The public health response

The global response to COVID-19 has emphasised the necessity for reduced close contact; hence, the intervention termed ‘social distancing’. To achieve this aim, many governments implemented ‘lockdown’ strategies to limit the free movement of the public, although the precise restrictions and severity of the measures have differed from country to country. The UK government urged people to ‘Stay Home, Save Lives, Protect the NHS’, with only essential travel permitted, restricted mixing of households and citizens at one point limited to a single exercise outing per day. There was a national drive to ‘flatten the curve’, with the stated intention to avoid overwhelming the National Health Service (NHS). A further patriotic message resonated with the public; that is, to protect the most vulnerable in society. Ultimately, the effectiveness of government and society's efforts to maintain this unconventional and rather antisocial injunction will be measured by the number of casualties.

A forensic mental health hospital facing the pandemic

We are based in a psychiatric medium secure unit (MSU) in the West Midlands, UK. The MSU has capacity for 90 male patients across multiple wards and provides care to men who present with complex risk behaviours and experience psychopathology that warrants treatment under the Mental Health Act 1983 (amended 2007). The reality of COVID-19 within the MSU community parallels the changes seen in wider society. Initially, the virus was an abstract threat. However, measures were quickly implemented to increase hand-washing, social distancing and isolation of symptomatic patients.

At the time of writing, there have been 24 COVID-19 cases confirmed by positive swab in our MSU. Many patients experienced mild to moderate symptoms. However, three individuals required transfer to an intensive care unit for intubation and ventilation. Fortunately, they made a good recovery and returned to the MSU. Those with milder symptoms have been encouraged to self-isolate in their bedrooms. In anticipation of an increase in infections, one ward was designated to be the ‘COVID ward’, to contain the infection within a specific area and minimise further spread.

Clinical practice has changed significantly and it is hoped that, by mimicking national restrictions, the spread of COVID-19 will be contained. However, it is acknowledged that true ‘lockdown’ cannot be instated owing to the necessary travel between wards to maintain essential care.

The Trojan horse: a split between staff and patients?

Patients in the MSU have been required to adjust to novel protocols (use of personal protective equipment (PPE), social distancing, etc.) while also processing the increased limitations on their movements at all times. Such dramatic changes, in the context of access to 24 h news coverage, have understandably heightened anxiety, fear and uncertainty. Of course, this is in addition to the usual physical and relational security provisions, such as air locks, keys and high fences that can be a source of angst for patients.

In these unprecedented conditions, we consider that there is a risk of an ‘us versus them’ dynamic developing, particularly as situational threat is high.^{Reference Van Prooijen and Douglas2} On closed wards, it is plausible that staff are the vehicles of virus transmission, transporting the contagion onto the ward asymptomatically, given the incubation period of COVID-19. It is possible that some patients may view the movement of staff as contamination. The usual psychological containment that high staffing levels can provide may now be perceived as hostile, dangerous and unpredictable – when the danger cannot be seen, who is infected and imposing threat to the community? As the staff group fulfil the role of caregivers, a complicated role reversal ensues, as the caregiver is viewed as the source of danger: the Trojan horse entering the fortress.

The emergence of conspiracy theories

We have noticed that conspiracy theories have emerged in tandem with the COVID-19 spread. Conspiracy theories have been defined as ‘attempts to explain the ultimate causes of significant social and political events and circumstances with claims of secret plots by two or more powerful actors’.^{Reference Douglas, Uscinski, Sutton, Cichocka, Nefes and Ang3} Notably, conspiracy theories are similar to, though distinct from, misinformation and/or ‘conspiracy hypotheses’. Misinformation – false or inaccurate information, often intended to deceive (e.g. ‘fake news’) – can underpin conspiracy theories as it undermines mainstream narratives; conspiracy hypotheses are legitimate counter-narratives that can occur when there is uncertainty about the official story. Again, these can increase uncertainty and trust in a centralised message. The relationship between these phenomena is likely to be fluid.

Research has shown that conspiracy beliefs are common. For example, 60% of Americans believe that the CIA killed JFK^{Reference Enders and Smallpage4} and 46% of leave voters in the EU referendum believed that the vote would be rigged.^{Reference Drochon and Uscinski5} There are many other types of theory that gather large follower groups.^{Reference Douglas, Uscinski, Sutton, Cichocka, Nefes and Ang3} COVID-19 conspiracy theories have included fear of 5G broadband networks and persistent notions that the virus is man-made.^{Reference Freeman, Waite, Rosebrock, Petit, Causier and East6}

Interestingly, individuals who hold one conspiracy theory are more likely to believe others,^{Reference Goertzel7} thus suggesting a possible underlying tendency to seek counter-narrative explanations and prefer them to information presented by institutions. Individuals who hold conspiracy beliefs are predominantly male, unmarried and of lower socioeconomic status. They are more likely to have weak social networks and belong to ethnic minority groups. Notably, they are likely to have had adverse childhoods and experience psychiatric problems as adults.^{Reference Freeman and Bentall8} Such demographics are highly consistent with a typical in-patient forensic population.^{Reference Duke, Furtado, Guo and Völlm9,Reference Singh, Greenwood, White and Churchill10}

Particular environmental conditions and psychological processes have been mooted to underpin such beliefs. In a review, Douglas et al^{Reference Douglas, Sutton and Cichocka11} identified three psychological motivations that led to a preference for conspiracy explanations: epistemic, existential and social. Each has particular relevance to the patient group in an MSU.

The epistemic motivation relates to an individual's or group's understanding and knowledge of a phenomenon; conspiracy theories can allow individuals to preserve a sense of understanding in the face of uncertainty and contradiction. These beliefs are noted to become stronger when events are widespread and/or significant,^{Reference Van Prooijen and Jostmann12} and when simplistic, mundane explanations are perceived as unsatisfactory.^{Reference Leman and Cinnirella13} Conspiracy beliefs can foster a sense of cognitive closure when the situation lacks a clear, consistent and understandable official message.^{Reference Marchlewska, Cichocka and Kossowska14}

When individuals feel anxious, threatened and powerless in the face of danger, they may gravitate towards conspiracy theories to achieve a sense of comfort.^{Reference Douglas, Sutton and Cichocka11,Reference Abalakina-Paap, Stephan, Craig and Gregory15,Reference Newheiser, Farias and Tausch16} These are viewed as existential motivations.^{Reference Douglas, Sutton and Cichocka11} Such powerlessness can be exaggerated by a perception of alienation from decision makers and a breakdown in containment and social order.^{Reference Goertzel7,Reference Abalakina-Paap, Stephan, Craig and Gregory15}

Douglas et al^{Reference Douglas, Sutton and Cichocka11} note that social motivations also contribute to the formation of conspiracy beliefs. Groups that have experienced persecution, for example victims of police harassment^{Reference Parsons, Simmons, Shinhoster and Kilburn17} or racial discrimination,^{Reference Simmons and Parsons18} are more likely to perceive dominant groups as conspiring against them. Research has shown that members of low-status groups are more likely to endorse conspiracy theories than those of higher status.^{Reference Abalakina-Paap, Stephan, Craig and Gregory15,Reference Uscinski and Parent19} In-group attachments can strengthen in the face of group threat, and ‘collective narcissism’ (an emotional investment in an unrealistic belief about the in-group's greatness)^{Reference De Zavala, Cichocka, Eidelson and Jayawickreme20} can develop, particularly when underprivileged, undervalued and under threat.^{Reference Uscinski and Parent19} This may function to protect the in-group by forming a shared ‘us versus them’ narrative.^{Reference Wood, Douglas and Sutton21} Similarly, individual narcissism is understood to emerge as a defence in response to perceived powerlessness; a conspiracy theory is powerful as it ascribes ‘special knowledge’ to the believer, imbuing a safe sense of superiority.^{Reference Cichocka, Marchlewska and De Zavala22}

Such motivations and psychosocial characteristics are relevant and, in some circumstances, exaggerated in the MSU population. For example, research has linked subclinical delusional thinking^{Reference Dagnall, Drinkwater, Parker, Denovan and Parton23} and schizotypy^{Reference Barron, Morgan, Towell, Altemeyer and Swami24,Reference van Der Tempel and Alcock25} to conspiracy thinking. Individuals diagnosed with paranoid personality disorder demonstrate similar conspiratorial thinking.^{26,Reference Lee27} Cognitive/affective mechanisms at play in such samples are also relevant to those at the distressing/impairing end of the psychosis continuum, i.e. those diagnosed with schizophrenia.^{Reference Van Os, Linscott, Myin-Germeys, Delespaul and Krabbendam28} For example, the omission of true cognitive information^{Reference Crittenden29} could precipitate a jumping to conclusions (JTC) bias that is associated with the rapid appraisal of ambiguous or anomalous stimuli to form a conclusion without a sound evaluation of evidence.^{Reference Garety and Freeman30} Such a bias is evident in subclinical^{Reference Freeman, Pugh and Garety31} and clinical populations.^{Reference Rauschenberg, Reininghaus, ten Have, de Graaf, van Dorsselaer and Simons32} Moulding et al^{Reference Moulding, Nix-Carnell, Schnabel, Nedeljkovic, Burnside and Lentini33} have identified that holders of conspiracy beliefs are more likely to view the world as threatening. Such schematic views of the world as dangerous^{Reference Smith, Fowler, Freeman, Bebbington, Bashforth and Garety34} can underpin the process whereby delusional beliefs – in an attempt to secure cognitive closure – form from misappraisals of anomalous stimuli.^{Reference Garety and Freeman30} Of note, a high proportion of our in-patient population hold – or have held – delusional beliefs.

Disproportionately, MSU in-patients have been exposed to early life danger^{Reference Varese, Smeets, Drukker, Lieverse, Lataster and Viechtbauer35} and hold negative schematic beliefs about self, others and the world.^{Reference Appiah-Kusi, Fisher, Petros, Wilson, Mondelli and Garety36} Psychotic delusions, conspiracy theory beliefs and self-protective distortions have a propensity to surface when conditions are dangerous and uncertain.^{Reference Abalakina-Paap, Stephan, Craig and Gregory15,Reference Newheiser, Farias and Tausch16}

The impact of the pandemic within the clinic

Meme theory can help to explain how such ideas spread, particularly in contained environments. Dawkins^{Reference Dawkins37} considered memes to be cultural phenomena that pass from one mind to another, and survive (or die) through a process analogous to genetic selection. Goertzel^{Reference Goertzel38} noted ‘conspiracy theorizing [sic] is a rhetorical meme that transforms scientific controversies into human dramas with villains who can be exposed’.

In the general population, COVID-19 conspiracy theory memes (e.g. 5G phone masts, man-made virus) have gone viral, with some harmful and persistent consequences. More broadly, memes that run as counter-narratives to the government's explanations and advice affect some people, who may then spread their ideas to others. This may lead to a failure to act according to government guidelines and in the best interest of public health.^{Reference Freeman, Waite, Rosebrock, Petit, Causier and East6}

We have observed conspiracy theory memes to develop in two distinct ways within the MSU. First, ‘organic memes’ have developed on one ward. These have taken the form of a belief that the pandemic is orchestrated by the hospital staff to restrict leave and delay discharge. Such a belief is likely to have formed with no outside influence and is perhaps good evidence that humans will seek conspiracy theory explanations in isolation to allay epistemic, existential and social concerns.^{Reference Douglas, Sutton and Cichocka11,Reference Uscinski and Parent19} It is our view that, despite several men endorsing this meme to a greater or lesser degree, it will likely wither and fail to spread owing to its fallibility in the face of simple counter-evidence and the physical health restrictions that prohibit mixing of wards (this meme is unlikely to be shared by staff members).

The type of second conspiracy meme is more problematic and harder to contain. These are externally generated conspiracy theories. Such memes may find traction among the internal population by direct or indirect conversations, through telephone contact, media consumption and where there are exchanges of perspectives. It is not possible – or ethical – to stop the introduction of conspiracy theory memes via telephone contact with relatives. However, staff members may be prone to conspiracy beliefs because of their own sense of powerlessness, threat and existential anxiety. As staff members move around the MSU, there is a risk of them spreading conspiracy beliefs to others. Additionally, misinformation might be introduced into the hospital. This new discrepant information may destabilise an already vulnerable in-patient population and prime conspiratorial thinking.

The impact of a COVID-19 conspiracy theory meme outbreak

Healthy secure wards are able to maintain a negotiated homeostasis, whereby clear boundaries and good clinical practice maintain order, safety and containment, while also promoting mental health rehabilitation. Conspiracy theory memes present a threat to this architecture. A possible consequence is a breakdown in trust and cohesion, which would undermine physical and psychological safety, and challenge measures to contain the virus.^{Reference Freeman, Waite, Rosebrock, Petit, Causier and East6}

Uncertainty and unpredictable danger can be precipitants of anxious threat states. Changes in routine or the introduction of new conditions can trigger a loss of perceived environmental control and subsequent attempts to regain safety. As such, periods of stress and threat require the use of automatic self-protective behaviours and implicit information processing strategies.^{Reference Crittenden29} Harmful conspiracy theories or hypotheses can increase uncertainty and decrease trust in authority figures. For many men in forensic in-patient settings, violence or self-harming behaviour has been – or is – an adaptive part of their self-protective behavioural repertoire. When in conditions of threat, such behavioural expressions might manifest to gain control, discharge arousal, communicate distress or elicit care.

Similarly, splitting is a possibility, with competing memes generating an ‘us versus them’ dynamic. As described previously, this is an evidenced component of conspiracy theory motivation, and staff members can become targeted if inequality is perceived (e.g. locked down versus transient, exposed versus PPE). Systemically, these processes can heighten the sense of danger for other residents and group anxiety can escalate. Of course, staff members are not immune to such effects and negative consequences are possible (e.g. burnout, increased punitiveness).

The response

Memes are hypothesised to spread in a manner analogous to a virus.^{Reference Dawkins37,Reference Goertzel38} Hence, we propose that a fast, stringent and proactive strategy is required to curb the sharing of unhelpful and false memes. We suggest that the response to ‘prevent’ and ‘treat’ conspiracy theories can be pitched according to the public health approach to diseases: primary, secondary and tertiary prevention.

Importantly, some degree of uncertainty is unavoidable owing to a global lack of clarity regarding COVID-19. It has to be acknowledged that there are few unambiguously true known facts about the virus. We do not advocate the suppression of questioning or critical challenge of official narratives. A host of different memes, differing in strength, transmissibility and potential harmfulness, will spread among staff and patients. We recommend that professionals demonstrate clinical judgement to determine if and when intervention is required and listen to alternative perspectives, discussing them in context.