We all have standards by which we live our lives.  Some say we blindly accept those passed down by our families and friends.  I’d argue most of us question the passed down standards as we grow up.  Starts at two years old or so.  The advent of that great word ‘No.’  Or even “Noooo…” coupled with a high pitched whine.  Drives parents nuts.  This is the first step towards the un-acceptance of received authority, the beginning of a separate individual, separate from parents.  Unpleasant process, but crucial.  ‘Me’ based on denial of your authority.

The Western tradition begins with with disobedience.  The first story in the Bible, Adam and Eve eat the forbidden apple.  From there on out they have to put clothes on and act civilized.  In the Greek origin myths, Prometheus disobeys Zeus to bring fire to humanity.  His punishment is to have his liver eaten out by an eagle.  Daily.  Forever.  Though there are plenty of stories of the acceptance of the prevailing rule, (Abraham prepares to sacrifice his son, Isaac; Agamemnon sacrifices his daughter, Iphigenia), the rebellion against received rule set up the origins of Western society.  

After the horrors of the Twentieth Century’s violence, psychology began to study how  blind acceptance of authoritarianism works:  ‘The Authoritarian Personality,’ the Milgrim Studies, the Zimabardo prison study.*  As an early college student, I first became fascinated by psychology when I read the Milgrim experiments.  Certainly fed my 60’s rebellious nature.

Later in life I was taken with the Greek Oxi Day.  Oxi, (οχι) pronounced ohi, means ‘no’ in Greek.  When Mussolini requested Greece to allow his troops to enter Greece, the prime minister denied him.  There were demonstrations in Athens where people shouted “oxi!” This is celebrated in Greece every October 28.  Oxi Day.  Greece paid the price for their ‘oxi’ by Fascist brutality.  Ultimately Churchill said about their defense:  “Hence we will not say that Greeks fight like heroes, but that heroes fight like Greeks.”

There is something compelling about a big fat oxi.  No!  I will not accept your authority over me.

But how do you say no to a pandemic?  I guess the moral choice here is— “No, I will not become one of the ill, hurt myself, my family, and overload the hospital beds.  I will stay home.”  Yet, in the wider world, there are those who have lost their jobs, health care coverage, have children to feed with no income.   What is the moral choice for them?  And the others, those who automatically say no to Public Health concerns because of their political viewpoint?

It would be nice if the moral issues in the pandemic were simple.  Virus evil, us good.  Yet, even with all the pain and suffering, now you can see blue skies above Beijing and Mumbai.  It’s complicated.

A morality based on ‘no’ is insufficient.  It does not build into a prevailing life code that includes care for others, building positivity, creating a caring community.  Plus, neurological research suggests we are hardwired for empathy. “The ventromedial prefrontal cortex processes feelings of empathy, shame, compassion and guilt. Damage to this part of the brain, which occupies a small region in the forehead, causes a diminished capacity for social emotions but leaves logical reasoning intact” according to an article on the research (LA Times, 3/22/2007).

Much of my clinical work has been working with those suffering from Post Traumatic Stress Disorder (PTSD).  In this pandemic, I’ve written on methods to prevent PTSD.  Though the concept of PTSD facilitated a clearer understanding of what psychologically injured folks are going through, it can miss a subtle, but crucial variable— the moral dimension.

Moral distress, moral injury, and moral repair.

Beginning in the 1990’s, writers and researchers have added the moral aspects to the understanding of trauma.  While the current treatment approaches to PTSD are mostly effective, they do not work with everybody. In fact, research now suggests that work with PTSD for some that does not include the moral dimension may be deleterious.  Further, in early neurobiological research, one can see the differences between PTSD and a moral injury in brain scans.

Moral Distress occurs when one knows the moral action to take, but feels powerless to take that action.   Taking that action may be limited by the internal (fear, doubt) or the external (no clear effective approach, failure of leadership).  Here is what one believe one should do, but can’t. Moral Injury is characterized as the result of being forced to engage in actions contrary to one’s moral values; a violation of what each of us considers right or wrong.  

These are wounds that are derived from damage to a person’s moral foundation.  These moral crises are not based on fear as is PTSD.  One of the tools psychotherapists use to treat PTSD is exposure therapy— easing one into remembering the traumatic event to decrease the emotional storm.  For the morally injured, this brings no relief, and can intensify the pain…and shame.

In this pandemic, we are all in a perpetual state of moral distress.  We see the mounting death toll among the elderly, the weak, the wounded, the poor. We may be at risk ourselves.  We may be on economic survival mode.  We may not be able to see a clear path to help.  So we are stuck.  

Hence, moral distress.  And moral distress over time can lead to moral injury. 

According to a VA report: “Guilt, shame, and betrayal are hallmark reactions of moral injury. Guilt involves feeling distress and remorse regarding the morally injurious event (e.g., “I did something bad.”). Shame is when the belief about the event generalizes to the whole self (e.g., “I am bad because of what I did.”). Betrayal can occur when someone observes trusted peers or leaders act against values and can lead to anger and a reduced sense of confidence and trust.“ https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp

The idea of stages of psychological reaction to this pandemic includes the cynical/disillusion stage.  Here is where folks may experience depression, burn out, exhaustion.  A part of this may include ongoing moral distress moving toward moral injury.  The cognitive dissonance between what we feel we should do and what we actually do eventually overwhelms.  Our morale drops.  

Let’s talk about moral repair and resilience in a later time.  But the initial steps to sort through the moral issues here are yet again the same as dealing with the power issues: Acknowledgement, resources, strategize.

 1. Acknowledgement:  look at what you are doing and feeling.  Over watching the news and feeling anxious; avoiding all the news and feeling empty; physical symptoms can include GI issues, insomnia, headaches, nightmares.  Is there guilt? Shame?

2. Resources: Imagine what you would like to be able to do and yet can’t, or won’t. Then think it out… talk to a friend, spiritual leader, 12 step sponsor, a therapist.

3. Strategize: Be clear on what you can do and cannot do.  Note what you have been able to do.  Then consider what may be possible: donations, checking on a neighbor, nodding to a passerby on the street.  And underlying all of this— be kind to yourself… and others.. if you can.

Go easy, folks.

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‘The Authoritarian Personality,’ the Milgrim Studies, the Zimabardo prison study:

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