Care of the Soul in the Time of COVID-19

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.” -President Harry S. Truman In our profession, the term psyche is usually defined as “mind,” but the term’s history and etymology are more complex. The ancient Greek term psykhÄ 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 COVID-19 pandemic. For example, Drs Nidal Moukaddam and Asim Shah have rightly noted that.1 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 Care of the Soul (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 soul is nearly impossible but tells us that it “…has to do with depth, value, relatedness, heart and personal substance.”2 In any case, Moore points out that when we discuss “the soul,” we are entering the realm of the sacred. 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. The five-fold assault on the soul Impotence. 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.”3 Grief. Grief and its attendant rituals of mourning are expected and healthy adaptations to loss, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I discuss in the context of pastoral care. Grief differs substantially from major depressive disorder, although the two conditions may co-occur.4 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 New York Times, Michelle Goldberg put it this way: “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.”5 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. Lonliness. There is a cruel, soul-crushing paradox at work in this pandemic, as Frank Bruni observed. 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.”6 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. Mistrust. Drs Moukaddam and Shah identified one type of mistrust that can arise during infectious pandemics:1 …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 Other”-the stranger, the foreigner, the outcast. In this regard, we should recall that during the Black Death-the bubonic plague that killed one-third of the European population in the fourteenth century-Jews were maliciously blamed for spreading the plague by poisoning the wells.7 Let’s recall that the first stage of Erikson’s theory of psychosocial development is called “Trust vs. Mistrust.”8 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).9 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?” Displacement. 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.”10 I suspect Dr Gordon may have had in mind the kind of existential displacement that I am describing. Healing the soul in the time of COVID-19 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 cognitive or non-cognitive-some might say meta-cognitive-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.11 Similarly, the ancient philosophy of Stoicism tends to emphasize cognitive and behavioral approaches to restoring emotional equanimity.12 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.”2 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 gratitude as a means of dealing with misfortune.13 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. 14 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 soul music did not arise out of the blue; rather, it evolved from the African American church music called gospel music.15) In his 2004 book, Dark Nights of the Soul, 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 homeopathy. 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.”16 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…”17 Conclusion 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 observed, sometimes it is a good thing “to be reminded that we have not mastered the universe.”18 Additional Reading: HS Moffic. Our powers in the face of a pandemic. Behavioral Healthcare Executive.www.psychcongress.com/article/our-powers-face-pandemic. March 17, 2020. Grohol JH. Coronavirus anxiety: Social distancing helps stop the spread. PsychCentral. https://psychcentral.com/blog/coronavirus-anxiety-social-distancing-helps-stop-the-spread/. March 13, 2020. This article was originally published on March 23, 2020, and has since been updated. -Ed Disclosures: Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is Editor in Chief Emeritus of Psychiatric Times (2007 to 2010). References: 1. Moukaddam N, Shah A. Psychiatrists beware! The impact of COVID-19 and pandemics on mental health. Psychiatric Times.2020;37(3). 2. Moore T. Care of the Soul. Harper-Collins Publishers; 1992. 3. Horowitz J, Bubola E. Italy’s coronavirus victims face death alone, with funerals postponed. The New York Times. March 19, 2020. 4. Pies RW, Geppert CMA. Clinical depression or “life sorrows”? Distinguishing between grief and depression in pastoral care. Ministry. May 2015. 5. Goldberg M. Grieving for my sick city. The New York Times. March 16, 2020. 6. Bruni F. Why the coronavirus is so much worse than Sept. 11. The New York Times. March 17, 2020. 7. McNeil DG. Finding a Scapegoat When Epidemics Strike. The New York Times. Aug. 31, 2009. https://www.nytimes.com/2009/09/01/health/01plague.html. 8. Cherry K. Trust vs. Mistrust: Psychosocial Stage 1. Very Well Mind. www.verywellmind.com/trust-versus-mistrust-2795741. March 21, 2020. 9. Romm T. ‘That can actually kill somebody’: Scam robocalls are pitching fake coronavirus tests to vulnerable Americans. Washington Post. March 19, 2020. 10. Achenbach J. Mental health experts offer counsel on staying calm during coronavirus pandemic. Washington Post. March 17, 2020. 11. Ellis A, Harper RA. A Guide to Rational Living. Wilshire Book Company; 1961. 12. Pies R. How the stoics can keep us calm during the coronavirus outbreak. PsychCentral. https://psychcentral.com/blog/how-the-stoics-can-keep-us-calm-during-the-coronavirus-outbreak/. March 2, 2020. 13. Pies R. The Three-Petalled Rose. iUniverse, 2013. 14. Quote Search. Beliefnet.com. www.beliefnet.com/quotes/buddhist/general/t/the-buddha/let-us-rise-up-and-be-thankfulfor-if-we-didnt.aspx. Accessed March 21, 2020. 15. Errey M. History of Soul Music. English Club. www.englishclub.com/vocabulary/music-soul.htm. Accessed March 21, 2020. 16. Moore T. Dark Nights of the Soul. Gotham Books; 2004. 17. Leedy J. Poetry as Healer. New York: Vanguard Press; 1985. 18. Friedman M. Coronavirus: The Jewish Perspective. www.youtube.com/watch?v=Lvh8DN2WhxY. March 19, 2020.