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Ask an Expert: What Is COVID-19 Survivor’s Guilt, and How Can I Cope With It?

Pedestrians in flu masks walking in city - stock illustration.

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Jaime Zuckerman, PsyD, is a Philadelphia-based licensed clinical psychologist in private practice who treats mood disorders, anxiety, adjustment to medical illness, and relationship difficulties. Dr. Zuckerman breaks down the concept of survivor's guilt and how it's manifesting during the pandemic.

While millions of people have recovered from COVID-19, they aren’t always left unscathed. Some can’t breathe the way they used to; others never regain their senses of taste and smell. And for many, there’s a certain scar inscribed by survival itself—the remorse of surviving when others did not. This is survivor’s guilt: a concept coined in the 1960s to capture the guilt that many Holocaust survivors grappled with, and one that still trails tragic events that take some lives and spare others.

With COVID-19, there are varying degrees of survivor's guilt. It manifests itself in life versus death scenarios, full recoveries versus partial ones, and even job security versus unemployment.

Dr. Zuckerman spoke to Verywell on what COVID-19 survivor’s guilt can look like and how to cope with these feelings of shame.

Verywell Health: How can COVID-19 trigger survivor’s guilt in people who recover?

Dr. Zuckerman: Typically, survivor’s guilt is directly associated with loss of life. However, it can also apply to situations where someone escapes injury or illness, while others are not as fortunate. COVID-19 and its relation to potential survivor’s guilt is complex and multilayered. The virus’s contagious nature and unpredictability make its connection to survivor’s guilt somewhat unique.

It is not uncommon for an asymptomatic COVID-19 positive individual to infect another person who then develops obvious symptoms. Should this infected person become gravely ill or die, the asymptomatic person may then experience some level of survivor’s guilt. They may feel an overwhelming sense of responsibility and guilt for potentially being the “cause," while there are so many other extraneous variables that would have contributed to the severity of illness or death.

Characteristics of Survivor’s Guilt

  • Physical symptoms such as stomach pains, headaches, and joint pain
  • Difficulty falling or staying asleep and restless sleep
  • Flashbacks of the traumatic event or near-death experience
  • Irritability and anger
  • Substance abuse to suppress uncomfortable emotions
  • Feelings of helplessness, hopelessness, and worthlessness
  • Suicidal ideation
  • Depression
  • Anxiety disorders, including PTSD
  • A chronically overactive nervous system
  • Social isolation
  • Low motivation

Given COVID-19’s rapid spread, it has been an unfortunate, yet common occurrence, that entire families fall victim to this virus. Tragically, in some cases, one or several family members end up dying. Not only does this scene set the stage for someone to develop survivor’s guilt, but it is further compounded by the fact that the deceased are members of the same family.

Another scenario unique to COVID-19 is the development of long-term symptoms known to leave many with chronic pain, cognitive impairment, pulmonary issues, and heart disease. Those who had COVID-19, yet were fortunate enough to be spared long-hauler symptoms, may begin to think, “Why not me? Why didn’t I get these long-term conditions?” Watching their loved ones suffer while they seem to have almost arbitrarily escaped these symptoms can foster an intense amount of guilt, anger, and helplessness.

Given hospitals’ precautionary measures, patients are not allowed visitors, making it difficult for family members to effectively advocate for their loved ones. This again sets the stage for survivor’s guilt thought processes to develop: “If I was there, maybe I could have done something.” Family members may feel as if they failed their loved ones in their time of dire need.

Another example of survivor’s guilt unique to COVID-19 is the response of frontline workers to the repeated exposure to loss of life. Many healthcare workers are reporting early symptoms of PTSD, particularly survivor’s guilt.

Lastly, there is the issue of the COVID-19 vaccine. Think of a healthcare worker who receives the vaccine, but their family member does not. Their family member then ends up in the hospital with COVID-19. This is yet another scenario unique to COVID-19 that could possibly trigger survivor’s guilt, leading to thoughts such as: “That person died because they didn’t have access to the vaccine that I took from them.”

Verywell Health: What are the symptoms of survivor’s guilt in relation to COVID-19, and what can it lead to if left untreated?

It is important to understand that, while devastatingly painful, survivor’s guilt is a normal grief response to a tragic situation. Some people are better able to effectively manage this guilt, while others have more difficulty. While anyone can develop survivor’s guilt, there are some variables that may place people at higher risk, such as a history of childhood trauma, PTSD, depression, low self-esteem, and being higher in dependency features (i.e., always putting others’ needs before your own).

Survivor’s guilt can become a vicious cycle of irrational thought leading to intense anxiety, fear, and depression. It can significantly impact self-esteem and one’s sense of self-worth. It can also lead to numerous physical conditions, most notably chronic pain. Those who resist seeking treatment are at much higher risk to abuse substances and are at increased risk for suicide.

Verywell Health: What is your best advice for coping with COVID-19 survivor’s guilt? What are some coping strategies?

Dr. Zuckerman: It is not possible to think your way, or simply talk your way, out of guilt. This only keeps us stuck in our heads, taking us out of the present. You must feel your feelings, as guilt is a normal and appropriate grief response. The more you attempt to ignore or suppress these emotions, the more overwhelming and pervasive they become.

Seek help: It is not uncommon for people who experience survival guilt to believe they do not deserve therapy because they do not deserve to get “better.” However, you cannot do this alone. Attempting to resolve such heavy guilt within your own head leads to increased rumination, irrational thought patterns, and social isolation. Acceptance and Commitment Therapy (ACT), Cognitive Behavior Therapy (CBT), or Eye Movement Desensitization and Reprocessing (EMDR) can be highly effective in the treatment of survivor’s guilt.

Mindfulness exercises: This is extremely effective in helping people learn to sit with their discomfort until it passes rather than trying to push uncomfortable thoughts and feelings away.

Maintain a daily schedule: Adhering to a set routine helps keeps us engaged in our daily lives rather than being stuck in our heads. Be sure to schedule at least one pleasurable activity each day, even if it’s extremely small. Many times, those with survivor’s guilt feel as though it’s wrong to feel pleasure and joy. It is almost as if depriving themselves of enjoyment is a well-deserved punishment for surviving while others did not. Setting small, measurable goals composed of previously enjoyable activities allows the person to slowly habituate to this emotional dichotomy. It helps them to see that it is possible to have two emotions simultaneously (guilt and happiness) while still engaging in healthy, pleasurable behaviors.

Focus on what you do have control over in your life: Rather than focusing on their internal state, it is helpful for the person to identify the external factors responsible for the crisis. This creates a sense of objectivity and de-centering from the event and the thoughts about the event. The thoughts and feelings of guilt will not necessarily go away immediately, but you can shift your perspective of them.

Focus on self-care: Those who experience survivor’s guilt feel undeserving and selfish for focusing on themselves. Self-care can be viewed as disrespectful of the deceased. Slowly engaging in self-care tasks exposes a person to pleasurable thoughts and feelings they may have been avoiding. This helps to improve their self-worth and strengthen the belief that they deserve happiness.  

Give back to the community: Giving back or doing something nice for someone else can help reduce guilt by eliciting compassion and empathy.

Maintain social support: Social support is critical. The less social support, the more at-risk one is for developing survivor’s guilt. Support groups are an excellent way to connect to others in a safe, non-judgmental way.

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