With Northern Ireland experiencing some of the highest rates of poor mental health in the UK, transgenerational trauma is a term that has surfaced more frequently in recent years and been linked to various mental health issues here.
The term essentially refers to how the trauma of a previous generation impacts upon the next i.e. those who have experienced trauma may also pass this trauma on to their children. In 2022, OUR Generation, a collaborative PEACE IV programme between various organisations – of which Action Mental Health is lead partner – launched Transgenerational Trauma Awareness Day (TTAD). Essentially, this is a day to highlight what transgenerational trauma is and to generate discussion around it. As OUR Generation (OG) is a cross-border initiative with a specific focus on youth mental health and wellbeing, addressing the issue of transgenerational trauma is subsequently an important element of OG’s ongoing work.
As part of the TTADs to date, events have included speakers such as Northern Ireland’s Mental Health Champion, Dr Siobhan O’Neill, along with experts from Ulster University, Queen’s University Belfast and the Northern Trust’s Regional Trauma Network.
While it’s important to highlight that transgenerational trauma is a very real issue, however, there should also be clarity around what exactly it is – which is another element of TTAD. Indeed, not everyone who experiences trauma will suffer from conditions like PTSD and the children of those who do will not necessarily always experience trauma themselves.
Dr Michael Duffy is a Consultant Cognitive Psychotherapist specialising in PTSD and complex grief. A Senior Lecturer and Director of the Specialist MSc (Trauma) in Cognitive Behavioural Therapy at Queen’s University Belfast, he leads the QUB Trauma Research Network and is a research/clinical advisor to the Northern Ireland Regional Trauma Network. He subsequently spoke with us about transgenerational trauma, including his ongoing research into Complex PTSD (CPTSD) and Prolonged Grief Disorder (PGD) – and how this will help to shape the future of mental health services.
When it comes to discussing transgenerational trauma, “we need to take care about what we mean,” said Dr Duffy, “because a lot of research is based on false assessments.”
“It would be wrong to assume that just because your parents have been exposed to trauma that you’re going to suffer,” he said. “That’s not the case. The vast majority of people exposed to traumatic events don’t get PTSD. It’s a false assessment to say that they do.
“However, there are some studies internationally and here, in Northern Ireland, that very clearly indicate that the children of people who have suffered from prolonged and severe trauma are more at risk of developing mental health problems. One example of this is with survivors of the horror camps during World War Two. Follow-up research with the children of these survivors showed they had a high risk of PTSD, even the grandchildren. But what we don’t know is the detail – the mechanism that led to that.”
Discovering this detail – the exact cause of any subsequent mental health issues in the descendants of trauma survivors – will ultimately help to explain transgenerational trauma more precisely. Indeed, recent American research with Holocaust survivors has suggested that transgenerational trauma within that context could actually be biological and therefore physically inherited.
“Their hypothesis was that transgenerational trauma can be conveyed in a very physiological way,” said Dr Duffy. “But I think we have to be quite careful about that. There are various answers to this – and no simple answer.”
He added that, with a range of factors to consider when discussing transgenerational trauma, there were also different reasons as to why children could develop mental health issues. Particularly in Northern Ireland, where there was a legacy of the Troubles, it was important not to assume that childhood mental health issues, when they presented, were always due to trauma passed on by parents or carers.
“For example, we’ve always known that children raised by mothers that have depression are more at risk of developing depression,” he said. “The kids grow up vulnerable and have anxiety conditions. These children are at high risk of developing mental health problems.
“Some small studies have been done here with my colleagues where they have looked at children exposed to challenges from the Troubles. They used drawings [to gain insight into their mental health] and most of those kids drew normal pictures. Some drew pictures of soldiers etc. but where there were incidents that the children had difficulties, we traced it back again to the fact the mother had mental health problems.”
In short, conflict situations like the Troubles mean that more people are exposed to high-risk situations and those who then go on to become parents are subsequently more susceptible to having mental health problems. A direct result of this is that their children are also more likely to experience mental health issues – although not all of them necessarily will. Whether or not this can be referred to as transgenerational trauma, however, is less clear.
Regarding his own research, Dr Duffy recently studied children within the care system, assessing whether frontline services had a validated diagnostic tool to identify PTSD in children who had suffered maltreatment [1]. The results indicated that there were “very high amounts of PTSD and very few had been diagnosed.”
“Without the correct diagnosis you’re not going to get the correct therapy,” he said. “I shared that as a wake-up call.”
His current research, however, is predominantly focused on Complex PTSD (CPTSD) and Prolonged Grief Disorder (PGD) – two terms recently added to the International Classification of Diseases-11 (ICD-11) Diagnostic Manual (WHO, 2018).
According to a report on Conflict, Trauma and Mental Health published by QUB and the Commission for Victims and Survivors (CVS) in 2022 [2], which was led by Dr Duffy, “both of these conditions are pertinent to the psychological distress experienced by many victims of the Northern Ireland “Troubles”.”
“We have a large multi-sector trial taking place in England and Northern Ireland for CPTSD – PTSD that’s usually linked to childhood traumas, child abuse or prolonged and extensive trauma in adulthood, for example, rape or being held prisoner,” he said.
“Complex PTSD is a new condition. There have been no studies so far to test what works in terms of therapy for this, so we’re testing trauma-focused cognitive therapy that works for PTSD – does it also work for CPTSD? The argument ‘in field’ has always been that we shouldn’t start straight in with therapy for PTSD – proceed slowly. So, half of the patients will be randomised phased and the others will go straight into the 26 therapy sessions. Follow-up will then take place three and six months later to see where they are.”
Delivered as part of a £2m research grant, the project involves a wide range of people from across Northern Ireland and England, many of those from NI having had experiences of the Troubles.
“Mental health is noticeably different from all other forms of healthcare in that the concept of evidence isn’t held in the same regard,” said Dr Duffy. “But the wrong therapy can make people worse, so it’s really important that evidence-based treatment is embraced in the mental health sector. Clients who have a certain condition should only be offered the therapy that works for that condition. When clients are referred, they should then be offered a range of therapies – and those with the strongest evidence base.
“The rates of poor mental health are on the increase and we can’t afford as a society to have people drifting through ineffective therapies. We’re getting better with this, though.”
Another key piece of research Dr Duffy is currently running relates to Prolonged Grief Disorder (PGD) – also recently added to the International Classification of Diseases-11 (ICD-11) Diagnostic Manual (WHO, 2018).
“Like CPTSD this is a relatively new category developed in the last few years,” he said. “It’s to differentiate people who suffer from normal grief reactions and those who have prolonged grief. These people need an evidence-based response as studies show that traditional grief counselling doesn’t work with them. What we’re doing is looking at what does seem to work and developing a therapy model for PGD.”
Using current PTSD treatments as a baseline for PGD therapy, Dr Duffy said that PGD usually occurred after a traumatic or sudden loss and was characterised by social withdrawal. “There’s an element of trauma that we have to treat with PGD,” he added. “We have to try to find out about what’s going on in their minds and how their patterns of behavior change. We’re getting very encouraging results but we need good research to understand PGD better and develop more effective therapies. That’s our next big project.”
With a clear need for more evidence-based practice within the mental health sector and more specialised and consistent treatment for conditions such as CPTSD and PGD, there is still a way to go on this front. Indeed, the joint report commissioned by QUB and the CVS stated that a “substantial proportion of victims and survivors of the recent Northern Ireland conflict have enduring mental health needs that requires a comprehensive, joined-up, evidence-based service response.”
Research like Dr Duffy’s is, however, helping to address this, with all learning feeding back into training up the next generation of therapists and, ultimately, evolving mental healthcare delivery.
“It’s been a learning model over the years,” he said. “We research, bring that back into our courses at QUB and then update our teaching based on what we learn. And from there, we enable more effective treatment to be delivered to those who need it.”
About Dr Duffy
Dr Michael Duffy is a Consultant Cognitive Psychotherapist specialising in PTSD and complex grief. A Senior Lecturer and Director of the Specialist MSc (Trauma) in Cognitive Behavioural Therapy at Queen’s University Belfast, he leads the QUB Trauma Research Network and is a research/clinical advisor to the Northern Ireland Regional Trauma Network. Dr Duffy is also a Fellow of the Centre for Evidence and Social Innovation; Assoc. Fellow of the George J Mitchell Institute for Global Peace Security & Justice; Fellow of the British Association for Behavioural and Cognitive Psychotherapy and a member of the UK Trauma Council.
Dr Duffy led the work of the trauma team after the Omagh bombing in Northern Ireland in 1998 and published research on the psychological effects of this event on adults, children and adolescents. He was later team leader at the Northern Ireland Centre for Trauma (NICTT) and led two clinical trials on the application of TF-CT for conflict-related PTSD. In addition to this, Dr Duffy has provided many workshops on PTSD after large-scale traumas, including: 2004, New York the 9/11 Twin Towers attack; 2005, 7/11 London bombings; 2012 Oslo bombing and Utoya Island shootings; 2017, the Manchester Concert bomb.
Dr Duffy’s main research is focused on PTSD and evidence-based psychological interventions and he is currently researching PTSD with children who have been maltreated or abused. He is also looking into new cognitive approaches for complex grief and complex PTSD. Dr Duffy has provided many webinars and podcasts including a recent BBC documentary entitled ‘PTSD – Stress of the past’.
References
[1] Duffy, M. et al. (2021) Screening Children with a History of Maltreatment for PTSD in Frontline Social Care Organisations: An Explorative Study. Child Abuse Review, Vol 30 (6) pp. 594-611. https://doi.org/10.1002/car.2735
[2] Duffy, M. (2022) Conflict, Trauma and Mental Health: How psychological services in Northern Ireland address the needs of victims and survivors. Available at: https://www.cvsni.org/wp-content/uploads/2023/07/FINAL-Trauma-Services-Report.pdf
Further reading:
Yehuda, R.; Lehrner, A. (2018) Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World Psychiatry, 17 (3), pp. 243-257. DOI: 10.1002/wps.20568. PMID: 30192087; PMCID: PMC6127768.
Day, N.; Shloim, N. (2021) Therapists’ experiences of working with the intergenerational impact of troubles-related trauma. Available at:https://doi.org/10.1002/ppi.1585
