional groups coming together, with counsellors probably the last professional group to respond to people in crisis. However, it is becoming much more common for people who present issues such as post-traumatic stress (PTSD), self-injury and suicide to seek counselling for support. This blog will reflect on the Troubles of Ireland with the increase in trauma and suicides.

The Greeks initially used trauma to describe a physical wound or injury. However, today, it has become synonymous with psychological trauma by referring to the psychological reactions experienced after a traumatic event or event. 

Describing psychological trauma as not a simple healable event but an existential crisis that threatens our understanding of ourselves and the world in which we exist Freud (1922). Caruth (1996) suggested trauma has much more than a wound of the mind by erasing the reality and truth an individual once believed. 

Psychological trauma is, therefore, something that not only causes considerable problems with our functioning but also irrevocably shatters our beliefs about ourselves, others and the world around us, altering our sense of self and our identities (JanoffBulman, 1992). The charity MIND defines crisis as a feeling that mental health is at a breaking point and needs urgent help and support. An example of emotions or experiences that feel very painful or difficult to manage are suicidal feelings, self-harm, panic attacks, flashbacks, hypomania or mania, or psychosis, such as paranoia or hearing voices. 

Some people feel crisis as part of ongoing mental health problems or stressful and difficult life experiences such as abuse, grief, addiction, money problems or housing problems. Alternatively, a particular reason may not exist (MIND, 2019).

The types of traumatic events attempt to classify traumatic events on how likely they are to cause problematic reactions. Distinguishing two kinds of trauma associated with different types of events: 

1. Small-T traumas are associated with distressing life events that involve adverse emotional reactions and provoke unpleasant thoughts and memories, such as the loss of a pet or family fights. 

2. Large-T traumas are associated with overwhelming, highly distressing events, such as torture, rape and war, which views as hallmark events for a traumatic reaction. 

This distinction supports psychologists in distinguishing between life-threatening events and those that are not. Some critics of this distinction claim that it often negates the devastating effects that ongoing minor traumas can have on an individual's lived experience (e.g., James and MacKinnon, 2012). The approach distinguished between type 1 and type 2 traumas experienced in childhood, referring to the nature of the events rather than their age. 

Type 1 trauma is a one-off unexpected traumatic event such as a car accident or a natural disaster, and type 2 is an ongoing and repeated exposure to traumatic events such as domestic violence and childhood abuse. 

Type II traumas are also often associated with more complex responses, such as disjointed memories, emotional numbing, anger and dissociation (Herman, 1992).

Trauma risk factors have been identified and can influence whether or not someone is likely to experience psychological trauma as a result of a traumatic event, having been grouped into three areas:

1. Pre-trauma: Things that happened before the traumatic event 

2. Peri-trauma: Things that happen during the traumatic event 

3. Post-trauma: Things that happen or develop after the traumatic event 

Working with risk in counselling seems to have become shorthand for the risk of self-injury and suicide, with the reality that risk is a multifaceted concept. It is essential to be familiar with the type of risk relevant to the situation and the skills to work actively with it. 

Risk tends to be defined negatively, such as the risk of harm or an undesired outcome. However, mental health support can be practical for those who present as risks when the risk is collaboratively identified, discussed, and explored in therapy. 

Positive risk-taking, increasingly described by the term, acknowledges that mental health work commonly involves engaging risk to facilitate change rather than simply avoiding the potential of harm. This approach encourages practitioners to consider the potential benefits of taking calculated risks in therapy, such as promoting client empowerment and fostering resilience.

A crisis plan, a keep-safe document, can effectively collaborate with people about risk. This structured plan helps individuals identify potential triggers, warning signs, coping strategies, and sources of support they can use to prevent or manage a developing crisis. It should be completed collaboratively by the counsellors and the client, fostering a sense of shared responsibility and empowerment in risk management. 

The impact of working with issues could have on the mental health practitioner who works closely with trauma-related problems or crises, especially by self-injury. Practitioners are not immune to the effects of working with trauma and risk, having shown that many professions working with traumatised and high-risk people are vulnerable to its contagious effect. 

The professions included are nurses (Wies & Coy, 2013), doctors (Nimmo & Huggard, 2013), social workers (Canfield, 2005), and community health workers (Lynch & Lobo, 2012). 

Practitioners have been given various labels over the years, including secondary traumatic stress (Figley, 1995), burnout (Maslach, 1982), compassion fatigue (Figley, 2002), and vicarious trauma (McCann & Pearlman, 1990). Each label brings a new understanding of what happens to practitioners due to their work. 

Trouble in Northern Ireland.

From the late 1960s until 1998, Northern Ireland was the site of a civil conflict known as The Troubles, with the heart of the conflict being a disagreement between Northern Ireland's religious communities - Protestant and Catholic over the region's governance and civil rights.

Whilst the Protestant community wanted Northern Ireland to remain part of the United Kingdom with an ideology called unionism or loyalism, most members of the Catholic community wanted to see a united Ireland, nationalist or republicans. 

The ensuing conflict between the two sides resulted in over 3,500 deaths and tens of thousands injured, formally ended with the Belfast Agreement, also referred to as the Good Friday Agreement (1998), allowing Northern Ireland's constitutional status to become settled by a future referendum. Violence between the two communities continued in the many years after the official ceasefire. 

During the period of The Troubles, the Northern Irish population lived with high levels of violence, and as a deeply divided society with armed checkpoints being ordinary and armed men, both British soldiers and paramilitary groups, patrolling the streets. 

Divided communities, politically, show the importance of community understanding and healing in addressing the mental health issues in Northern Ireland. This understanding can empower and motivate us to take action. 

Siobhan O'Neill (Professor of Mental Health Science) outlines ongoing mental health difficulties in Northern Ireland and answers the subsequent questions.

Understanding Trauma

From the accounts from 'Stories from Silence', a storytelling project by WAVE Trauma Centre in Northern Ireland, supporting cross-community victims who help people who were bereaved, injured or traumatised by The Trouble. Trauma refers to the intensity and quality of a person's response to a stressful event rather than the event itself. 

Below is the diagram for the Hypothalamus Pituitary Adrenal (HPA) axis.

A well-functioning HPA axis keeps cortisol circulating for the appropriate time within the environment. There is evidence that both long-term experiences of threat, such as an abusive relationship, and severe threatening events like murder can have the effect of changing how someone's HPA axis works. It leads to difficulties in responding to threats and stress, making it more likely for people to have a traumatic reaction to a threatening event (Delahanty & Nugent, 2006), one example of how our past bodily experiences can help shape our future biological responses.

Coping with danger: Dissociation.

Some psychological reactions to stress and danger operate similarly instinctually to protect us in situations of risk and threat. As an experience, it is being separate or distanced from a part of the experience. 

Dissociation, which happens during trauma, is known as peritraumatic dissociation (Marmar et al., 1998). 

Not everyone who experiences trauma will develop psychosis or have long-term difficulties as a result. However, dissociation has been suggested to be one process linking someone's immediate response to trauma, to keep themselves safe, and the longer-term difficulties which some people then develop.

Remembering and forgetting.

Memory is crucial in understanding the psychology of trauma. The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialogue of psychological trauma. Traumatised people become driven to remember and forget the experience, rupturing the usual processes of memory and how we integrate our ongoing experiences into our memory and a sense of self and understanding of the world.

When trying to recover from a traumatic experience, people struggle with memories and lack of memories. Memories can be incredibly vivid and present (such as flashbacks), and it can also be challenging to remember the events easily. The aftermath of trauma often involves trying to come to terms with and integrate memories of the events in ways that make them healthier to process. 

Working with traumatic memories is qualitatively different to our usual memory systems; there have been various attempts to find ways to work with trauma survivors to find ways to integrate these emotional and situational memories into our normal flow of memories. The problem with trauma interventions is that not everyone who experiences a catastrophic event, such as a natural disaster or a violent incident, will go on to develop a trauma reaction. A minority will go on to establish experiences understood as PTSD and have long-term difficulties in relationships and with memories of the event. 

Psychological debriefing in the immediate aftermath of trauma has been found to have no effect on many people and a negative effect on a minority. Other approaches argue that intervening in the aftermath can help prevent the likelihood of people developing long-term problems, leading some authors to say that many people can recover independently and that only a minority benefit from intervention (Litz et al., 2002).

Approaches include asking people to create a narrative of the event's aftermath and to try to integrate the traumatic memories into their usual memory systems. 

Stages of recovery.

Herman (1992) reviewed major approaches to recovery from trauma and identified three stages familiar to them all:

1. Safety, stabilisation and containment.

Traumatised people, whether after a single incident or an ongoing experience like domestic abuse, need first to feel safe again.

2. Exploration: telling the story, remembering and mourning to make sense.Once safety is achieved, exploring and making sense of the experience becomes possible.

3. Reconnection, resolution and making sense. After telling the story of the trauma and integrating it within an understandable framework, it may be possible to resolve the issue and reconnect with the world.

Suicidal thinking and behaviour: Northern Ireland has the highest rates of suicide in the UK. 

The role of the past may help answer some questions by identifying why some people develop suicidal thoughts, who will act on these thoughts and when.

The city's contested name is emblematic of the divide between Northern Ireland's two dominant communities, with the Catholic nationalist community referring to it as Derry and the Protestant unionist community preferring Londonderry. The city witnessed significant violence during The Troubles, most notably the Bloody Sunday massacre, when the British Army shot and killed 13 unarmed civilians participating in a protest march, with the city having the lowest employment rate and the highest economic inactivity for any area in Northern Ireland (Northern et al. Agency (NISRA), 2019). From 1997 to 2017, there were 315 deaths from suicide recorded in the city, with an approximate 3:1 male-to-female ratio (NISRA, 2018).

Reducing suicidal ideation and behaviour

There are three broad strategies for reducing suicidal ideation and behaviour:

1. Prevention: addressing the everyday circumstances and problems that can lead to suicidal ideation and behaviour.

2. Intervention: working with people who are thinking about suicide.

3. Postvention: working with survivors of suicide attempts, supporting those who have been bereaved or affected by suicide, and preventing suicide amongst those who are at high risk after exposure to suicide.

Charities such as Foyle Search and Rescue (established in 1993) in Derry/Londonderry in response to the high number of drownings in the River Foyle, which runs through the city. In recent years, it has played a prominent role in local suicide prevention.

Literature on trauma focuses on the negative impacts of trauma, including people who develop long-term difficulties. However, trauma and adversity can also have positive effects as experiences that transform our understanding of the world. Even in divided communities where people have experienced a lot of trauma, such as Northern Ireland, there are also always possibilities for hope, recovery and building bridges. 

Fostering post-traumatic growth has been continuing to perpetuate difficulties in Northern Ireland and has been the segregation of the Protestant and Catholic communities. There have been ongoing and various attempts to foster cross-community understanding and dialogue to build awareness and help heal the divisions in the community.

Akhtar, (SAC Dip), Lead Counselling Psychologist. 

www.akhtarcounselling.co.uk