Ronald W. Pies, MD

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

In the midst of a frightening spike in COVID-19 

 how do we understand those who adamantly refuse to wear protective masks in public? Barring some (very rare) medical contraindication to wearing a mask, I can think of no ethical justification for such a refusal. Given that face masks help prevent asymptomatic spread of COVID-19 and may also 

 of anyone contracting the COVID-19 virus,

 wouldn’t any decent, responsible citizen put up with such a minor inconvenience?

It is tempting to write off the mask refusers as selfish, irresponsible yahoos, or as “COVID deniers”—those who simply don’t believe the pandemic is “real,” or that it represents a serious health threat. There may be some truth to those characterizations. But, in my view, the picture is more complex and provides a window into a cultural archetype that I call the 

 First, though, we need to deal with mask refusal and 

, I referred to a venerable tradition of tough-minded individualism that has marked this country from its very inception.

“The image of the self-reliant, iron-willed “loner” is an iconic American archetype, from the days of the lone cowboy, out on the range, to the novels of Ernest Hemingway. The motto, “

”—which arose during the years of the American Revolution—nicely sums up the feisty spirit of American individualism. Indeed, during recent anti-restriction protests, “

” appeared on numerous flags and banners.”

, this rugged individualism serves as a useful counterweight to the

 impulse—the belief that the community is a “bearer of rights,” to which an individual’s interests may have to be subordinated in some cases. But carried to an extreme—what I called, “hyper-individualism”—the “Don’t Tread on Me” mentality can become an insidious force for societal disintegration.

In my view, many mask refusers are acting out of a debased form of individualism that some would call “toxic masculinity,” and which I would call 

. I hasten to add that I am using the latter term in a broad, generic sense, and 

 as a trait endemic to “Latin” culture or society. A very useful definition of 

“Exaggerated pride in masculinity, perceived as power, often coupled with a minimal sense of responsibility and disregard of consequences.”

In my view, this brand of American machismo helps explain the behavior of many (though not all) mask refusers. In effect, refusal to wear a mask in public settings has become a mark of being “a man’s man”—someone who won’t be pushed around or “muzzled” by governmental “tyranny.” To be clear: I’m not saying anything new here. In April of this year, social scientist Prof. Peter Glick 

“Why the reluctance to model safe behavior? My 

research with Jennifer Berdahl and others

 suggest one critical reason, which is that appearing to play it safe contradicts a core principle of masculinity: 

 In short, wearing a mask emasculates . . . [mask refusers] prove their manhood by showing resistance to experts’ opinions, hypersensitivity to criticism and constant feuding with anyone who seems to disagree with them.”

But, in my view, machismo is just one piece of the puzzle. We now need to examine an archetype that, in academic circles, is called 

—Latin for the “eternal boy” or “eternal child”—and which I want to call, “The American Man-Child.”

“. . . is used in mythology to designate a child-god who is forever young; psychologically, it refers to an older man whose emotional life has remained at an adolescent level . . . He covets independence and freedom, chafes at boundaries and limits, and tends to find any restriction intolerable.”

from an Ohio state representative who refuses to wear a mask:

“I will not wear a mask . . . quite frankly, everyone else’s freedom ends at the tip of my nose. You’re not going to tell me what to do.”

How many frustrated parents have heard, “You can’t make me!” from their petulant, early adolescent child?

 archetype was popularized by the psychoanalyst, Dr Dan Kiley, in his 1983 book, 

The Peter Pan Syndrome: Men Who Have Never Grown Up

. Kiley describes men of this type as follows:

"Narcissism locks them inside themselves . . . pursuit of other people's acceptance seems their only way to find self-acceptance. Their temper tantrums are disguised as manly assertion."

 Now, add in a dollop of magical thinking—as in, “This whole virus thing is a big hoax!”—and we have the makings of the American 

 Tragically, we also have the makings of a resurgent American pandemic that threatens to overwhelm us once again.

 is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

1. Knowles H, Wagner J, Shaban H, et al. Seven states report highest coronavirus hospitalizations since pandemic began. 

https://www.washingtonpost.com/nation/2020/06/23/coronavirus-live-updates-us.

2. Texas A&M University. Face masks critical in preventing spread of COVID-19. 

https://www.sciencedaily.com/releases/2020/06/200612172200.htm

3. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

https://www.psychiatrictimes.com/view/freedom-does-not-mean-being-loose

https://www.britannica.com/topic/machismo

5. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

 April 30, 2020. Accessed June 29, 2020. 

https://blogs.scientificamerican.com/observations/masks-and-emasculation-why-some-men-refuse-to-take-safety-precautions

https://frithluton.com/articles/puer-aeternus/

7. Polman D. Refusing to wear a mask is about the most un-American thing to do right now. Pennsylvania Capital-Star. May 11, 2020. Accessed June 29, 2020. 

https://www.penncapital-star.com/commentary/refusing-to-wear-a-mask-is-america-at-its-worst-dick-polman

The Peter Pan Syndrome: Men Who Have Never Grown Up.

9. Lithwick D. Refusing to Wear a Mask Is a Uniquely American Pathology. 

https://slate.com/news-and-politics/2020/05/masks-coronavirus-america.html

Articles

Given that face masks help prevent asymptomatic spread of COVID-19 and may also reduce the chances of anyone contracting the virus, wouldn’t any decent, responsible citizen put up with such a minor inconvenience? Apparently not.

Masks, Machismo, and the American Man-Child

After what seemed like a period of relative national unity in the face of the COVID-19 pandemic, we now find wide cultural rifts emerging in the American landscape. As 

Divisions have emerged along a timeworn North vs. South divide, on ideological and geographical grounds nationally and within states, and on the level of respect accorded by political leaders to epidemiological science.

Furthermore, we have witnessed what the New York Times called “a rash of 

well-organized protests against state restrictions

” in several US cities, revealing that “not everyone is on board with the new, government-mandated limits on public assembly and economic activity.”

that these protests are not of grassroots origin but are driven, at least in part, by “an informal coalition of influential conservative leaders and groups.”

According to Timothy J. Lombardo, PhD, a history professor at the University of South Alabama, 

 “an underlying rage at elites, liberals, government and the media that is part of a half-century tradition of right-wing populism.”

It is not my intention to dive headlong into the political fray or the “culture wars” that seem so much a part of 

 (Personal disclosure: I have voted for candidates of both major parties but consider myself progressive and left of center, politically). Rather, I want to raise the question of psychiatry’s role, if any, in dealing with the kind of rage and resentment that seems to underlie these antirestriction protests. That said, as a physician and an ethicist committed to ensuring the public’s health and safety, I can only deplore the lack of social distancing seen at several of the protests, virtually guaranteeing more cases of COVID-19 infection.

Psychiatrists, like other physicians, are not politically homogeneous or uniformly liberal or conservative. However, there is 

 that most psychiatrists lean to the left on the political spectrum.

 Indeed, data from political science professor Eitan Hersh, PhD, and psychiatrist Matthew Goldenberg, DO, suggest that about 76% of psychiatrists who have a party registration are Democrats. In contrast, around two-thirds of physicians in surgery, anesthesiology, and urology who have registered a political affiliation are Republicans.

How might the leftward political leanings of most psychiatrists affect their response to protests driven largely by conservative or right-wing groups? And how might the liberal leanings of a psychiatrist affect their countertransference to, say, a very conservative or extreme right-wing patient?

I am not aware of research that has examined precisely that question, and I acknowledge that terms like liberal, conservative, right-wing, and left-wing are open to various definitions. However, the research by 

 strongly suggests that the medical decisions primary care physicians make are indeed influenced by their political leanings. In their survey of 1529 physicians (with a response rate of 20%) in 29 states, after controlling for physician age, gender, and religiosity, the authors found that:

[P]olitical beliefs predict the professional decisions of primary care physicians. On politicized health issues, like marijuana and abortion, physicians’ partisan identity is highly correlated with their treatment decisions. Because physicians regularly interact with patients on politically sensitive health issues and because the medical profession is increasingly politicized (eg, state governments are regulating politicized aspects of medicine), it is necessary to understand how doctors’ own political worldviews may impact their actions in the medical examination room.

There is also an intriguing literature suggesting that neurobiological factors may mediate or influence one’s conservative or liberal tendencies, in surprising ways. In a review of this issue, Mario F. Mendez, MD, PhD,

[N]eurobiological factors mediate where people fall on a general conservative-liberal axis that involves social, cultural, religious, economic, and other domains, as well as political ideology… Conservatism-liberalism is also associated with differences in personality, attention, memory, perception, emotional reactions, problem-solving, and response choices.

Mendez observed that “Political ideology divides people, societies, and nations, often with serious consequences.”

 Indeed, taken together, the findings of Mendez, Hersh, and Goldenberg suggest that a serious political mismatch between psychiatrist (or psychotherapist) and patient could lead to disruptions in the therapeutic alliance, as well as to strong transference and counter-transference reactions.

In a provocative article titled, “Navigating the Minefield of Politics in the Therapy Session,”

 and colleagues raise just such a possibility:

In the aftermath of one of the most contentious presidential elections in recent US history, many of us have noted a marked increase in our clients’ expressions of anger, anxiety, and depression. At the same time, we have been challenged by managing our reactions to the election results and subsequent heightened societal tensions… Even if a client does not ask about our views, the books on our shelves or artwork on our office walls can reveal our values without us speaking a word. Within the current climate of general cultural divisiveness and mistrust, political self-disclosures—whether overt or unwitting—can potentially lead to ruptures [in the therapeutic alliance]…Although society has been growing increasingly polarized over the past two decades, the 2016 election was a tipping point for many. Until that point, unresolved anxiety about election results was not an obvious source of countertransference for most psychotherapists…

Sprangler and colleagues observed that “In managing any countertransference, gaining awareness is the first step, specifically by recognizing our political hot button topics and the triggers for them.” Ethical dilemmas may arise when a patient’s political or religious views are so deeply offensive to the clinician’s own that the therapeutic alliance becomes almost impossible to sustain. Sprangler et al. opined that “while we may not impose our own views, we must not condone others’ prejudicial activities. The dilemma arises when a client presents a bigoted view that is integral to the client’s political identity.”

There are no simple solutions in such cases, although ideally, the therapist can explore the roots of the patient’s bigoted beliefs and “provide data from the client’s own experiences to counter these views.”

In the ongoing crisis of the COVID-19 pandemic, psychiatrists are understandably focused on helping their patients deal with feelings of isolation, anxiety, and often overwhelming stress. And, to be sure, many of our colleagues on the front lines—especially in inpatient settings—are deeply concerned about their own health and safety as well as that of their families. Owing to the risk of contagion, telepsychiatry has now nearly replaced the traditional face-to-face sessions. However, it presents challenges of its own, as when treatment calls for 

It may seem a bit of a luxury to begin an examination of our countertransference at a time when life itself hangs in the balance. Yet the recent wave of protests against pandemic-related restrictions should remind us that deep currents of anger and resentment are roiling the waters of American culture—and that we, as clinicians, may be working with patients whose political views make it very difficult to address their emotional needs.

is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

1. Collinson S. Divisions on battling coronavirus deepen as Trump and Southern states push opening. 

www.cnn.com/2020/04/22/politics/donald-trump-coronavirus-economy/index.html

. Updated April 22, 2020. Accessed May 7, 2020.

2. Russonello G. What’s riving the right-wing protesters fighting the quarantine? 

www.nytimes.com/2020/04/17/us/politics/poll-watch-quarantine-protesters.html

3. Vogel KP, Rutenberg J, Lerer L. The quiet hand of conservative groups in the anti-lockdown protests.

www.nytimes.com/2020/04/21/us/politics/coronavirus-protests-trump.htm

4. Lombardo TJ. The far right hates liberals, government and the media — and now, quarantines. 

www.washingtonpost.com/outlook/2020/04/21/far-right-distrust-quarantine

5. Peters JW. How abortion, guns and church closings made coronavirus a culture war. 

www.nytimes.com/2020/04/20/us/politics/coronavirus-protests-democrats-republicans.html

6. Sanger-Katz M. Your surgeon is probably a Republican, your psychiatrist probably a Democrat. 

www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html

Democratic and Republican physicians provide different care on politicized health issues.

8. Mendez MF. A neurology of the conservative-liberal dimension of political ideology. 

9. Spangler PT, Thompson BJ, Vivino BL, Wolf JA. Navigating the minefield of politics in the therapy session. 

10. Brauser D. COVID-19: Dramatic changes to telepsychiatry rules and regs. 

. March 26, 2020. Accessed May 7, 2020.❒

Although it may seem a bit of a luxury to begin an examination of countertransference at a time when life itself hangs in the balance, clinicians may be working with patients whose political views make it very difficult to address their emotional needs.


Culture Wars, COVID-19, and Countertransference: What America’s Cultural Rifts Might Mean for Psychiatry

Many years ago, I treated depression in a man in his 50s who regaled me with stories of his tumultuous teens and twenties. “Doc,” he said, “back then, I was drinking and drugging anytime I felt like it, sleeping with whoever I wanted to. I really thought I was free. But you know what? I was just on the loose!”

My patient was on to something. His nice distinction was brought home to me in the past few weeks, as I viewed some of the more extreme “anti-restriction” protests springing up in several state capitals-ostensibly in the name of “freedom.”

No, I’m not comparing protesting to drinking and drugging. But I am distinguishing between freedom and 

-and between genuine individualism and what I call 

. To unpack these terms, we need a bit of historical and linguistic perspective.

A common dictionary definition of “freedom” is “the absence of necessity, coercion, or constraint in choice or action.”

In that very narrow sense, my patient was arguably “free,” back in the day. But psychologists and philosophers point to a deeper and more mature concept of freedom, as philosopher Montague Brown explains:

“Freedom and license must not be confused: freedom embraces responsibility and is guided by reason and virtue; license is choice without restraint . . . License is the throwing off of all responsibility. It is a carte blanche to do as we feel. As such, it is incompatible with virtue and destroys community.”

In short, “license” means being “on the loose.” But Brown is making a larger point. He is gesturing toward two principles that have guided American society since the earliest days of the Republic: 

. These principles have coexisted in dynamic tension throughout our national history and are deeply ingrained in our national identity. I would argue that this dialectic has been one of the great strengths of American culture and government.

With regard to individualism, the writer Ralph Waldo Emerson, in his essay, “Self-reliance,” famously argued, “To believe your own thought, to believe that what is true for you in your private heart is true for all men-that is genius.”

The image of the self-reliant, iron-willed “loner” is an iconic American archetype, from the days of the lone cowboy, out on the range, to the novels of Ernest Hemingway. The motto, “

”-which arose during the years of the American Revolution-nicely sums up the feisty spirit of American individualism.

 Indeed, during recent anti-restriction protests, “

” appeared on numerous flags and banners.

In contrast to this spirit of fierce individualism, American society has always had a strong communitarian dimension.  As philosophy professor Aeon J. Skoble explains,

“The essence of communitarian thought is that the community can be thought of as a bearer of rights, or at least as the holder of interests, to which an individual’s interests may have to be subordinated in some cases.”

A clear example of communitarian priorities is the imposition of isolation and quarantines to contain certain infectious diseases, such as cholera, diphtheria, and infectious tuberculosis-and, of course, COVID-19.

 The federal government derives its (rarely-used) authority for quarantine from the Commerce Clause of the U.S. Constitution. And-contrary to the claim of some protesters that quarantines apply only to “sick people”-the Center for Disease Control states that, “Isolation and quarantine help protect the public by preventing exposure to people who have 

The tension between individualism and communitarianism has come to the fore in recent weeks, as protesters have gathered in opposition to the quarantines and business closures associated with the COVID-19 pandemic. Many protesters voiced perfectly understandable concerns about lost jobs, missed opportunities, and social isolation. These individuals deserve our empathic understanding. However, in my view, some revealed a troubling mindset that I call “hyper-individualism.” For example, some protesters have characterized COVID safety precautions as acts of “tyranny.”

And while some protesters complied with “social distancing” directives or wore masks, many did not-thus exposing themselves and others to the risk of a potentially lethal infection. These anti-communitarian actions have been rationalized under dubious notions of “freedom.” For example, Rep. A. Nino Vitale (R) of Ohio commented, “I will not wear a mask . . . quite frankly, everyone else’s freedom ends at the tip of my nose. You’re not going to tell me what to do.”

Rep. Vitale’s notion of freedom is not grounded in responsibility, reason, and virtue. What Vitale advocates is not a mature construct of freedom, but a raw manifestation of license. It is not traditional “rugged individualism,” but 

individualism-in my view, bordering on sociopathy.

I hasten to add that hyper-individualism is not the province of one political party or orientation. Although the brand of hyper-individualism we find in the COVID-19 anti-restriction protests emerges from the “far right” of the political spectrum, this trait can also be found on the “far left.” Its anti-communitarian nature is exemplified in Abbie Hoffman’s 1971 work, 

, described as “. . . a compendium of methods that individuals can use to live freely, 

without participating in the social order

As for the anti-restriction protestors, I believe political columnist Dick Polman put the matter well: “Going mask-free is the new “don’t tread on me.” If more people die on the altar of others’ selfishness, well, I guess that’s the price of freedom.”

Or, as my patient would have put it, that’s not freedom-that’s just being “on the loose.”

 (2007-2010). The author reports no conflicts of interest concerning the subject matter of this article. 

1. Extremists Involved in Nationwide Protests Against Coronavirus Restrictions. Jewish Defense League. Accessed May 15, 2020.

https://www.adl.org/blog/extremists-involved-in-nationwide-protests-against-coronavirus-restrictions

2. Freedom. Merriam Webster. Accessed May 15, 2020. https://www.merriam-webster.com/dictionary/freedom?src=search-dict-box

3. Brown M. Freedom/License. Catholic Education Resource Center. Accessed May 15, 2020. 

https://www.catholiceducation.org/en/religion-and-philosophy/philosophy/freedom-license.html

4. Self-Reliance. Project Guttenberg. Accessed May 15, 2020. https://www.gutenberg.org/files/16643/16643-h/16643-h.htm#SELF-RELIANCE

5. The Gadsden Flag. Chamber of Commerce. Accessed May 15, 2020. https://www.chamberofcommerce.org/usflag/history/gadsden.html

6. Hutchinson B. Protests against coronavirus 'stay-at-home' orders spread across the country. ABC News. Accessed May 15, 2020. 

https://abcnews.go.com/US/protests-coronavirus-stay-home-orders-spread-country/story?id=70242988

7. Skoble A. Communitarian and Individualist Ideas in Business. Foundation for Economic Education. Accessed May 15, 2020. 

https://fee.org/articles/communitarian-and-individualist-ideas-in-business/

8. Legal Authorities for Isolation and Quarantine. Centers for Disease Control. Accessed May 15, 2020. https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html

9. Betz B. Maine protesters hit back at ‘tyranny’ of state’s coronavirus restrictions. Fox News. Accessed May 15, 2020. https://www.foxnews.com/us/maine-protesters-state-coronavirus-restrictions

10. Steal this book. Encyclopedia.com. Accessed May 15, 2020. https://www.encyclopedia.com/arts/culture-magazines/steal-book

11. Polman D. Refusing to wear a mask is about the most un-American thing to do right now. Pennsylvania Capital Star. Accessed May 15, 2020. 

Reflections on the anti-restriction protesters and hyper-individualists.

Freedom Does Not Mean Being on the Loose

There is no one-size-fits-all formula for healing the soul. Each of us will need to find the unique path that leads us from grief or despair to healing.

“The reward of suffering is experience.” -

 is usually defined as “mind,” but the term’s history and etymology are more complex. The ancient Greek term 

 had a range of meanings, including mind, spirit, or soul

 It is this last meaning that I want to explore in relation to the frightening pandemic we are now encountering.

A good deal has already been written regarding the possible psychiatric complications of the 

. For example, Drs Nidal Moukaddam and Asim Shah have rightly 

On an individual level, [the pandemic] may differentially exacerbate anxiety and psychosis-like symptoms as well as lead to non-specific mental issues (eg, mood problems, sleep issues, phobia-like behaviors, panic-like symptoms).

Less has been said regarding what I would call “the care of the soul” in the midst of this pandemic. I borrow the phrase from the classic work 

 (1992), by the psychotherapist and former Catholic monk Thomas Moore. Moore was heavily influenced by proponents of archetypal psychology, such as Carl Jung and James Hillman. Moore admits that defining the term 

 is nearly impossible but tells us that it “…has to do with depth, value, relatedness, heart and personal substance.”

 In any case, Moore points out that when we discuss “the soul,” we are entering the realm of the 

Moore sees “the great malady” of our age as “loss of soul”-a sweeping topic for another time. For now, I would like to suggest that-beyond unsettling our minds-the current pandemic also unsettles our souls in ways we are just beginning to understand. Just as the COVID-19 virus attacks the respiratory tract, the pandemic itself can assault the soul. I would identify five manifestations of this: impotence, grief, loneliness, mistrust and displacement. After exploring these manifestations, I will suggest some ways by which we might care for our souls during these perilous times.

There are few states of the soul more difficult to bear than the feeling of powerlessness. This was painfully brought home by a woman in a small Italian town, whose husband, age 85, had just died from the coronavirus. Five days later, his body still lay in a coffin, as the local cemetery was closed, and traditional funeral services were prohibited throughout the country. The man’s wife of 50 years struggled to explain her feelings. “It’s not anger,” she said. “It’s impotence in the face of this virus.”

 Grief and its attendant rituals of mourning are expected and healthy adaptations to loss, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I 

in the context of pastoral care. Grief differs substantially from major depressive disorder, although the two conditions may co-occur.

 Thus, it is perfectly understandable that those who have lost loved ones to the COVID-19 pandemic will feel deep and consuming grief.

But this pandemic may evoke grief on more levels than we are used to, in our everyday life. For some, this multi-pronged attack may overwhelm our usual, adaptive mechanisms for handling grief. Writing in the 

: “There is a lot to mourn right now. Many…are mourning dead loved ones. People are mourning lost jobs, lost savings, lost security. Senior citizens in locked down nursing homes are mourning the loss of visitors. I’m lucky. I’m just mourning the city…So many of the pleasures and conveniences [of city life] have disappeared.”

 And, on a deeper level, I suspect that many of us are grieving the loss of what we imagined were our relatively safe, stable, and protected lives.

There is a cruel, soul-crushing paradox at work in this pandemic, as Frank Bruni 

. We are dealing with “…a psychological contradiction and emotional oxymoron that are peculiar to a pandemic. At the very moment when many of us hunger most for the reassurance of company and the solace of community, we’re hustled into isolation.”

 For those without family, friends, or a supportive community, the ensuing sense of loneliness-sometimes accompanied by feelings of abandonment-can be overwhelming. Although social connections via the internet are often helpful, they are no substitute for the embrace of a friend or loved one.

. Drs Moukaddam and Shah identified one type of mistrust that can arise during infectious pandemics:

…a lack of trust in medical treatment and advances . . . During infectious pandemics, medical mistrust has been linked to conspiracy theories. In one US study, up to half of those surveyed endorsed belief in at least one health-related conspiracy theory.

Furthermore, during pandemics, there is a strong tendency to scapegoat “

”-the stranger, the foreigner, the outcast. In this regard, we should recall that during the 

-the bubonic plague that killed one-third of the European population in the fourteenth century-Jews were maliciously blamed for spreading the 

 of Erikson’s theory of psychosocial development is called “Trust vs. Mistrust.”

  We may reasonably surmise that individuals who did not successfully negotiate this crucial stage will be especially vulnerable to strong feelings of mistrust during the present pandemic-but on some level, these feelings may affect most of us. (And, yes-there are sound reasons to be mistrustful in certain instances, eg, when dealing with scams aimed at exploiting during the pandemic).

During the present pandemic, the mistrust that can afflict the soul may prove broader, deeper, and more insidious than in ordinary times. It is the kind of mistrust that can spread, pandemic-like, over the whole of life. The vulnerable person may wonder: How can I trust that I will have enough food for the next few months? Or that I will be able to get medical care if I get sick? How can I trust the person next to me, who may be carrying and spreading the virus? How can I trust myself, since I might unknowingly infect my children or spouse? How can I trust that the world is a safe place? Or that I still have control over my life?”

I am referring now not to the defense mechanism of displacement-eg, kicking the candy machine instead of the abusive boss-but to displacement in the existential sense; that is, losing one’s customary and valued position, role, or status in life. In the COVID-19 pandemic, thousands of people are being displaced from their usual jobs and accustomed roles. The teacher may be bereft of students and class; the minister bereft of congregation. The nurse or physician infected with the coronavirus and quarantined is suddenly deprived of liberty, power, control, and the immense privilege of caring for others. Suddenly, the doctor is a patient: vulnerable, passive, and sometimes powerless. Citing the pervasive uncertainty attendant to the pandemic, Joshua Gordon, MD, PhD-Director of the National Institute of Mental Health (NIMH)-referred to the need to “find your place in the world.”

 I suspect Dr Gordon may have had in mind the kind of existential displacement that I am describing.

There is no one size fits all formula for healing the soul. Each of us will need to find the unique path that leads us from grief or despair to healing. In general, we can describe approaches to soul-healing as either 

-in nature. For many people coping with the five-fold problems previously described, a cognitive approach may be useful. For example, Rational Emotive Behavioral Therapy (REBT)-developed by psychologist Albert Ellis, PhD-emphasizes the identification of irrational fears and catastrophizing thoughts.

 Similarly, the ancient philosophy of Stoicism tends to emphasize cognitive and behavioral approaches to 

But, as Thomas Moore points out, the soul is not grounded primarily in reason and logic; rather, “…it persuades more with desire than with reasonableness.”

 This suggests that healing the soul, for many people, may best be achieved through non-cognitive strategies. Thus, some may find comfort in one or more of the world’s great religious and spiritual traditions. For example, in Judaism and Buddhism (and Stoicism), great emphasis is placed on 

This may seem far-fetched in the present context: how can anyone experience gratitude in the midst of a deadly pandemic? And yet, in my own experience, it is precisely my gratitude during trying times that has allowed me to reduce my stress and anxiety. Each of us will find different things in our lives for which we feel gratitude; for example, during this pandemic, I am grateful for my friends, my family, and for the heroic efforts of my over-worked medical colleagues. The power of gratitude is nicely summed up in this saying, often attributed (perhaps erroneously) to the Buddha:

Let us rise up and be thankful, for if we didn’t learn a lot at least we learned a little, and if we didn't learn a little, at least we didn't get sick, and if we got sick, at least we didn’t die; so, let us all be thankful. 

For some who do not embrace a specific religious or spiritual orientation, “care of the soul” may involve the therapeutic use of music, poetry, or literature. (The term 

 did not arise out of the blue; rather, it evolved from the African American church music called 

 Thomas Moore describes how, when we are feeling melancholic, the best strategy may involve “…going with the darkness, rather than fighting it”-an approach Moore calls 

. He gives the example of listening to Samuel Barber’s “Adagio for Strings,” which “…speaks directly to the melancholic emotions and depicts the dynamics of grief and sadness.”

Similarly, poetry of the right tone and content can be a great comfort to the wounded soul. When I was a psychiatric resident working on the inpatient unit, I led a very unusual therapy group. Patients were encouraged to bring in poetry-whether their own or that of others-and read it to the group. A psychiatric nurse and I encouraged discussion of the feelings, images, and memories the poems would almost invariably evoke. We often selected poems that resonated with themes of loss, longing, loneliness, and love-the Four Ls. But we were careful to avoid poems that, in the words of Jack Leedy, MD, “…offer no hope, or that might increase the depth of the [patient’s] depression…”

Nobody would ever suggest that the present pandemic is a good thing. To the sickness and suffering and dislocation it has caused, we may justly say, “Begone-now!” To the scientists working around the clock to develop a vaccine, we should say, “Godspeed!” And yet, we may learn important things from this ordeal-and not just in the critical fields of virology and epidemiology. For there is a sense in which our souls may grow stronger, wiser, and deeper, through this terrible trial. As Rabbi Manis Friedman has 

, sometimes it is a good thing “to be reminded that we have not mastered the universe.”

HS Moffic. Our powers in the face of a pandemic. 

www.psychcongress.com/article/our-powers-face-pandemic

Coronavirus anxiety: Social distancing helps stop the spread

Beyond unsettling our minds, the current pandemic unsettles our souls in ways we are just beginning to understand. Just as the COVID-19 virus attacks the respiratory tract, the pandemic itself can assault the soul. Dr Pies identifies five manifestations of the crisis.

Author | Ronald W. Pies, MD

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