The principal responsibility of the Commissioner for Survivors of Institutional Childhood Abuse is to promote the interests of Victims and Survivors of historical institutional childhood abuse. The Commissioner’s role, responsibilities, duties and powers are outlined in the Historical Institutional Abuse (Northern Ireland) Act 2019. The Act places certain duties on the Commissioner regarding provision of services for Victims and Survivors of historical institutional childhood abuse (see Appendix A below).
The Draft Mental Health Strategy acknowledges the need to target approaches to groups “more likely to be adversely affected by mental ill health..., [and] people with a specific trauma exposure.” The Commissioner would observe that Victims and Survivors of historical institutional childhood abuse come within that definition and therefore they and their mental health needs, based on their experiences, must be recognised, responded to and provided for in the context of the proposed mental health strategy.
Victims and Survivors of Institutional Childhood Abuse
Victims and Survivors were subjected to physical abuse, emotional abuse, sexual abuse and neglect while children while resident in institutions. This systemic abuse of children was perpetrated in institutional settings over decades
· Victims and Survivors can have experienced more than one form of abuse as well as neglect in one or more institutions. They can also have witnessed the abuse of other children within institutions which is in itself abuse and a source of trauma
· Victims and Survivors of institutional childhood abuse in Northern Ireland may have additional compounded trauma as the abuse perpetrated on them as children may intersect with experiencing Troubles-related trauma
· Victims and Survivors of institutional childhood abuse are primarily over the age of 50 (but they can be younger) with survivors in their 50, 60s, 70s and 80s; this has implications for mental health and services provision as there can be increased mental health issues associated with aging. The latter is particularly true for Victims and Survivors who may be living with but not receiving treatment for trauma-related conditions resulting from their abuse or psychiatric disorders exacerbated by abuse-related trauma
· Victims and Survivors’ needs around mental health are varied and subject to a complex intersection of factors. In common with other Victims and Survivors of childhood abuse, Victims and Survivors of historical institutional abuse can experience anxiety, depression, substance misuse issues, psycho-social challenges, post-traumatic stress disorder and other trauma-related disorders.
As Commissioner, I would observe the following: there appears to be a relatively low level of population-wide research in Northern Ireland in relation to the mental and physical health needs of Victims and Survivors of historical institutional childhood abuse from which to inform evidence-based policy making and service provision to address these needs.
For example, the Scottish Child Abuse Inquiry (SCAI) commissioned a research project to document the outcomes of institutional abuse in long-term child care in Scotland. It found among Victims and Survivors of institutional childhood abuse that 95.6% had experienced physical abuse; 85.3% had experienced emotional abuse; and 60.4% had experienced sexual abuse; 51.1% had experienced emotional neglect and 37.3% had experienced physical neglect. It found that across Victims and Survivors’ lifespans that 96% had experienced negative outcomes in psychosocial adjustment; 84% in mental health and 43% in physical health (retrieved from Survivors of institutional abuse in long-term child care in Scotland - PubMed (nih.gov))
Recommendations
Therefore, I am recommending:
1. Recognition of Victims and Survivors of historical institutional childhood abuse in the context of the proposed mental health strategy as a potentially at risk group of people, based on what we know of childhood abuse-related mental health issues and outcomes. The strategy itself references that Adverse Childhood Experiences (ACEs) have been found to account for 29.8% of mental disorders.
1.1. (I would suggest that Victims and Survivors of childhood abuse where abuse took place in other contexts outside institutions should also be recognised as an at risk group in reflection of negative mental health impact of childhood abuse for individuals)
2. Realise and acknowledge the existence of Victims and Survivors’ mental health needs with reference to the compounding trauma of potentially multiple abuses being perpetrated on Victims and Survivors, and potential intersection with Troubles-related trauma.
Respond with appropriate quality general and specialist, appropriately resourced services for Victims and Survivors of historical institutional childhood, that have been co-designed with Victims and Survivors. Victims and Survivors may benefit from community and focused, but non-specialised, support services but may also require specialist services as a result of their mental health needs and/ or the type of abuse they experienced (for example, CBT psychological interventions and specific counselling supports around experiences of child sexual abuse). The strategy itself notes that one of the weaknesses of the mental health system here is the lack of specialist supports.
These needs around specialist services and potentially acute services will also intersect with the needs of Victims and Survivors as they age, which will potentially be at the more resource intensive end of the services-provision spectrum.
My emphasis on services provided by the State, is not to devalue the crucial role of community and peer-to-peer supports. For many Victims and Survivors, peer-to-peer supports i.e. supports of other Victims and Survivors have been their key supports. It is rather to underline the type and quality of services that the State needs to provide in response to the compound and intersecting trauma Victims and Survivors experienced as a result of institutional childhood abuse; the trauma which they have carried with them through their adult lives and their resulting mental health needs. The State could consider services provision in the context of overall accountability to Victims and Survivors as envisaged under the Hart recommendations.
3. Respond to Victims and Survivors’ mental health needs by adopting a Victim and Survivor-centred, trauma-informed approach to services provision informed by engagement with Victims and Survivors. Trauma-informed is a widely used term, in this context, the recommendation is based on the SAMSHA (US Substance Abuse and Mental Health) Principles which define trauma-informed as:
3.1. Realises the widespread impact of trauma and understands potential paths for recovery;
3.2. Recognises the signs and symptoms of trauma in clients, families, staff and others involved in the system;
3.3. Responds by fully integrating knowledge about trauma into policies, procedures and practices and;
3.4. Seeks to actively resist re-traumatisation
Adopting a trauma-informed approach is particularly important as Victims and Survivors of historical institutional childhood abuse, in common with other Victims and Survivors of abuse, may be reluctant to disclose their experience of abuse even to loved ones. Therefore creating a greater onus on the State to adopt a trauma-informed approach in order to meet these presenting but potentially unexpressed needs.
The reasons for non and limited disclosure of abuse are many and varied. A Victim and Survivor may have disclosed as a child and been disbelieved and/or punished for their disclosure or had their experiences minimised. Disclosure as an adult may have elicited similar responses. There may also be a fear on the part of a Victim and Survivor that by disclosing their experiences they will alienate people, particularly those whom they love. Victims and Survivors may also have denied or minimised their experiences for themselves in order to cope “It wasn’t that bad…” or “It wasn’t as bad…” Or they may have had to re-tell their experiences so many times to different service providers/ agencies that this becomes a source of trauma in itself, where re-telling has brought no improvement instead increasing a Victim and Survivor’s feelings of powerlessness.
5. Reach-out to Victims and Survivors of historical institutional childhood abuse by mental health services, potentially via awareness initiatives, recognising that based on childhood abuse experiences Victims and Survivors are potentially at risk of poorer mental health; their needs going unmet and at risk of reduced health outcomes.
Finally, as Commissioner I would also observe that State initiatives involving Victims and Survivors of historical institutional childhood abuse could have potential consequences for mental health services including increased disclosures in a therapeutic setting and increasing demand for these services and that mental health services may need to plan accordingly.
Conclusion
Victims and Survivors of institutional childhood abuse did not have their physical or mental health needs responded to as children. It was their treatment and abuse by institutions that created or exacerbated mental health needs. Many Victims and Survivors would say their mental health needs as adults have still yet to be adequately met. The Mental Health Strategy is an opportunity to make a difference. Victims and Survivors of historical institutional childhood abuse deserve to have their mental health needs responded to now and going forward the future.
Appendix A
Legislation relating to Provision and Co-ordination of Services to Victims and Survivors of Childhood Abuse
Section 26 of the Historical Institutional Abuse (Northern Ireland) Act 2019 requires the Commissioner to encourage the provision, and the coordination of the provision, of relevant services in Northern Ireland to victims and survivors. Such relevant services are set out in the legislations as the following:
(a) to improve a person's physical or mental health,
(b) to help a person to overcome an addiction,
(c) to provide a person with counselling,
(d) to improve a person's literacy or numeracy,
(e) to provide a person with other education or training, or
(f) to enable a person to access opportunities for work.
The Commissioner is further required to take account of the current provision of relevant services to victims and survivors and to identify any gaps in the provision of those services and to provide, or secure the provision of, advice and information to victims and survivors on:
(a) the relevant services that are available to them and the facilities that are available for the provision of those services, and
(b) how to obtain those services and access those facilities.
Section 27 of the Act requires the Commissioner to monitor the operation of whatever facilities there are currently available in Northern Ireland which are solely for providing victims and survivors with;
(a) counselling and supplementary information about how to access health services, housing services, education services or employment services,
(b) help to improve literacy or numeracy, or
(c) advice on opportunities for education or work or on entitlements to housing or social security benefits.