In This Moment,We Are All Dr. Rieux: COVID-19,Existential Anxiety,and the Absurd Hero

As I write this article, I watch an exponential growth of the COVID-19 global pandemic. Writing the first draft, between March 20th and April 1st, the U.S. COVID-19 case totals rose from 50,000 to 100,000 to 200,000. Returning for revisions a month later, the U.S. COVID-19 case totals have risen to more than a million and continue to rise. Although I live in an area with strict physical distancing and shelter-in-place orders passed down by our governor, Kate Brown, I am struck with the realization that this pandemic will invariably affect me, the clients I encounter, and the people I love. I know this will be difficult to avoid. Through these events, I am immersed in an existential anxiety wherein I am brought face to face with the fragility of life and its inevitable end. And yet, working in a community mental health center with some of the most vulnerable people, I simultaneously feel committed to continue on, day by day, through anxiety and despair, encountering clients with the same love and respect I believe they deserve. Through my encounters, I find myself coming face to face with clients struggling with the same anxiety and despair that I am experiencing.

The existential threat of COVID-19 touches both clients and therapists alike. Together, we experience an existential anxiety that calls everything we have come to expect into doubt. And this leads to the central question guiding the following text. How can therapists encounter and maintain healing relationships with clients through this pandemic when therapists themselves experience the same anxiety and despair as do their clients? In order to answer, the following text develops a formulation for how COVID-19 provokes the response of existential anxiety and provides a prophylactic. In this endeavor, first, the formulation of existential anxiety as described by Irvin Yalom provides a means to grasp the fundamental framework, and second, the absurd hero as described by Albert Camus provides the prophylactic for existential anxiety in the face of a global pandemic.

What is existential anxiety? Within the field of philosophy, Kierkegaard explains in The Concept of Anxiety that there are two like affects named anxiety (angest; Kierkegaard, 1855, 1980). Where anxiety as fear has an object, there is also an anxiety without an object sourced from a terrifying choice to believe against all reason or to withhold faith (Kierkegaard, 1855, 1980). This insight is taken up by Sartre in describing anxiety (angoisse) as the fundamental affective component of freedom where the source of anxiety is found in choices as such (Sartre, 1943, 1993). Bridging the philosophical-clinical divide, Irvin Yalom defines existential anxiety, on the one hand, as a psychic mechanism akin to the signal anxiety described by Freud but which, on the other hand, is grounded in primary existential conflicts akin to those of Kierkegaard and Sartre.

As a psychic mechanism, Yalom defines existential anxiety through an elaboration of dynamic processes wherein “a conflict that flows from the individual’s confrontation with the givens of existence” (Yalom, 1980, p. 8). As a set of existential givens, according to Yalom, these fundamentals are death, freedom, isolation, and meaninglessness. Existential anxiety arises from these givens by way of a dynamic conflict between an existential given and a wish for its opposite. These conflicts are structured as follows: first, a confrontation with death wherein each living person is faced with the inevitability of their final exit and their wish for immortality (Yalom, 1980); second, a confrontation with freedom wherein each individual must contend with the ultimate groundlessness of the universe and their wish for structure to ground them (Yalom, 1980); third, a confrontation with fundamental isolation wherein a person is faced with the reality of being in this world alone and their wish for contact, protection, and togetherness (Yalom, 1980); and fourth, a confrontation with the meaninglessness of existence wherein an individual must contend with the meaninglessness of the universe and a wish for meaning (Yalom, 1980).

Through this analysis, the existential anxiety provoked by the COVID-19 pandemic can be grasped as a confrontation with each of these existential conflicts, thus triggering an existential dread as the response to the fear and suffering experienced in the midst of a pandemic. Yalom emphasizes that arising from the conflict between these four existential givens and the wish for their opposite, existential anxiety is manifested as a means to bury the conflict beneath the conscious. When anxiety and despair exceeds the capacity for the individual to hold, the result is psychopathology as “a graceless, inefficient mode of coping with anxiety” (Yalom, 1980, p. 110). Thus, through traumatic encounter with the invisible and inescapable, the threat posed by COVID-19 brings one face to face with ones deepest existential angst: Yes, you shall die; yes, you are responsible for your actions that brought you here; yes, you must face this alone in the end; and yes, your entire life has no meaning in the face of this threat.

What is the prophylactic? Yalom posits that “the goal of psychotherapy is to bring the patient to the point where he can make a free choice” (Yalom, 1980, pp. 5, 401). As focused on anxiety, this is accomplished through confronting and embracing the existential givens of death, freedom, isolation, and meaninglessness. In a similar way, Albert Camus describes the despair of existence as the absurd and the will to continue as an act of tragic heroism (Camus, 1942, 1947, 1948, 1955). In the following discussion, the absurd hero becomes a model for therapists to look at in their struggle against existential anxiety provoked by COVID-19. Of particular importance in the following are Camus’ novel The Plague (Camus, 1947, 1948) and his essay The Myth of Sisyphus (Camus, 1942, 1955). Here, Dr. Bernard Rieux, the protagonist of Camus’ novel who hopelessly treated patients of the plague, and Sisyphus, the ancient king of Corinth, who was doomed to eternally push a boulder up a hill, become the model prophylaxis for psychopathological response under the stress of the COVID-19 pandemic.

The Plague (Camus, 1947, 1948) follows the events surrounding the outbreak of bubonic plague and the wake of destruction this leads to in the colonial French town of Oran, Algeria. The novel is narrated by a medical doctor, Dr. Bernard Rieux, as a documentation of the failed struggle to hold back the infection and his endless task of treating the sick. Early on during the initial rise of infection, Dr. Rieux advises the city of Oran to take more stringent measures against the rising infection rate, but the administration of Oran ignores his warnings until it is too late. Meanwhile, as Dr. Rieux struggles to treat the ever mounting rate of infection, the corpses begin to pile at an exponential rate. The handling of the dead becomes ever more impersonal and meaningless. Finally, the plague overtakes the town with nothing left to be done except wait for it to extinguish itself. Nevertheless, Dr. Rieux presses on, treating the infected with limited medical supplies and with dignity. In the end, the plague extinguishes itself, and the town of Oran reopens to the outside world.

According to his notebooks, Camus conceived of The Plague in the early 1940s during his time in the French Resistance to the Nazi occupation, began writing it shortly after the end of World War II, and published it in 1947 (Kałuża, 2017). Camus described The Plague as an allegory of the Nazi occupation of France and a critique of French existentialism (Rossi, 1958; Yalom, 1980). However, Camus declared that allegory was greater than a mere condemnation of the Nazi occupation (Kałuża, 2017). The struggle faced by Dr. Rieux is an allegory in which “one may find inspiration . . . not only to honor the historical resistance, but also to support anti-totalitarian movements struggling” in the present (Kałuża, 2017, p. 96). Scholars have interpreted the novel as an allegory of fascism (Cruickshank, 1957; Finel-Honigman, 1978), of resistance to fascism (Bernard, 1967), of French colonialism in Algeria (Carroll, 2001), of social hygiene (Lund, 2011), and of death and dying (Abram, 1973). Across each of these interpretations, a set of common themes jump out of the text regarding the place of the therapist today living under the tyranny of global pandemic—the absurdity of human existence and meaningless suffering.

As iterated in The Myth of Sisyphus (Camus, 1942, 1955), human life is always faced with the “the certainty of a crushing fate” (Camus, 1955, p. 54). For this reason, Camus posited that the only philosophical problem was to decide “whether or not life is worth living” (Camus, 1955, p. 3). For Sisyphus, the eternal labor exerted on the boulder as he pushes its weight up the mountain is chained to a meaningless responsibility to continue his isolation and damnation. As with Sisyphus, Dr. Rieux was faced with a struggle against the plague, bringing him face to face with a meaningless responsibility to continue his labor. Laboring on toward oblivion, both “must despair of ever reconstructing the familiar, calm surface which would give [them] peace of heart” (Camus, 1955, p. 18). Nevertheless, both Sisyphus and Dr. Rieux continued their labor “without the resignation that ought to accompany it” (Camus, 1955, p. 54). It is this struggle without resignation that is the mark of the absurd hero.

In order to come to this point of absurd heroism, Camus explains, one must become conscious of their fate, knowing that there is no escape. Thus, Sisyphus comes to “the hour of consciousness” wherein “at each of those moments when he leaves the heights and gradually sinks towards the lairs of the gods, he is superior to his fate” (Camus, 1955, p. 121). As with Sisyphus, while remaining trapped in the absurdity of meaningless human suffering and death, Dr. Rieux’s consciousness of the absurdity gives him the power and strength to continue. Where Sisyphus and Dr. Rieux confront their own oblivion and meaninglessness, they embrace the absurdity of their existence. At this point, where the laborer embraces the absurdity of their existence and becomes conscious of their death, their isolation, and the meaninglessness of their labor, they pass through their angst and suffering to defeat the bonds of their existence. They become the absurd hero.

How can these insights speak to the COVID-19 crisis? During the early days after the World Health Organization declared COVID-19 a global pandemic, a group of colleagues and I began to read The Plague (Camus, 1947, 1948). As my friends and I worked through Camus’ novel, as we watched the rate of infection rise exponentially across the globe, and as we became personally affected by COVID-19, I began to see the events confronting the world today as eerily similar to Camus’ story. COVID-19 has no intrinsic meaning. It has no teleological purpose. It is a virus that passes from person to person without a conscious direction. Thus, faced with the consequences of the COVID-19 pandemic, existential anxiety is triggered by the confrontation with death, isolation, nothingness, and meaninglessness. Therapists are no more immune from the anxiety the crisis arouses than are the rest of the world.

Nevertheless, despite harboring the same existential anxieties as their clients, “it is the relationship that heals” (Yalom, 1980, pp. 5, 216, 288, 401). Hence, the therapist must encounter the client through I-Thou (Ich-Du), wherein both therapist and client are travelers through this experience (Buber, 1923, 2010; Scott et al. 2009). Like Dr. Rieux, it is in consciousness of this absurd fate that “the tireless fighter of the plague” (Yalom, 1980, p. 428) becomes the tragic hero and passes the barrier of existential anxiety to come out on the other side with power and strength. As therapists and health care workers, we all march toward this fate while maintaining meaningfulness in treating our clients with dignity. Actualizing “the goal of psychotherapy is to bring the patient to the point where he can make a free choice” (Yalom, 1980, pp. 5, 401); to become conscious of the absurdity allows one to choose to continue the struggle despite the hopelessness of that struggle. Illustrating this point through a dialogue between Dr. Rieux and Jean Tarrou, Camus (1948) writes,

“Yes. But your victories will never be lasting; that is all.”

Rieux’s face darkened.

“Yes, I know that. But it’s no reason for giving up the struggle.”

“No reason, I agree. Only, I now can picture what this plague means for you.”

“Yes. A never ending defeat.” (p. 128)

Between the absurd of Camus and the existentialism of Yalom, the fate faced through COVID-19 by client and therapist alike is provided with a prophylactic: Although tragic, meaningless, and isolating, it is through consciousness of the absurd that one can uncover a source of power and strength. Encountering clients confronted by the same anxiety I face becomes an exercise in uncovering the source of my own existential anxiety while simultaneously allowing for a confrontation with an existential anxiety experienced universally. Although my personal sense of dread has intensified, I have begun to feel resolute. Like the plague endured by the town of Oran and the ever steady work of Dr. Rieux, I “must despair of ever reconstructing the familiar” (Camus, 1955, p. 18). Through the exponential growth of COVID-19, I have begun to form a sense of security. My labor may be absurd, but my consciousness of this absurdity gives me the power and strength to continue this fight. In this moment, we are all Dr. Rieux, and it is as Dr. Rieux that the therapist begins to confront their anxiety and move beyond.