Narrative Review
Interpreting the Effects of the COVID-19 Pandemic: Bridging Psychological and Sociological Perspectives

Ege Gungor Onal¹
Published online: July 3, 2022

¹Department of Bioengineering, University of Illinois at Urbana-Champaign, United States
Corresponding Author: Ege Gungor Onal, email egeonal2@illinois.edu
DOI: https://doi.org/10.26443/mjm.v20i2.905

Introduction

The most significant global health challenge in recent time has been the novel coronavirus (SARS-CoV-2) outbreak, which was first identified in Wuhan, China, in December 2019 (COVID-19). (1) By March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic, with cases reaching 118,000 in over 110 countries. (2) Speaking of the severity of COVID-19 on March 11, WHO Director-General Dr. Tedros Adhanom Ghebreyesus said:

“Pandemic is not a word to use lightly or carelessly. It is a word that, if misused, can cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death...I have said from the beginning that countries must take a whole-of-government, whole-of-society approach, built around a comprehensive strategy to prevent infections, save lives and minimize impact.” (3)

Dr. Ghebreyesus argues that the COVID-19 pandemic necessitates a thorough, holistic, and societal approach to control and surmount its negative effects. By October 2020, Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, likened the social and public health crisis caused by COVID-19 to the Spanish Flu of 1918, among the worst in history, underlining that “it has devastated the whole world.” (4) The impact of this highly contagious disease has been cataclysmic: hospitals have overflowed and lockdowns have been imposed in over 90 countries. (5) COVID-19 has not only caused a public health burden but has also led to social and economic disruptions as well as environmental challenges. The highly contagious nature of COVID-19 led to a collective social effort to mitigate its effects beyond so-called “social distancing.” (6) For example, many schools shifted to online/remote instruction, workplaces were adapted to promote distancing efforts and online meetings, travel decreased significantly, and public spaces and restaurants closed down permanently. In the early stages of the pandemic, the global economy became destabilized and the economic impacts of the pandemic were unevenly distributed among the world’s population. Recent research has shown that COVID-19 has disproportionately affected different socioeconomic groups within the United States. The lowest socioeconomic groups suffered from higher incidence and mortality rates compared to higher socioeconomic groups. (7) The multitude of factors has led commentators to label this pandemic a period of “new reality.” (8)

Within the realm of this “new reality,” COVID-19 has had specific consequences for the way in which individuals interact with one another. Due to its highly contagious nature, the disease has altered social interactions in important and often uneven ways especially between different groups in the population. Physical-distancing and the risk of contracting the virus has led to increased social isolation along with psychological unease and fear fueled by negative emotions. (9) Consequently, researchers have been investigating the disease's psychological and social implications. Yet, much of the social science literature remains partial towards one perspective over the other, despite having the common aim to elucidate causal factors underlying the social and psychological implications of the disease. To date, much of the medical literature has been interested in psychological, physiological, and public health consequences of the disease, whereas sociological studies have evaluated the impacts of COVID-19 on society at large and along specific lines of community, politics, and socioeconomic status. In contrast, the primary purpose of this article is to bridge the gap between psychological and sociological perspectives, providing a more comprehensive understanding of the social and psychological implications of the COVID-19 pandemic. This paper focuses on two major themes: guilt and stigma, reviewing them within the context of the COVID-19 pandemic. The social construction of stigma and guilt will be discussed and social-psychological implications on individuals will be depicted using both scholarly literature and news articles.

COVID-19, Guilt and Stigma: Developing a Social-Psychological Reading

The concepts of guilt and stigma have been extensively explored in the fields of psychology and sociology. As psychologists June Price Tangney and Kurt W. Fischer have defined it, “guilt is a form of self-conscious emotion that influences our behavioral decisions.” (10) Guilt is the emotion by which individuals reflect and feel distress for their acts. Conversely, the notion of stigma, most famously elaborated by sociologist Erving Goffman, is “an attribute that is deeply discrediting.” (11) Goffman differentiates these two terms, indicating the highly social dimension of stigma. Stigmas arise due to relational factors, such as interpersonal interaction or lack thereof. In more recent literature, guilt has mostly been explored through a psychological lens whereas stigma has remained largely within the realm of sociology. Therefore, it is important to highlight the ways in which both guilt and stigma are related through social interaction as well as emotions and psychology. This has been recognized by social psychology scholars like Roy Baumeister et al., who, in 1994, asserted that “guilt is a phenomenon that happens between people as much as it happens inside them.” (12) Similarly, stigma has been linked to the concept of deviance, which is a consequence of the responses of others to behavior that breaks social rules. Here it is important to state that deviance is not solely a behavioral quality, but it stems from the interaction between society and the individual committing the act. (13) According to Edward E. Jones et al. (1984), the process of stigmatization is a building block for the social construction of deviance: “it is the essence of the stigmatizing process that a label marking the deviant is applied, and this marking process typically has devastating consequences for emotions, thought, and behavior.” (14) This close link between stigmatization and deviance is crucial in analyzing social structure during the COVID-19 pandemic, as mitigating the effects of the pandemic is heavily reliant on either social compliance with regulations or deviation from such stipulations for any number of ideological, political, or other reasons.

The complex processes surrounding guilt, stigma, and deviance inform our perspectives on pandemics and epidemics. For instance, Erving Goffman’s dramaturgical theory of social interaction offers useful insight on the sociology of pandemics and epidemics as both lead to an inevitable alteration of social life. Within Goffman’s dramaturgical framework, one views social life as a theatrical performance in which we are all actors on metaphorical stages with scripts, roles, costumes, and sets. (15)

But how might this perspective be useful in analyzing the implications of epidemics? In Charles Rosenberg’s 1989 paper, “What is an epidemic?”, he defines epidemics as a social phenomenon that take on a dramaturgical form: “Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure.” (16) Within this perspective of epidemics and pandemics, the main antagonist is the disease itself. Similarly, what distinguishes a tragic character from a non-tragic one is the state of being infected or not, which allows for the proliferation of social stigma against infected individuals. Thus, it is of utmost importance for social scientists to elucidate the impact of guilt and stigmatization to mitigate the negative societal and psychological consequences of pandemics like COVID-19.

It is also important to consider medical perspectives and more contemporary sociological viewpoints. The diagnosis of COVID-19 evokes worry for possible transmission to a family member, affects work responsibilities, and can promote a pessimistic outlook on the future. (17) In addition to physical suffering, the disease itself will affect one’s social-self and social relations. This recalls Susan Sontag’s statement in Illness as Metaphor: “Etymologically, patient means sufferer. It is not suffering as such that is most deeply feared but suffering that degrades.” (18) Therefore, a COVID-19 diagnosis itself is a social and mental burden as much as it is a physical burden. The duality of being sick and being a carrier of the disease complicates our social interactions, which is figuratively depicted in figure 1, providing a concrete analogy to the restriction of intertwined social ties.

Stigma during COVID-19: The Self as a Victim or as a Threat?

Social construction of stigma during COVID-19

Pandemics are biosocial phenomena pertaining to the infectious nature of diseases and the requirement of human interaction for transmission. Due to the social nature of pandemics, stigma and the negative association attached to infected individuals has led to decreased cooperation with public health guidelines. For example, during the COVID-19 pandemic, fears of being stigmatized led to increased delays in seeking medical care. (19) The fear of being discriminated against or the fear of being held responsible for transmitting the disease may cause an individual to fear testing positive, leading to delays in seeking medical care and decreased compliance with public health regulations.

COVID-19 has caused multiple societal impacts, including, but not limited to, increased social inequalities, marginalization, and xenophobia. (20-22) Additionally, current border restriction policies have to potential to amplify support for anti-immigration policies. (23) The sudden shift towards remote work also poses a challenge for communities of lower socioeconomic status. Higher socioeconomic status is correlated with greater opportunities for remote work, whereas individuals in lower socioeconomic classes are less likely to be involved in jobs performed remotely. (24) This exposes individuals of lower socioeconomic status to a higher likelihood of becoming infected, thus further stigmatizing poorer individuals. In fact, the stigma associated with transmitting the virus led to new social hierarchies in India. (25) During the pandemic, healthcare workers have been the victims of stigmatization, which has even led to harassment and violence. (26-29) Therefore, the perception of risk due to transmission, social roles, and social determinants of health such as access to healthcare, income inequality, culture, and religion, has played a dominant role in the stigmatization of certain communities, leading to increased mortality and transmission of the virus. (30) As in figure 2, where the “sticker” is analogous to the labeling process that leads to stigmatization and the subsequent societal fear emerging from it, the COVID-19 pandemic has generated a climate of societal stigma. To quote the director-general of the WHO, Dr. Tedros Adhanom Ghebreyesus, “Our greatest enemy right now is not the coronavirus itself. It’s fear, rumours and stigma.” (31)

Stigma and mental health

In light of the COVID-19 pandemic, increased isolation, financial insecurity, limitations to personal freedom, and the highly contagious nature of SARS-CoV-2 have caused detrimental effects on the mental health of individuals. (32) The psychological impacts of quarantine have been reported to range from post-traumatic stress to confusion and anger, amplified by fear, misinformation, and stigma. (33)

The literature has reported that prevalent anti-Asian stigma in the context of COVID-19 could induce anxiety and depression among the Asian community and lead to adverse mental health outcomes. (34) In a study by Charissa Cheah et al., 50.9% of 543 Chinese American parents and 50.2% of their 230 children experienced at least one in-person incident of COVID-19 related direct racial discrimination. Those higher levels of racial discrimination were associated with poorer mental health. (35)

Further, in a review by Giorgi et al., negative mental health effects in the workplace, associated with depression, anxiety, post-traumatic stress disorder (PTSD), and sleep disorders, were more commonly expected among frontline workers and healthcare workers who are in continuous contact with the public. (36) There have even been reports of doctors in India being evicted from their homes amid fears linked to the coronavirus (26,37,38). Clinicians have also been reluctant to share psychological distress, an attitude that has further deteriorated the mental health of healthcare workers. (39)

Due to the fear, isolation, stigmatization, and financial uncertainty surrounding COVID-19, suicide rates have increased across various populations, including the elderly, students, and healthcare professionals. (40) To mitigate the negative mental health consequences of stigma related to the pandemic, researchers have suggested early-preparedness for mental health services, strengthening social cohesion, eliminating false information, increasing general awareness of the disease, and wording sensitively when referring to individuals affected by COVID-19 to prevent discrimination against them. (41-43) Emphasizing and supporting initiatives that aim to address mental health issues during the pandemic is crucial, especially considering that the impact of psychiatric disorders have the potential to persist even following the eradication of the SARS-CoV-2 virus. (44)

Guilt and COVID-19

Collective guilt and social groups during COVID-19

As psychologist Paul Gilbert defines it, “Guilt is rooted in the worry for the well-being of others, such that the distress experiences of others matter.” (45) Gilbert’s notion of guilt has intellectual origins in psychoanalysis. According to Freud, the fear of loss of love from authority figures during childhood, such as parents, is the primitive sense of guilt, which transitions into an internal authoritative voice (superego) during adulthood and judges one’s own acts, rendering guilt to be defined as “superego anxiety.” (46) Similarly, Paul D. MacLean and psychologist Nancy Eisenberg suggest that the origin of guilt often stems from early childhood, when the self-awareness of being a source of distress in others during social interaction leads to the subsequent worry that arises from this realization. (45,47,48) Collectively, the construction of guilt occurs through social interaction and acknowledgment of the “other,” where the latter is a natural consequence of the former.

Émile Durkheim’s notion of “social solidarity,” pertaining to the relationship between the individual and society, depicts the social cohesion that establishes societal order and stability. Social solidarity is further divided into two main types: where mechanical solidarity establishes social cohesion through resemblances in values and beliefs, organic solidarity is established in more advanced societies through the division of labor. Durkheim also proposes that “collective consciousness” is a unifying force that brings individuals around centrally shared ideas, beliefs, attitudes, and norms. (49) These are the central themes of the formation of collective behavior and collective emotions. (50) The individual awareness of one another’s emotional reactions towards specific events creates a common social identity. For instance, sociology scholars Christian von Scheve and Sven Ismer depict how protest marches exemplify individuals coming together in mutual dissatisfaction, leading to increased awareness of shared emotions and beliefs. This collective awareness ultimately forms a social identity within the group. (51)

The notions of social solidarity and collective consciousness have a bearing on our conceptualization of guilt. For instance, the notion of “collective guilt” arises through the perception that one’s group is harming or manipulating another. (52) During the COVID-19 pandemic, we were all responsible for following governmental guidelines to mitigate the transmission of SARS-CoV-2. However, certain groups have disobeyed these guidelines for personal reasons, such as spring break vacation. (53) Moreover, it has been shown that the US counties that voted for Donald Trump (Republican) over Hillary Clinton (Democrat) displayed 14% less social distancing between the dates of March 2020 and May 2020. The authors of this study, Anton Gollwitzer et al., have suggested that political partisanship was the key factor linked to social distancing, among other factors such as median income, race, and population density. (54) Therefore, although collective guilt may arise from the subsequent increase in transmission and mortality due to actions of a certain group, mechanical solidarity can overcome it. Leading individuals to choose social solidarity over the guilt that can be sensed when the recognition of the risks posed by COVID-19 would be akin to asking someone to effectively break their extant social ties. Indeed, this phenomenon, coined as cognitive constraint by sociologist Craig Rawlings (2020), can occur when attitudes and sentiment relations are unaligned or when social influence can lead us to adjust our attitudes to be more in line with the group’s attitude system. Cognitive constraint has been elaborated in other case studies of social networks to emphasize how network structure and characteristics inform the way in which people think and feel beyond more atomized theories of the individual. (55)

Aside from protecting one another through social distancing, social media has also served as an important tool for increasing awareness, improving cooperation for the benefit of society, and protecting one another. Conversely, however, sharing misinformation can lead to adverse outcomes even if done unintentionally. The sharing of misinformation can also be contagious as it spreads throughout social networks with a snowball effect. For example, in a study by public health scholars Md Saiful Islam et al., the authors provide evidence linking the death of 800 people and the hospitalization of another 5876 to the proliferation of a rumor claiming that concentrated alcohol can kill the virus. (56) In a recent study investigating the role of anticipated guilt in the social correction of COVID-19 misinformation, communication and media scholar Yanqing Sun et al. have elucidated that the possible severity of consequences on others stimulated anticipated guilt, which led individuals to take action and correct misinformation. (57) In a separate study investigating guilt and compliance during COVID-19, psychologists Giovanni A. Travaglino and Chanki Moon have shown that self-reporting and compliance are positively correlated with feelings of guilt. (58) Therefore, feelings of collective guilt can also be prosocial and lead individuals to report infections and correct misinformation with the potential of harming others.

The collective actions of individuals, as a social determinant for COVID-19 mortality, may be linked to social solidarity and collective guilt. Therefore, to minimize COVID-19 mortality along these parameters, governments should concentrate their efforts on forming social cohesion against the virus and decreasing the spread of misinformation, which would help eliminate the root causes of collective guilt.

Psychological toll of guilt during the COVID-19 era

While sociologists have investigated guilt during COVID-19 by analyzing governing social beliefs and structures, psychologists have taken a more individuated approach.

During the pandemic, the emergence of “COVID-19 induced guilt” mainly originated from the fear of transmitting the virus to a loved one. Psychiatry scholar Swapnajeet Sahoo et al. documented cases of COVID-19 patients who dealt with internalized guilt, shame, anger, and stigma. In one case, a 49-year-old village leader from India tested positive for COVID-19 and felt guilty of possibly transmitting the virus to loved ones and other villagers. News of additional infections throughout the village overamplified his feelings of guilt, which eventually led him to present with psychiatric symptoms, such as sleep disorders and anxiety. Moreover, the report suggests that he started blaming his own lack of responsibility and developed a fear of possible stigmatization that could end his political career. Another report depicts a couple whose baby tested positive for SARS-CoV-2 after they had traveled to India. After the male partner’s mother was admitted to the intensive care unit (ICU) due to respiratory distress, the male partner felt intense guilt and blamed himself for her infection. In the same paper, the authors report a 23-year-old man who met with a friend from abroad and contracted the virus. After testing positive for COVID-19, the man became worried about his parents, who had pre-existing conditions. The man later called and blamed his friend for infecting him. (59) In another report, a mother committed suicide after fearing that she might infect her daughters, who were scheduled to visit the following day. The mother suffered from depression and an autopsy revealed that she did not have COVID-19 symptoms or a history of having been infected. The woman’s suicide was linked to anxiety over coronavirus and her fear of infecting loved ones. (60)

These reports exemplify individual instances of guilt arising from blaming one’s own actions for the transmission of the virus. During the pandemic, guilt has proven to serve as a constructive force for social compliance and taking responsibility; however, in most of the cases described above, guilt has taken the form of maladaptive guilt, which occurs when one feels responsible for events that occur outside of the individual’s control. Moreover, untreated maladaptive guilt has been shown to lead to mental health disorders such as depression, PTSD, substance abuse, and suicidal ideation. (61)

Similar to maladaptive guilt, patient anxiety is linked with the development of survivor’s guilt. (62) Survivor’s guilt refers to the discomfort arising from having survived a life-threatening situation when others have not. Survivor’s guilt has also had adverse mental health implications during the COVID-19 pandemic. (63)

In addition, feelings of guilt have been reported among healthcare workers. For example, David B. Reuben, M.D., reported “sideline guilt,” which he experienced during the pandemic while working as a physician. In his case, he was not required to schedule in-person consults with patients infected with the virus. Yet, media coverage of healthcare workers showing “hand-to-hand combat” on the frontlines coupled with the gratitude shown to him by his patients for his presumed efforts led to “sideline guilt.” This type of guilt is misleading because one might think that they are not contributing enough effort in combating the virus because they are on the “sidelines” of the healthcare response to COVID-19. (64)

Recommendations to prevent stigma and guilt in the general public

From a psychological perspective, negative outcomes of stigmatization and guilt can be decreased through cognitive behavioral therapy, mindfulness-based therapy, and compassion-focused therapy. (61, 65) From a sociological perspective, a social structure that strengthens social support and resilience among communities is crucial for fighting stigma and guilt. For the development of social resilience, governments, physicians, and scientists should combat misinformation not only from a scientific perspective but also from a perspective that aims to eliminate the effects of stigma and guilt. In parallel, creating online support groups can be done by means of telephone helplines that connect individuals with volunteers or healthcare professionals, as well as providing mental health support by telemedicine. (66) In addition, peer-support systems along with increasing awareness of mental health difficulties in healthcare settings should be implemented to support healthcare workers, reduce burnout, and facilitate deeper community-centered engagements. (65) Therefore, multi-faceted approaches that bridge sociological and psychological approaches with medicine will build social consciousness in the community to actively reduce the effects of stigma and guilt that arose during the pandemic.

Conclusion

From a sociological viewpoint, stigmatization and the labelling of infected COVID-19 individuals can lead members of society to fear potential forms of discrimination that result, not from illness per se, but the way that others perceive COVID-19. This stigmatization has had several important consequences, including delayed care-seeking and diagnosis, which posed barriers to compliance with public health guidelines and further affected members of the society in uneven ways.

The psychological effects of isolation have also been varied. Misinformation, combined with stigma, have amplified feelings of anxiety, post-traumatic stress, confusion, and anger, particularly in some ethnic groups such as the Asian community. Front-line workers became particularly susceptible to stigma-induced stress-related disorders, which were compounded by over-work, long hours, and a lack of adequate medical care and equipment.

The literature highlights how various forms of guilt have played a role during the COVID-19 pandemic. It can be prosocial and lead individuals to report infections and counter misinformation, while in other cases it has led to an increased number of psychological disorders.

By synthesizing evidence from sociological and psychological viewpoints and elucidating the role of “stigma” and “guilt” during the pandemic, this paper proposes that— while complying with public health guidelines— healthcare providers, governments, and institutions need to continue to focus on inclusiveness, social cohesion, elimination of misinformation, and preparedness towards mitigating the effects of stigma and guilt for social compliance in healthcare settings.

Acknowledgements

I am especially indebted to Brian F. O’Neill for inspiring me and giving me his generous support for the conception of this project. I would also like to thank the University of Illinois at Urbana-Champaign, Department of Bioengineering for fostering an outstanding academic environment for undergraduates.

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