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Prisoners of the Pandemic:
Social and Forensic Consequences of the Coronavirus
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
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
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
• The presenter has no financial conflicts of interest to declare
Conflicts of Interest
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
• 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
Pandemic to Syndemic
• 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
• 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
• 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
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
• 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
• 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
• 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?
Sensory Deprivation Experiments (Hebb)
• 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?
Maternal Deprivation
(Bowlby)
Reference: Bowlby J. (1982). Attachment and Loss, Vol. 1: Attachment (2nd ed.). New York: Basic
Books. (Original work published 1969).
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
• 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
“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
Social Psychiatry and Forensic Psychiatry
• 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
• 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”
• 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
• 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
• 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
• Confinement, Masking, Social Distancing
The Experimental Child
• Social distancing
• Class and cultural differences
• Confinement
• Impact on vulnerable groups, relationships
• Adverse Child Experiences (ACE)
• Associated with poorer health outcomes
Impacts
Isolation vs.
connection
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.
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.
Army trucks in Bergamo, Italy (Reuters – March 19, 2020)
Antigone and Polynices (Nikiforos Lytras, 1865)
Incident at Antares
• Érico Veríssimo
(Novel, 1971)
• Carlos Manga
(Film, 1994)
• The Coronavirus Syndemic
The Longest Shadow
John Bowlby
(1907-1990)
• 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
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
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
Attachment
in action …
42
• What do the history of madness, prisons and pandemics have
in common?
Madness, Prisons & Pandemics
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)
• 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
• 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
Source: www.stars-portraits.com
Photo: Public domain
• Madness and Civilization
“The Great Confinement”
Hamilton anecdote:
Dr. Marcel Lemieux, Medical Director of HPH,
introduced me to Foucault
Michel Foucault
Bethlem Hospital (1828) – Imperial War Museum (since 1926)
• Discipline and Punish
“The Panopticon”
Michel Foucault
Bentham’s Panopticon
…. the practice
(Presidio Modelo – Cuba, 1925-31)
The plan (Jeremy Bentham,
1791) and …
Literature Review:
Social and Forensic Impacts of the Coronavirus
“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
“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
“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
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
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
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
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
“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
“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
• 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
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/
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
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
Conclusion: “Cruising at 35K Feet”
• 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”
• 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
• 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
• 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”
• 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”
• 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”
• 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
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
Questions
&
Comments
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
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.
Fovet T, Thibaut F, Thomas P, Lancelevée C (2020). French forensic mental health system during
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Prisoners of the Pandemic: Social and Forensic Conequences of the Coronavirus

  • 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
  • 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
  • 15.
  • 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?
  • 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
  • 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
  • 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
  • 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
  • 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
  • 56.
  • 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
  • 66.
  • 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
  • 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
  • 78. 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 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. 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. 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 References: Consequences of COVID-19
  • 79. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396: 874. 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 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 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. References
  • 80. 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 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. 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 References
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