“Prisoners of the Pandemic: Social and Forensic Consequences of the Coronavirus” Abstract: My title is a play on the word “prisoners” that forensic psychiatry deals with but, in fact, hearkens back to Plato's analogy of the cave with its prisoners in a situation of sensory deprivation. The confinement and social distancing strategies adopted almost universally across the planet to deal with the viral pandemic effectively imprisoned entire populations, leading to social isolation and sensory deprivation. My talk will focus on the impacts of coronavirus syndemic on children and families and highlight the impacts of the isolating strategies of social distancing and confinement using the ACE (Adverse Childhood Experiences) Study as a model. These strategies increase the risks for everyone but even more so for more dependent and vulnerable populations, especially children, creating what I call an "experimental child." The developmental impacts may be best understood through the new field of social neuroscience, an allied field of social psychiatry. The term for these wider consequences of the pandemic, triggering parallel social impacts beyond the viral disease, is syndemic which will be defined and described. And among children, those who are already at risk are becoming even more vulnerable with consequences for normal development and social functioning and higher levels of anxiety, mental and relational disturbances with potential forensic consequences as well. The long-term consequences will require prospective longitudinal studies for decades to come, with a careful eye on all aspects of social and neurobiological functioning from school failure to higher delinquency and crime rates. This will require greater resources for following entire populations and targeting those at greater risk for prevention at every level - primary, secondary and tertiary. Key words: Plato's cave, pandemic, syndemic, confinement, social distancing, sensory deprivation, social isolation, Social Determinant of Health (SDoH), Adverse Childhood Experiences (ACE) Study References: Di Nicola V. From Plato’s cave to the Covid-19 pandemic: Confinement, social distancing, and biopolitics. Global Mental Health & Psychiatry Review, 2021, 2(2): 8-9. Di Nicola V, Daly N. Growing up in a pandemic: Biomedical and psychosocial impacts of the COVID-19 crisis on children and families. Special Theme Issue: COVID-19 Pandemic and Social Psychiatry. World Social Psychiatry, 2020, 2(2): 148-151. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermetten E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge, UK: Cambridge University Press; 2010:77-87.

1. Prisoners of the Pandemic:
Social and Forensic Consequences of the Coronavirus

2. Professor Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA
16th Annual Risk & Recovery Conference
Forensic Psychiatry Institute, McMaster University
April 21, 2023
Prisoners of the Pandemic:
Social and Forensic Consequences
of the Coronavirus

3. Professor of Psychiatry, University of Montreal
President, World Association of Social Psychiatry
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA
Email: vincenzodinicola@gmail.com

4. McMaster has once again been recognized as one of the
world’s top 50 universities for the study of life sciences
and medicine, according to the 2023 QS World University
Rankings by Subject.
Ranking 48th in the world and fourth in Canada for life
sciences and medicine, McMaster also saw significant
growth in the areas of engineering and technology,
natural sciences and social sciences and management.
McMaster Achievements

5. • The presenter has no financial conflicts of interest to declare
Conflicts of Interest

6. 1. Syndemics – To offer a comprehensive model for the coronavirus crisis as
a syndemic, integrating the infectious disease (SARS-CoV-2) and the related
non-communicable diseases (NCDs) that put youth at risk for psychosis,
related mental and relational disorders, and for delinquency.
2. The Experimental Child – To identify the pre-existing conditions of
inequity, poverty, mental illness, racism, ableism, and ageism that create
stigma and discrimination and amplify the impacts of the syndemic.
3. The Longest Shadow – To describe the cascade of consequences
impacting on children during major crises such as the coronavirus syndemic,
using the Adverse Childhood Experiences (ACE) model.
4. Following Through – To offer an overview of the social and forensic
consequences of the coronavirus syndemic.
Learning Objectives

7. • I am not a forensic psychiatrist
• I am a child and adolescent psychiatrist, a family psychotherapist,
and a social psychiatrist
• However, I trained and worked in places where Canadian forensic
psychiatry is especially strong:
• I trained at McGill with Bruno Cormier and Renée Fugère
• University of Ottawa - a junior colleague of John Bradford
• Queen’s University a colleague of Steven Hucker
• Université de Montréal: Institut Philippe-Pinel
Introduction

8. Pandemic to Syndemic

9. • The coronavirus pandemic has been renamed a syndemic,
encompassing two different categories of disease—an infectious
disease (SARS-CoV-2) and an array of non-communicable diseases
(NCDs) *Note: SARS-CoV-2 is the virus, COVID-19 is the disease
• Together, these conditions cluster within specific populations
following deeply-embedded patterns of inequality and vulnerability
(Horton, 2020)
• And children – and their caregivers mostly women – are the most
vulnerable population around the world
Reference: Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396: 874.
Pandemic to Syndemic

10. • A syndemic or synergistic epidemic is the aggregation of two or
more concurrent or sequential epidemics or disease clusters in
a population with biological interactions, which exacerbate the
prognosis and burden of disease
• Developed by medical anthropologist Merrill Singer
(mid-1990s)
Reference: Wikipedia contributors. “Syndemic (n.d.).” In Wikipedia. Retrieved March 27,
2023, from: https://en.wikipedia.org/wiki/Syndemic
Defining a Syndemic

11. • Syndemics develop under health disparity, caused by poverty,
stress, or structural violence and are studied by
epidemiologists and others concerned with public health,
community health, and the social determinants of health
References: Singer M. Introduction to Syndemics: A Systems Approach to Public and
Community Health. San Francisco: Jossey-Bass; 2009.
Singer M, Bulled N, Ostrach O, Mendenhall E. Syndemics and the biosocial conception of
health. Lancet. 2017; 389: 941-950.
Wikipedia contributors. “Syndemic (n.d.).” In Wikipedia. Retrieved March 27, 2023, from:
https://en.wikipedia.org/wiki/Syndemic
Defining a Syndemic

12. Plato’s Cave
An Illustration of The Allegory of the Cave from Plato’s Republic
Source: https://commons.wikimedia.org/w/index.php?curid=73850232

13. • A group of prisoners is chained in a cave since childhood
where they cannot see each other, only shadows on the
cave wall ahead cast by a fire behind a parapet
• Puppeteers parade along the parapet with two-
dimensional objects poorly representing the real world
outside the cave
Reference: Di Nicola V. From Plato’s Cave to the Covid-19 Pandemic: Confinement, Social
Distancing, and Biopolitics. Global Mental Health & Psychiatry Review, 2021, 2(2): 8-9.
Plato’s Allegory of the Cave

14. • Sounds bouncing off the walls from beyond the cave are
attributed by the prisoners to the shadows, their only
reality
• The philosopher who frees himself to seek the truth
beyond the cave is received with scorn when he returns to
the cave to inform his fellow prisoners who see illusions
as their reality
Reference: Di Nicola V. From Plato’s Cave to the Covid-19 Pandemic: Confinement, Social
Distancing, and Biopolitics. Global Mental Health & Psychiatry Review, 2021, 2(2): 8-9.
Plato’s Allegory of the Cave

16. • Plato’s prisoners are in a situation of sensory deprivation much like the
subjects of Hebb’s psychological experiments at McGill University
• Hebb’s experiments demonstrate that Plato’s prisoners would
experience sensory deprivation and begin to hallucinate to make up for
the lack of external stimuli
• The brain lives – and only functions normally – in a bath of stimuli
which makes the brain grow and the mind develop
How is COVID-19 Making Us Like the Prisoners
of Plato’s Cave?

17. Sensory Deprivation Experiments (Hebb)

18. • Chained since childhood, the prisoners have experienced long-term
sensory deprivation which impacts brain structure
• Nobel-prize winning research by Hubel & Wiesel on cats showed that
blocking visual stimuli at a critical stage radically alters their
neurophysiology
• COVID-19 is creating an “experimental childhood,” subjecting billions
of youth to confinement and social isolation casting a deep shadow
with potentially devastating life-long impacts (Di Nicola & Daly, 2020)
How is COVID-19 Making Us Like the Prisoners
of Plato’s Cave?

19. Maternal Deprivation
(Bowlby)
Reference: Bowlby J. (1982). Attachment and Loss, Vol. 1: Attachment (2nd ed.). New York: Basic
Books. (Original work published 1969).

20. Isolation Tanks
(Lilly)
Reference: Williams C. (2019). On ‘modified human agents’: John Lilly and the paranoid style in
American neuroscience. History of the Human Sciences, 32(5), 84–107.
https://doi.org/10.1177/0952695119872094

21. • The practice of solitary confinement in the United States traces its
origins back to the 19th century when Quakers in Pennsylvania
used this method as a substitution for public punishments.
• Research surrounding the possible psychological and
physiological effects of solitary confinement dates as far back as
the 1830s.
Source: Wikipedia contributors. “Solitary confinement.” Wikipedia, The Free Encyclopedia, 17
Apr 2023.
Solitary Confinement

22. “A robust scientific literature has established the negative psychological
effects of solitary confinement,” leading to “an emerging consensus
among correctional as well as professional, mental health, legal, and
human rights organizations to drastically limit the use of solitary
confinement.” (Haney, 2018)
The long-term psychological impacts of solitary confinement in South
Africa, as well as deprivation and constraint torture techniques in
prisons, were observed as analogous to those of post-traumatic stress
disorder.
There is a scholarly consensus that solitary confinement is harmful,
which has led to a growing movement to reduce or abolish the practice.
Reference: Haney C (2018). Restricting the Use of Solitary Confinement. Annual Review of
Criminology, 1: 285–310.
Solitary Confinement

23. Social Psychiatry and Forensic Psychiatry

24. • I see forensic psychiatry situated at the crossroads of medicine and
the law
• I also see these discourses or domains as sometimes in partnership,
sometimes adversarial, potentially compatible, hopefully
complementary
Reference: Liebrenz M. (2022). A rose is a rose is a rose: All psychiatry is social
psychiatry, but is all psychiatry forensic psychiatry? And is all forensic psychiatry social
psychiatry? Forensic Science International: Mind and Law, 3 December, 100110.
Social Psychiatry and Forensic Psychiatry

25. • Trauma leaves traces
• Confinement, isolation, masking and social distancing leave traces
• ACE Study, WHO SDoH Study
Reference: Erzinçlioglu Z. (2000). Every Contact Leaves a Trace: Scientific Detection in
the Twentieth Century. London: Carlton Books.
“Every contact leaves a trace”

26. • Italian criminologist and positivist
• Father of forensic psychiatry
• Theories of atavism and degeneration
and the notion of the “born criminal”
• Key works:
• The Man of Genius
• The Female Offender
• Crime: Its Causes and Its Remedies
Cesare Lombroso
(1835-1909)
Source: https://en.wikipedia.org/wiki/Cesare_Lombroso Photo: Public domain

27. • Lombroso’s essay (1856/1927) on the influence of civilization
on madness and of madness on civilization is surprisingly
modern, anticipating the work of Michel Foucault and serves
as an early contribution to social psychiatry
• Appears in a collection of essays on the influence of heredity,
the impact of the environment on madness, and the reciprocal
influences of madness and civilization
Reference: Lombroso C. Influenza della civiltà nella pazzia e della pazzia nella civiltà
[The influence of civilization on madness and of madness on civilization]. In: Lombroso, Gina, ed.
Psicologia e Natura. Studi Medico-Psicologico-Naturalistici [Psychology and Nature. Medico-
Psychologico-Naturalistic Studies]. Turin: Fratelli Bocca, Editori; 1927: 52-67.
Civilization and Madness

28. • Documents ~20 epidemics of both medical (pellagra) and
psychological (tarantism) contagion
• Contemporary view of “civilization” (culture) in terms of
economic, historical and sociocultural factors
Reference: Lombroso C. Influenza della civiltà nella pazzia e della pazzia nella civiltà
[The influence of civilization on madness and of madness on civilization]. In: Lombroso, Gina,
ed. Psicologia e Natura. Studi Medico-Psicologico-Naturalistici [Psychology and Nature. Medico-
Psychologico-Naturalistic Studies]. Turin: Fratelli Bocca, Editori; 1927: 52-67.
Civilization and Madness

29. • Confinement, Masking, Social Distancing
The Experimental Child

30. • Social distancing
• Class and cultural differences
• Confinement
• Impact on vulnerable groups, relationships
• Adverse Child Experiences (ACE)
• Associated with poorer health outcomes
Impacts

31. Isolation vs.
connection

32. Adverse Childhood Experiences (ACEs)
Adverse Childhood Experiences (ACEs – Felitti, et al, 1998) are strongly
associated with negative health outcomes
• Physical, emotional and sexual abuse, neglect and household dysfunction
• Linear gradient between the number of ACEs and worsening health outcomes
Reference: Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al.
(1998). Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14 (4): 245–258.

33. Social Determinants of Health (SDoH)
• Sir Michael Marmot – WHO Study (CSDH, 2008)
• Social Determinants of Health and Mental Health (SDH/MH)
• The most robust and relevant research done in medicine
• Key concept: Mental health gaps
• Children and women are the most vulnerable populations
• “There is no health without mental health” has become the mantra of the Global
Mental Health Movement
Reference: CSDH (2008). Closing the gap in a generation: Health equity through action on the social
determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva,
Switzerland: World Health Organization.

34. Army trucks in Bergamo, Italy (Reuters – March 19, 2020)

35. Antigone and Polynices (Nikiforos Lytras, 1865)

36. Incident at Antares
• Érico Veríssimo
(Novel, 1971)
• Carlos Manga
(Film, 1994)

37. • The Coronavirus Syndemic
The Longest Shadow

38. John Bowlby
(1907-1990)

39. • John Bowlby – psychiatrist and psychoanalyst – Tavistock Clinic
• Synthesized all the relevant literature of paediatrics, child psychology,
psychiatry & psychoanalysis to create attachment theory
• Bowlby’s trilogy
• Attachment, Separation, Loss (1969, 1973, 1980)
• A Secure Base: Parent-Child Attachment and Healthy Human
Development (1988)
Attachment

40. Attachment
Dominant model for the study of early social development
Key Features
• Toddlers form emotional attachments to familiar caregivers
• Establishing a lifelong “secure base”
• Foundation of later behaviour, emotions and personality

41. Attachment
Events that interrupt or interfere with attachment have consequences
• Separation of a toddler from attachment figures
• Caregivers’ lack of sensitivity, responsiveness or consistency when
interacting with toddlers

42. Attachment
in action …
42

43. • What do the history of madness, prisons and pandemics have
in common?
Madness, Prisons & Pandemics

44. Sometimes I think this whole world
Is one big prison yard
Some of us are prisoners
The rest of us are guards
- Bob Dylan, “George Jackson” (1971)

45. • What do the history of madness, prisons and pandemics have
in common?
• Madness: “the great confinement” (Foucault)
• Crime: “the carceral system” – “the panopticon” (Foucault)
• Pandemics: containment, mitigation, suppression
Madness, Prisons & Pandemics

46. • French psychologist, philosopher and
historian
• Two key works:
• Madness and Civilization
• Discipline and Punish
Michel Foucault
(1926-1984)
Source: www.stars-portraits.com
Photo: Public domain

47. Source: www.stars-portraits.com
Photo: Public domain

48. • Madness and Civilization
“The Great Confinement”
Hamilton anecdote:
Dr. Marcel Lemieux, Medical Director of HPH,
introduced me to Foucault
Michel Foucault

49. Bethlem Hospital (1828) – Imperial War Museum (since 1926)

50. • Discipline and Punish
“The Panopticon”
Michel Foucault

51. Bentham’s Panopticon
…. the practice
(Presidio Modelo – Cuba, 1925-31)
The plan (Jeremy Bentham,
1791) and …

52. Literature Review:
Social and Forensic Impacts of the Coronavirus

53. “The COVID-19 pandemic also posed major challenges in secure
psychiatric hospitals and for psychiatrist experts. Rapid changes in
working practices occurred.” …
“[T]he lockdown period was associated with an increase in domestic
violence, especially gender-based violence and child abuse and neglect.”
Reference: Fovet T, Thibaut F, Thomas P, Lancelevée C (2020). French forensic mental health
system during the COVID-19 pandemic. Forensic Science International: Mind and Law,
1,100034. https://doi.org/10.1016/j.fsiml.2020.100034.
French forensic mental health system during the
COVID-19 pandemic

54. “The communal isolation of the patients was further problematized
by the obligatory use of face masks among staff, which especially
challenged the creation of therapeutic relations between staff and
newer patients. Despite such additional challenges, we found that
patients still experienced meaningful moments within mundane
activities in the wards.”
Reference: Terkildsen MD, Vestergaard LK, Jette Møllerhøj J, Sørensen LU (2022).
Forensic Psychiatric Patients’ Perspectives on COVID-19 Prevention Measures: A
Qualitative Study, Journal of Forensic Psychology Research and Practice, DOI:
10.1080/24732850.2022.2118095
Danish study of forensic psychiatric patients’
perspectives on COVID-19 preventive measures

55. “The impact of the COVID-19 pandemic has been far-reaching.”
“Conclusion
The impact of the present pandemic era will be experienced across a
wide swath of our society, including the practice of forensic psychiatry
and forensic psychology. It is important for our respective disciplines
to consider how these changes might affect the provision of forensic
evaluations to courts and attorneys.”
Reference: Heilbrun K, Burke SC, NeMoyer A, Durham K, Desai A (2020). Editorial:
A Principles-Based Analysis of Change in Forensic Mental Health Assessment
During a Global Pandemic. J Am Acad Psychiatry Law 48(3) online, 2020.
DOI:10.29158/JAAPL.200039-20
US principles-based analysis of forensic mental
health assessments during a global pandemic

57. Results: There was an overall increase in long-term segregation (LTS) hours during the pandemic; 140%, (95%
Cl 107, 171%) during Lockdown 1; 113%, (159% Cl 127, 192%) during post-Lockdown 1; 45% (95% Cl 23,
68%) during Lockdown 2 and, finally, 90% (95% Cl 63, 113%) during Lockdown 3.
The most negative outcomes were evident during Lockdown 3. Incidents of violence were significantly more
frequent during Lockdown 3 than would have been predicted based on pre-pandemic data, including physical
assaults to service users (206%, 95% CI 57%, 346%), non-physical assaults to service users (206%, 95% CI
53%, 339%), and self-harm (71%, 95% CI 0.4%, 135%). Use of enforced medication also increased during
Lockdown 3 (317%, 95% CI 175%, 456%).
Conclusion: The pandemic and its related restrictions negatively affected some service outcomes. This resulted in
increased incidents of violence and increased use of restrictive interventions, beyond what would have been
expected had the pandemic not occurred.
Reference: Puzzo I, Aldridge-Waddon L, Stokes, N, Rainbird J, Kumari V (2021). The Impact of the
COVID-19 Pandemic on Forensic Mental Health Services and Clinical Outcomes: A Longitudinal Study.
Front Psychiatry, Sec. Forensic Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.780236
British study of the impact of COVID-19 on
forensic services and clinical outcomes

58. Summary
Prior to the Covid-19 pandemic, there was tolerance for a homeless, mentally ill and
substance misusing population who cycle between psychiatric and addiction services, prisons
and street services.
They represent a pool of risk to themselves and others that may now be seen differently.
There was prior awareness of seasonal excess mortality. Trolley queues in emergency
departments have now vanished overnight but waiting lists of severely mentally ill people in
prison remain with high risks of suicide for those with substance misuse and criticism by
international human rights bodies.
This may prompt a greater sense of social responsibility and should prompt social
intervention and prevention in ways that have not happened for the late 20th century/early
21st century epidemics of psychosis and drug-related morbidity, co-morbidity and mortality.
Reference: Kennedy HG, Mohan D, Davoren M. (2020). Forensic psychiatry and Covid-19: Accelerating
transformation in forensic psychiatry. Irish Journal of Psychological Medicine, 38(2): 145-153.
http://doi:10.1017/ipm.2020.58
Irish study of COVID-19 – Accelerating
transformation in forensic psychiatry

59. First line:
“The COVID-19 pandemic has dramatically altered the landscape of human
life across the globe.”
“The COVID-19 pandemic has provided a natural experiment capable of
answering a vital question: have stay-at-home orders impacted global crime
trends? A new study by Nivette and colleagues demonstrates that crime
largely decreased around the globe during COVID-19 stay-at-home orders—a
finding which likely carries international implications for crime policy.”
Reference: Boman JH, Mowen TJ (2021). Global crime trends during COVID-19. Nat Hum
Behav, 5, 821–822 (2021). https://doi.org/10.1038/s41562-021-01151-3
Global crime trends during COVID-19

60. Using daily crime count data from police agencies, Nivette and colleagues investigate how stay-
at-home orders impacted assault, theft, burglary, robbery, vehicle theft, and homicide across 27
cities in 23 countries worldwide. Nivette and colleagues reach five main conclusions:
1.1. Overall, crime decreased 37% worldwide after stay-at-home orders were issued by
governments.
2.2. Some crimes decreased more than others. Property-based crimes decreased substantially,
but homicide was relatively unchanged.
3.3. The extent to which stay-at-home orders impacted crime was heavily dependent on
location.
4.4. Cities with more stringent lockdowns experienced greater crime decreases than cities with
less stringent lockdowns.
5.5. As stay-at-home orders gradually eased, crime slowly increased to pre-COVID-19 levels.
“A universal truth is that crime, public health, and social policy are all intertwined.”
Reference: Boman JH, Mowen TJ (2021). Global crime trends during COVID-19. Nat Hum Behav,
5, 821–822 (2021). https://doi.org/10.1038/s41562-021-01151-3
Global crime trends during COVID-19

61. “The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an
unprecedented challenge to public health, food systems and the world of work. The economic
and social disruption caused by the pandemic is devastating: tens of millions of people are at
risk of falling into extreme poverty, while the number of undernourished people, currently
estimated at nearly 690 million, could increase by up to 132 million by the end of the year.”
“Millions of enterprises face an existential threat. Nearly half of the world’s 3.3 billion global
workforce are at risk of losing their livelihoods. Informal economy workers are particularly
vulnerable …”
“The pandemic has been affecting the entire food system and has laid bare its fragility.”
“Millions of agricultural workers – waged and self-employed – while feeding the world,
regularly face high levels of working poverty, malnutrition and poor health, and suffer from a
lack of safety and labour protection as well as other types of abuse.”
Impact of COVID-19 on livelihoods, health & food systems

62. “In the COVID-19 crisis food security, public health, and employment and labour issues, in
particular workers’ health and safety, converge.”* [Cf. syndemics]
“Countries dealing with existing humanitarian crises or emergencies are particularly exposed to
the effects of COVID-19.”
“We must recognize this opportunity to build back better, as noted in the Policy Brief issued by
the United Nations Secretary-General.”
Reference: Joint statement by ILO, FAO, IFAD and WHO (2020). Impact of COVID-19 on people’s
livelihoods, their health and our food systems. Statement date: 13 Oct 2020.
https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%27s-livelihoods-
their-health-and-our-food-systems
Impact of COVID-19 on livelihoods, health & food systems

63. • The COVID-19 pandemic has brought unprecedented digital acceleration, changing the face
of the economy and society.
• Internal and external thought leaders were asked to share their vision of this fundamental
digital transformation.
• The future of work, our social lives, education and security will all undergo major change in
the aftermath of the pandemic.
Reference: Willige A. (2021). What are the long-term effects of the COVID-19 pandemic? These
5 trends give us a glimpse. World Economic Forum, 21 August 2021. Available from:
https://www.weforum.org/agenda/2021/08/covid19-long-term-effects-society-digital/
Long-term effects of the COVID-19 pandemic

64. 5. Digitally accelerating and adapting how
children learn
Homeschooling during the lockdown may
have been a stressful experience for parents
and pupils - especially for families with
limited connectivity and access to digital
devices. More than 1.3 billion children were
shut out of their schools during the
pandemic, as the chart illustrates.
Reference: Willige A. (2021). What are the long-
term effects of the COVID-19 pandemic? These
5 trends give us a glimpse. World Economic
Forum, 21 August 2021. Available from:
https://www.weforum.org/agenda/2021/08/covi
d19-long-term-effects-society-digital/

65. Long-term impacts
Without massive global action, the COVID-19 pandemic is expected to have worldwide negative impacts on economic and other social
determinants of health in the long term. Mental health conditions most susceptible to negative social determinants include anxiety, mood,
and disorders related to trauma and stress, which are already leading contributors to disability worldwide, according to the Global Burden of
Disease study.
Prolonged school closures are likely to have a profound effect on the mental health of children, adolescents, and young adults globally.
Aside from the important academic benefits of schooling, schools have an essential role in shaping the mental wellbeing of young people by
providing a structured and supervised space for socioemotional development, friendship and social support networks, protection from risk-
taking behaviours and exploitative labour, delays to early marriage and childbearing, and gatekeeper services to detect and intervene early to
reduce child abuse.
Furthermore, schools often represent a key access point for food for children in many LMICs. School meal and feeding programmes are
essential for ensuring sufficient nutrition while promoting academic performance and cognitive development.
Therefore, the school closures in response to the pandemic might have the unintended consequence of increasing food insecurity among
children, which negatively affects mental health.
Reference: Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact and responses in low-income and middle-income countries:
reimagining global mental health. Lancet Psychiatry. 2021;8(6):535-550. Published correction appears in Lancet Psychiatry. 2021;8(5):e13.
COVID-19 and LMICs – reimagining global mental health

67. As in most domains of mental health research, the large majority of the COVID-19 literature
comes from high-income countries although about 85% of the world population lives in LMICs.
Clearly, the abilities of health care systems in LMICs to respond to the pandemic are dramatically
weaker than those of wealthier nations.
Prior to the pandemic, the gap between mental health needs and the provision of care (called the
“mental health gap”) was vast.
For example, among individuals with major depression in LMICS, only 1 in 27 received effective
care.
Reference: Thornicroft G (2021). Exploring the Global Consequences of the COVID-19 Pandemic. Psychiatric
Times, 2021, 38(12). Available from: https://www.psychiatrictimes.com/view/exploring-the-global-
consequences-of-the-covid19-pandemic
Exploring the global consequences of COVID-19 pandemic

68. Conclusion: “Cruising at 35K Feet”

69. • Psychiatric epidemiology & public health with their emblematic
SDoH and ACE studies offer us “the big picture” valuable for policy-
making, research, and training
• “Cruising at 35K feet”
• We need translational research to bring them down to ground level
“Cruising at 35K feet”

70. • I call it clinical social psychiatry
• We need to bring epidemiology down to ground level
• And the neuroscience up to the clinic
• Cf. Allen Frances’ critique of “the decade of the brain”
• Psychoanalysis off the couch and family therapy out from behind the
one-way mirror
Clinical Social Psychiatry

71. • Parameters for observing the conditions of this coronavirus-induced
syndemic in children, the family and in society
• Recommendations for social psychiatric interventions:
• Based on SDoH
• Integrative Community Therapy (Barreto, et al., 2020)
• Prospective paediatric, psychological, and social studies need to be
addressed
Reference: Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative Community Therapy in the Time of
the New Coronavirus Pandemic in Brazil and Latin America. Special Theme Issue: COVID-19 Pandemic
and Social Psychiatry. World Social Psychiatry, 2020, 2(2): 103-5.
Clinical Social Psychiatry

72. • Jon Taylor demonstrated compassion in his work where he privileges the
therapeutic alliance in recovery work
• In his work, I hear a plea not merely for the SDoHs/ACEs and not only for
neuroscience as such but how together they create the conditions where we
come to make the choices we do
• Jon argues for the exquisite interaction between the internal environment of
the individual who is continually bathed in cascading, interactive, reciprocal
influences that are part of growth across the lifespan
Reference: Taylor J (2023). “Human Nature, Human Suffering and Human Harmfulness: The Role of
Compassion-Focused Therapy as a Trauma-Sensitive Forensic Intervention,” Risk & Recovery Conference,
April 20, 2023.
“Compassion focused therapy”

73. • Karl Hanson has conducted detailed, precise research about risk for sexual
recidivism that clarifies who is more at risk – and, just as important, who is
less at risk
• There we have it – a wonderful synthesis of risk and recovery, the themes
of this conference
• Forensic psychiatry is already a social psychiatry (see Liebrenz, 2022)
• My challenge now is for social psychiatry to integrate findings of forensic
psychiatry
Reference: Hanson K (2023). “Going to Extremes: The High End and the Low End of Sexual Recidivism Rates,” Risk
& Recovery Conference, April 20, 2023.
Liebrenz M. (2022). A rose is a rose is a rose: All psychiatry is social psychiatry, but is all psychiatry forensic
psychiatry? And is all forensic psychiatry social psychiatry? Forensic Science International: Mind and Law, 3
December, 100110.
“Going to extremes”

74. • As an outside observer, ethical issues are front and centre in forensic
psychiatry as they should be in every branch of medicine and
psychiatry
• Eminent French philosopher Emmanuel Levinas held that “philosophy is
first ethics” deeply informed by the “face-to- face encounter” even in
the face of violence
Reference: Krycka KC, Kunz G, Sayre GG, eds. (2015). Psychotherapy for the Other: Levinas and
the Face-to-Face Relationship. Pittsburgh, PA: Duquesne University Press.
Ethics: “Face-to-face”

75. • Psychotherapy – all our clinical interventions – must first be ethical
• Medicine cannot be healing if it is not ethical
• Any form of healing is merely instrumental and limited if it is not in
an interpersonal context of ethical conduct
Ethics

76. Dr. Gary Chaimowitz
Professor of Psychiatry and Behavioural Neurosciences
Head of the Forensic Psychiatry Program
McMaster University
Dr. Enrico Suardi
Director of Psychiatry Services, Saint Elizabeths Hospital
Washington, DC, USA
Acknowledgements

77. Questions
&
Comments

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