Trauma in Northern Ireland

My copy of Therapy Today, the magazine of the British Association for Counselling and Psychotherapy (BACP), arrived at the weekend. Inside there was an interview with Helena Stuart, a psychotherapist at The Wave Trauma Centre in Belfast.

In her interview Helena says that despite the fragile peace in Northern Ireland there is still a big need for trauma counselling. It is, after-all, in the aftermath of conflict, during times of peace, when we are often most vulnerable to the affects of trauma; when we cease coping with the crisis around us and begin processing, experiencing and reliving the traumatic events we have survived. 

One recent study found that the suicide rate amongst middle-aged men in Northern Ireland has doubled since the Good Friday agreement, further evidence of the difficulties many have coping with the transition to peace. These men grew up when violence in Northern Ireland was at its height and its made them susceptible to mental health problems in later life.

Helena says that as life in Northern Ireland returns to something like normality the symptoms of trauma begin to appear but not just in those directly affected. She says the effects of trauma are 'reverberating down the generations', affecting adolescents and children aware of but unable to talk about the unspeakable trauma their families have experienced. 

Reading the interview I was reminded of a visit I made in 1992 to Belfast's Museum and Art Gallery on the edge of the Botanical Gardens. I was a philosophy and politics student at Queen's University at the time. There was an exhibition of children's paintings. Those painted by the youngest children, only four or five years old, featured big yellow suns and bright red tractors; but as the children aged the colours became darker, the scenes increasingly bleak. Teenagers painted scenes of violence with military helicopters overhead.

Helena works creatively with her clients, they paint and use sand play to help symbolise the horror they have experienced. She says, "The symbols of healing appear in the sandbox even when the person themselves hasn't found healing yet. The potential is there and we always grow towards potential'.

Mental Health and the Military

Events in Afghanistan and numerous articles on post-traumatic stress disorder have caused me to visit the web site of the King's Centre for Military Health Research and read once more the Centre for Mental Health Report, Across the Wire: Veterans, Mental Health and Vulnerability (25 October 2010). Written by Matt Fossey, the report gives an over-view of the mental health of British military personnel and the support they receive under the military covenant.

The impression I get from watching the media is of large numbers of soldiers suffering the effects of post-traumatic stress as a result of the horrors of war. Fossey's report suggests this is not the case, with just one per cent of service personal each year discharged because of psychiatric problems. According to Fossey, only 20-25 individuals per year are discharged because they're suffering from Post-traumatic Stress Disorder (PTSD). I don't think these figures give a complete picture of the mental health of service personnel leaving the military. How many military personnel choosing to leave the forces are struggling with the effects of acute and chronic stress? How many of those disclose the fact? How many leave self-medicating with alcohol? Maybe the Ministry of Defence and personnel leaving the forces have a common interest in not acknowledging the role that chronic and acute stress might play in an individual's decision to leave the armed forces. I'm told by colleagues working with ex-military personnel that many do not get their PTSD diagnoses until many years after leaving the forces and that not many of those were discharged on health grounds.

In fact the Fossy Report does highlight a much deeper problem when it considers two surveys about the health of ex-service personnel. According to one survey of 9,990 UK veterans four per cent were living with PTSD - four times the rate for the general population. Another survey of 3000 veterans suggested a rate of 19%. These surveys also point to high rates for alcohol misuse and general mental health problems. Fossey argues that the mental health of ex-service personnel isn't bad when compared with the mental health of the general population. Throughout the report Fossey seems to play down concerns about the mental health of UK veterans, yet if the rate of PTSD amongst the general population was 19% (it's 10% in Israel) it would be a catastrophe.

Fossey refers to the history of PTSD and it's numerous manifestations (Railway Spine, Shell Shock and Battle Fatigue). It seems to me that the military are still reluctant to accept combat stress as a cause of mental disorder. Blaming the individual for 'buckling under pressure' certainly happened during the Second World War as Fossey points out:

During WWII, the unfortunate acronym ‘LMF’ (lack of moral fibre) was stamped on the medical cards of aircrew who, through reasons of extreme stress or trauma, were unable to perform their duties – a millstone for many in future civilian lives (Jones, 2006). The acronym LMF was only removed from usage in 1960 by RAF Psychiatry

Having read the excellent Trauma by Gordon Turnbull I'm sure that military psychiatry has advanced since the 1960s but Fossey reminds us of the role "personality factors" still play in explaining (and excusing) high rates of post-traumatic stress amongst the military:

While there can be no doubt that those suffering from complex PTSD have many needs, some authorities debate the nomenclature and suggest that personality factors (which have been mostly a result of pre-service experience) are more important determinants of health in such people than their military experiences.

It impossible to say whether or not these individuals would have developed PTSD had they not joined the military, but I'm pretty sure joining up increased the risk.

Fossey argues that there's one group amongst the military who do raise concerns. These are young men under twenty-four years of age with less than four years service. They leave because military life doesn't suit them, and because they have served for a short time they get less help with their resettlement than personnel with long service. This group of young people are 2-3 times more likely to commit suicide than the same age groups in the general and serving populations. Fossey's Report suggests we should direct more resources at those young people who leave the forces early rather than those who serve for a long time and experience numerous tours of duty.

Fossey is arguing in his report that the military tends to recruit low educational achievers from poor areas. Many of these men and women have pre-existing problems before they join. They are recruited and successfully changed by the military and have long and successful careers. A number, however, are unable to settle and are discharged. Their inability to serve is not due to their experience with the Forces but the pre-existing problems these young men already have with authority, alcohol, drugs and crime. A brief survey of the cases I am familiar with does indeed suggest long-standing problems that pre-date their military experience.

So, what can be said about the mental health of British military and ex-military personnel. Firstly, most individuals serve in the armed forces without suffering any serious mental health problems at all. Secondly, there is a significant minority who suffer alcohol addiction, supported to some extent by the military's drinking culture. Thirdly, there is another group, young men at risk of depression and suicide, if they leave the forces early and without an adequate resettlement plan. Fourthly, a minority of personnel - between 4 - 19% - are suffering from the symptoms of PTSD as a result of combat. It is these three groups that require resources, care and support.

Brief Thoughts on Developmental Trauma

An interest of mine at the moment is the idea of 'developmental trauma'. Practitioners and researchers are attempting to include developmental trauma in the latest version of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association. I recently read a brilliant article about this by Mary Sykes Wylie which appeared in the Psychotherapy Networker as "The Long Shadow of Trauma". Wylie writes about the impact of early trauma on later life; but she also writes a fascinating piece about the importance of research in changing the minds of the medical establishment.

Developmental Trauma is the phrase used to describe a cluster of symptoms that result from early experiences of trauma, and in particular abuse and neglect. These experiences leave their mark on brain development (see, for example, this article in Science Daily or this one in New Scientist) and on the child's psychological, emotional, social and moral development. Indeed a child's ability to regulate their emotions and manage their behaviour will be impaired, leaving them vulnerable to alcohol and drug misuse, risk taking, violence, attachment problems and long-term health problems. In my current work as a counsellor I see the signs of developmental trauma; but it was as a probation worker and a youth justice worker, that I saw most clearly the negative impact of early neglect and abuse on the lives of individuals.

Links

Adverse Childhood Experiences Study referred to in the The Long Shadow of Trauma article, this mammoth study is demonstrating the long-term impact of early trauma.

Bessel Van der Kolk's Trauma Centre , website of one of the world's leading experts on post-traumatic stress and including numerous links to other resources

The Social Work Policy Institute has some good research pages on childhood trauma and recovery

National Child Trauma Stress Network, an excellent source of information and statistics about the impact of early abuse and neglect

Compassion Fatigue and Trauma Work

On Tuesday 29 November my students and I watched a DVD about secondary trauma, compassion fatigue and burn out; all conditions that can effect individuals working with clients who have suffered psychological trauma. Those of us who work with children are particularly at risk of developing a reaction - the vulnerability of children and an inbuilt need to protect them from harm can leave us feeling powerless and helpless when faced with a child's distress and suffering.

Secondary Trauma

Secondary trauma is a term used to describe a range of symptoms effecting individuals who attend traumatic incidents where people are killed or seriously injured. Fire fighters, police officers and paramedics are particularly at risk; but individuals working as nurses, doctors, therapists and support workers, caring for traumatised individuals, can also develop the symptoms of secondary trauma. Our ability to empathise with others leaves us vulnerable to traumatic reactions when we are helping individuals who have experienced overwhelming amounts of distress. Individuals exposed to secondary trauma may experience symptoms that are similar to Post Traumatic Stress Disorder (PTSD), a condition that effects individuals directly involved in the traumatic incident: flashbacks, intrusive thoughts, nightmares, depression, anxiety, avoidance, anger, hyper-vigilance, alcohol and drug misuse.

Compassion Fatigue

Individuals regularly working with the victims of trauma and abuse may develop or be at risk of developing compassion fatigue. Overwhelmed by the amount of traumatic information he or she is seeing, feeling and hearing, the individual's mind reacts to protect the individual. This involves closing down emotionally so the person is no longer emotionally available to their clients (and family); the individual may become tired, impatient, cynical and dissociated from their work. Stress builds and individuals react by becoming frustrated and angry. Losing our sense of humour is one of the first signs of compassion fatigue. An individual my also lose their common sense and become angry - passion replaces compassion. In these circumstances the individual needs to take a break. Once he or she has recharged his or her batteries the zest for work usually returns.

Burn Out

If the individual continues to work with trauma, despite experiencing compassion fatigue, then he or she may go on to experience burn out. In these circumstances the individual loses their desire and ability to do their job, a state of total exhaustion takes over, often accompanied by depression. The individual's mind and body is in revolt and will not allow them to continue being with distress and trauma. Recovery from burn out may take many months, or even years, and often results in a change of role for the individual or even a change in career.

Protecting Workers

Advice from senior professionals on the DVD centred on the need for a work-life balance: plenty of sleep, rest, exercise, sex, relationships, interests and hobbies, innoculate the trauma worker against compassion fatigue and burn out and increases resilience. At an agency level there is a need for supervision in order to help workers off load. Individuals new in post are particularly vulnerable to trauma reactions so effective training and support is essential.

Questions

How did you react to the DVD? What issues were important for you?

List some of the signs of stress in you and your colleagues?

Individuals working with children may be particularly at risk of developing compassion fatigue. What do you do to maintain a work life balance?

Further Reading

Educating Child Welfare Workers About Secondary Trauma and Stress: HERE

Book Review: Trauma by Gordon Turnbull

This book will be a very pleasant surprise for readers anticipating a dry textbook on psychological trauma. Instead Turnbull has written a wonderfully engaging account of his career as a psychiatrist in the Royal Air Force and private practice as an acknowledged expert on post-traumatic stress disorder (PTSD). The reader is alongside Turnbull as he uncovers the ways exceptionally traumatic events affect individuals and how PTSD develops as a means of coping in the midst of overwhelming terror.

For Turnbull PTSD is a natural response to events outside normal human experience and the symptoms of PTSD are often part of the recovery process. But his pioneering work is treated with suspicion by senior officers in the military who prefer to blame the individual for a ‘lack of moral fibre’ rather than accept PTSD as a natural outcome of military conflict.

Turnbull pioneered his technique of psychological debriefing with members of RAF mountain rescue teams attending the Lockerbie disaster. He worked also with released British POWs after the first Gulf War and the hostages John McCarthy and Terry Waite. He argues convincingly that service men and women need time for decompression before returning to civilian life, so soldiers returning from Afghanistan stop off in Cyprus to recuperate before returning home. Turnbull advocates a group approach to recovery and recommends cognitive therapy, but he also embraces hypnosis and EMDR as methods for transforming right-brain sensory material into left-brain narrative and meaning.

Turnbull illustrates his book with fascinating case material. He learns as much about trauma from his clients as he does from research and colleagues. Indeed the high regard Turnbull has for his clients and his view that trauma can lead to emotional growth makes his book an optimistic account of psychological trauma. Counsellors and psychotherapists of all persuasions will be entertained and educated by its insights.