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But we can help our patients cope with the polarities of hope and despair.
The concept of some kind of “way station” between heaven and hell—or between salvation and damnation—is apparently an ancient one, going back to Biblical times. But it was not until the late Middle Ages—around the year 1200—that the Christian concept of purgatory was fully developed. As medieval history professor Clifford R. Backman, PhD, explains, purgatory was then understood as “a sin-cleansing way station where devout, but imperfect souls might be absolved of their guilt and prepared for God’s salvation.”1
Theological perspectives of this sort are important for mental health professionals to understand. But there is also a psychological meaning to “purgatory” that seems well-suited to the current state of the COVID-19 pandemic. Indeed, in August of this year, psychologist David Rakovsky spoke of “pandemic purgatory” in these terms:
When you’re in pandemic purgatory, it seems that there’s no solid ground to make any plans with. We felt like there was a light at the end of the tunnel, there was a vaccine, and that most people would be taking it and we’d be out of this by now—making plans, dates, and all kinds of things. Now it seems that for the time being, we’re kind of out of traction again.2
I think Rakovsky was right: After some initial optimism at the beginning of last summer, we found ourselves, by late August, in the grips of the highly contagious Delta variant. At the same time, we were blessed with safe, effective, and promising vaccines. It was not exactly hell, but it certainly was not heaven. Suspended between dread and hope, we struggled to find the right image or metaphor, often verging on cliches: “The light at the end of the tunnel”? “Circling the airport”? “Caught between a rock and a hard place”? For many, late summer was a kind of dark-shrouded borderland, with no discernible boundaries and no clear way out. I felt myself resonating with Dante Alighieri, in the first lines of his masterpiece, the Inferno:
Midway through the journey of my life,
I found myself in a dark wood,
For the straight path was lost.
Now, 4 months later, as winter bears down on us, we are faced with yet another assault from the Greek alphabet: the rapidly spreading Omicron variant.3 And once again, many people find themselves in that state of psychic and spiritual suspension from which no immediate exit is apparent. As Roger Cohen observed:
Uncertainty bedevils plans. Panic spreads in an instant even if, as with the Omicron variant, the extent of the threat is not yet known. Vaccines look like deliverance until they seem a little less than that. National responses diverge with no discernible logic. Anxiety and depression spread. So do loneliness and screen fatigue. The feeling grows that the COVID era will go on for years, like plagues of old.4
Indeed, it seems likely we will be dealing with many evolving variants of SARS-CoV-2 for the foreseeable future. Yet this dismaying reality comes at a time of considerable medical progress in this country. While by no means a deliverance from the pandemic, several approved vaccines can avert the worst outcomes of COVID-19.3 (Sadly, many low-income countries have not been so fortunate.)5 Progress is also being made in developing oral antiviral agents that reduce the likelihood of hospitalization and death, among those already infected with COVID-19.6
As psychiatrists, we need not adopt a theological perspective on purgatory, although some may be comfortable doing so. We have enough depth psychology to help our patients—and each other—deal with the pandemic’s polarities of hope and despair. First, we can recognize that many people coping with the pandemic are demoralized. Demoralization is related to, but distinct from, clinical depression, and is not a “disease.”7 Psychologist John F. Schumaker has defined demoralization as “an overarching psycho-spiritual crisis in which victims feel generally disoriented and unable to locate meaning, purpose, or sources of need fulfilment.”8 He goes on to explain that, when we are demoralized:
The world loses its credibility, and former beliefs and convictions dissolve into doubt, uncertainty, and loss of direction. Frustration, anger, and bitterness are usual accompaniments, as well as an underlying sense of being part of a lost cause or losing battle. The label “existential depression” is not appropriate since, unlike most forms of depression, demoralization is a realistic response to the circumstances impinging on the person’s life.8
In short, demoralization is the bitter fruit of this pandemic purgatory. To help our patients and our fellow health care professionals, we need to recognize this syndrome and help guide the demoralized person back to the straight path. But to be clear: That path is likely to be different for each person, and it is not our role to choose the right path to follow. Yet there is much we can do by providing emotional support, empathy, and validation of the person’s emotional struggle. As I wrote in an earlier essay, we can act as midwives to our patients’ inner transformation—supporting and encouraging them as they struggle to give birth, often painfully, to new meaning in their lives.7
Purgatory, after all, was never conceived as a permanent state. Rather, it is a place of internal transformation and a gateway to something better.
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 Psychiatric TimesTM (2007-2010).
1. Backman CR. The Worlds of Medieval Europe. 2nd Ed. Oxford University Press; 2015.
2. Paddock B. How to face uncertainty in ‘pandemic purgatory.’ WTTW News. August 24, 2021. Accessed December 15, 2021.
3. Omicron variant: what you need to know. Centers for Disease Control and Prevention. Updated December 20, 2021. Accessed December 15, 2021.
4. Cohen R. Across the world, Covid anxiety and depression take hold. The New York Times. December 13, 2021. Accessed December 15, 2021.
5. Goldhill O. We have enough Covid vaccines for most of the world. But rich countries are stockpiling more than they need for boosters. STAT. December 13, 2021. Accessed December 15, 2021.
6. Erman M, Beasley D. Pfizer says COVID-19 pill near 90% protective against hospitalization, death. Reuters. December 14, 2021. Accessed December 15, 2021.
7. Pies RW. Psychiatry and the dark night of the soul. Psychiatric Times. December 14, 2021. Accessed December 15, 2021.
8. Schumaker JF. The demoralized mind. New Internationalist. April 1, 2016. Accessed December 15, 2021.