Posted on by Dr. William Vlach · 1 Comment

Sometimes You Gotta Fold ‘Em

An increasing part of my clinical work has to do with loss:  loss of social connection, employment, retirement; personal mobility, plans for the future.  It can be as simple as loss of a hug.  Or as complex as loss of identity.   Or as painful as loss of a love one.  Or even the feared loss of one’s own life.

Like with the ideas around resilience, there are moments we can stop, breathe, and figure the next step.  Holding on tight or bounding on have never served me well.  A moment in traffic after being cut off turned into a mini stupido Grand Prix, until the guy in front slammed on his brakes.  I rear ended him.  My car was totaled and his fine.  And it’s my fault.  Clearly, I needed a to take a brake, both metaphorical and real.

Take a break or have a break, I figure. Easier said than done.  And what kind of break?  A breather?  Or perhaps retire from the field all together.

Two of my oldest and dearest therapist friends have given up their offices because of the pandemic issues.  Norita (spouse and co-therapist) and I are currently paying to hold onto an office we are not using.  Paying for a placeholder.  Retire?  Move to full time teletherapy?  Easy to forget to be grateful that I even have the choice.

So let’s say you have spent years helping and guarding the city, the county, the state, the nation.  Your identity is profoundly connected to being a protector, whether it is as police officer, the service, firefighter, medical worker, social worker, or therapist.  You are our guardians.  And in this long term pandemic, you’re getting tired.  Now what?  Hold ‘em?  Fold ‘em?

Written by a 23 year old Don Schlitz, it took two years of trying to sell the song “The Gambler” before it was picked up.  Kenny Rogers recorded it, sending the song to spectacular heights.  It has been selected by the Library of Congress for preservation in the National Recording Registry.  Clearly, for Don, it was a good decision not to fold ‘em.  

You’ve got to know when to hold ’em
Know when to fold ’em
Know when to walk away
And know when to run…

When to hold ‘em, when to fold ‘em

Kind of like Hamlet’s ‘To be or not to be.’  Perhaps a bit less intemperate.  What are the factors in deciding whether to hold ‘em or fold ‘em?  

Having been hit with severe economic issues after my father died, (ranch to a small single parent home), my own approach is inevitably economic first.  Is a different life style sustainable?  Would I have to cut back things that are meaningful to me and my family?  Will the kids be okay?  We have been blessed with a solid financial advisor to help with that one.  Still not easy.

The psychological aspects are even more complex.

 In an earlier blog I proposed a series of emergent roles in this pandemic: The Guardian, The Opponent, The Isolate.  These were complimented with subsidiary roles:  Placater, Egoist, and The Chaos Creator.  Let’s see how these roles play out in the face of “hold ‘em or fold ‘em.” 

The Guardian:  Here is the ‘First Responder’ whose work is to be protective, vigilant.  Our society cannot proceed safely without these folks.  And here, I would argue, you would find those who would have the worst time with “Fold ‘em.”  Yeah, I know, towards the final quarter of one’s career there is the constant watching the retirement clock, rumination about the pension, griping about management, and all that.  But, still, when push comes to shove, the Guardian will show up, take risks that most would avoid, and get the job done.  Lots of folks in this role have dedicated their lives to saving lives, protecting the innocent and helping survivors.  The question for the guardian becomes— if I ‘Fold ‘em,’ who am I?  What good am I?  What value do I have?  And even more painful — have I failed those that I was born to protect? The victim.  The city itself.  And the flip side of that is— If I ‘hold ‘em’- put off retirement, put off a lateral transfer, etc., won’t I just burn out?  Make an error that will get me fired… or even worse?  

The Opponent:  This one might be better named The Contrarian.  I’d guess every Department, company, cohort, family has its share.  Who knows why?  Maybe for the species to survive we need those who say— “This is BS.  I’m not going to try and capture that saber tooth tiger with a couple of sticks and a rock.”  In any case, ‘Fold ‘em’ for this role is equally difficult.  The Contrarian finds identity in opposition.  There’s energy and ego there.  ‘Fold ‘em’ means not going to battle anymore, arguing against.  Let it turn out however it may.  Give up.  

The Isolate: Of all these roles in the pandemic, I’d bet The Isolate would have the easiest time letting it all go and withdrawing from the field.  The Isolate never wanted to go out and play ball in the first place.  More interested in drawing on their own resources.  The Isolate will have a harder time re-emerging into society when this damn pandemic gets a vaccine.

Knowing when to ‘fold ‘em,’ (move, quit, retire, transfer) is a tough call at any time.  Now it is particularly rough.  More than any time in the last 100 years, the future social, cultural, economic course of this country is unclear. 

Hold ‘em is a gamble.  Fold ‘em is a gamble.

Some thoughts on steps:

  1. Start with ‘what do I need.’
  2. Check in with family, friends, therapist, 12 step sponsor, etc. 
  3. Be prepared to grieve (either way there will be losses).
  4. Take a look at, maybe make a list, of what is pushing you out, what’s pulling you.
  5. Look at both the positive and negatives of the next step.
  6. And remember, stay or leave, neither will be perfect.  Both might be ‘good enough.’
  7. And if figuring this out becomes obsessive, grab the remote and switch the internal channel to mute… for a bit.  
  8. A lot of times, a simple bit of action helps- a drive, a kind act.
  9. How does hold ‘em, fold ‘em match up with my innate values?
  10. And let’s not forget Mark Twain:  “Good decisions come from experience. Experience comes from making bad decisions.” 

Go easy, folks

Posted on by Dr. William Vlach

Relationships During Times of Stress- III

I’ve mixed feelings about the idea of ‘stages’ in psychology.  A whole world seemed to open up when Elisabeth Kübler-Ross presented her book- On Death and Dying.  At last a road map on the pain around death.  She postulated a five stages of grief model: Denial; Anger; Bargaining; Depression; Acceptance.  The thing became so popular it was a adopted as a framework in a movie about the choreographer, Bob Fosse (All That Jazz, 1979).  Even though I liked the guideposts, I had doubts.  They didn’t seem to match up with my experience around my father’s death when I was twelve.  All I remember was a long tunnel filled with a dark fog.  And from there, those five, in no particular order, and a few more…Then, of course, I felt some shame that my grief didn’t match up with the way I was supposed to feel things.

The argument about the power of cycles and stages is a big deal in Western philosophy, goes back to Classical Greece.*

In the first essay on the Pandemic I spoke of the stages of a community response to a natural disaster—Shock, Heroic, Honeymoon, Disillusionment. Right now, I’m trying to figure out where we are. And, figure where I am on the individual’s reaction to stress stages—Alarm, Resistance, Exhaustion.  There is also the stages of a First Responder’s career— Heroic, Cynical, Resilient.  These all seem pretty close to how it works, but they are not necessarily sequential.  They are not for everybody.  Gender, culture, class, and many other things play into this.  We are not locked into these sequential stages. 

In the discussion on roles, I ended up with— there are powerful pulls toward being a certain way (genetic, class, culture, history), they might even go from the possible to the probable, but they are not mandated.

Given the urgency of the pandemic and the social crisis, many families have had to re-form themselves without the outlet of schools, friends, couple date nights, etc.  First responders, work groups, and roommates the same.  This creates increased intensity. Pressure cooker city. There will be meltdowns.

So let’s take a look at Stages of Group Developement in this time of Covid and social crisis.  Again, these are ‘tendencies,’ not absolutes.

 The classic social psychology work on group development suggests several stages:  Forming, Storming, Norming, Performing, and Adjourning.  In each stage, various roles come into play such as Leader, Follower; Counter-dependent, Dependent, Independent, etc. 

Group Stages:

Forming:  Folks are unclear on what the goals are, what the roles are, who are the leaders, what the boundaries are.  There can be poor morale, poor listening, and low commitment.

Storming: Emotions that were disregarded at the beginning surface.  Arguments about boundaries, leadership, and power are abundant.    Cohesion and consistency are low while anger, resentments, and power struggles ascendant.

Norming: coming out of the conflict of the Storming Phase, members move toward ‘rules of the road.’  This is the way we do things.  Folks increasingly listen to and take each other into consideration.  Leadership issues, while not necessarily solved, are calmed.  Assertiveness is rewarded.

Performing:  After the earlier struggles, Folks relax into taking care of business.  Tasks tend to be less fraught with power issues.  There is increased creativity, openness, flexibility and pride in the group. 

Adjourning: The crisis looses its urgency and the intensity of the pandemic and social /cultural crisis decreases, folks return to the world.  Here there is a sense of loss, and hopefully, a sense of respect for their history together as well as respect for lessons learned.

There is a great hope in both role and group development models.  The roles we have become attached to are in fact flexible and can be dropped like a three day old halibut.   What seems like an intractable unproductive family, work group, is best seen as a thing in transition.  It is helpful to name the stage. This is especially true now in this time of monumental global change.

So today, I’d say I am in the Disillusioned, Exhausted, Group Storming stage, with a touch of Acceptance. Mañana? I’m planning on the Group Performing and Resilience Stages. We’ll see…

We are not stuck. This may be good time to take a look at the role you play, the stage your family, roommates, work group might be in.  Where do you want it to go?  What role do you want to play?  What do you need?

Step back and take a look.

Go easy, folks.

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* In Western philosophy, the argument about stages goes back to Plato.  He theorized there were several forms of societies that evolved from each other, tyranny, meritocracy, democracy, etc., ending in rule by the Philosopher King (presumably him and his buddies).  That stage idea went even further in the cycles of history theories of Giambatistta Vico (Theocratic->Aristocratic->Democratic, then Chaos leading back to the first). Karl Marx’s stages of society ends in a classless and free society.  Sure, right. Arguments against these political deterministic cycles of history were led by Karl Popper (The Open Society and Its Enemies).   Camus also weighed in for freedom from stages in his arguments with Sartre about Marxism. 

I guess I am with that great Marxist, Groucho, who proclaimed— “Be open minded, but not so open minded that your brains fall out.”

Posted on by Dr. William Vlach

Understanding Relationships During Times of Stress- II

“All the world’s a stage,
And all the men and women merely players.”

-William Shakespeare

There are masks and there are masks. We put on masks to slow the process of disease transmission— us to them, them to us. And, we put on an identity mask everyday.

In an earlier essay— Negotiating Relationships During Shelter in Place—I  explored the tension between a compliant response to the health care mandates, and the ‘lone wolf’ individualistic/rebellious response.  In the blog on children, the stress and strategies of the protective parent/guardian was explored.  Let’s take a deeper look at these masks, these roles.

As we grow up, for a lot of reasons, we assume certain roles.  Much of adolescence is devoted to trying out new ones, discarding one and trying on another, until it seems to fit.  Then we glide along in that role through adulthood.  Misfortune can hit (divorce, illness, trauma, midlife crisis, etc.)  which then can make us question— is this role Really right for me? Does it really fit?

Beginning in the 1970’s there was a lot of work in the family therapy field on how family roles play out in various contexts:  the alcoholic family (Rescuer, Persecutor, Victim), the dysfunctional family (Blamer, Distractor, Enabler, Computer), culture and ethnicity variables (Mexican, African-American, etc), gender (male/female, fluid), birth order (oldest sib vs youngest), adult children of alcoholics (The Responsible One, The Adjuster, The Placater,  The Acting Out).

I got a National Alcoholism and Alcohol Abuse (NIAAA) grant in graduate school.  We explored the roles around addictions.  I was struck with the flexibility of roles  The ‘rescuer’ can switch to ‘persecutor’ and back again.  The ‘victim’ can switch to ‘persecutor’.  It seemed to me then, and now, that there is a certain hope in that.  We are not absolutely stuck in a position.   Since then there has been an explosion in biomedical research.  We have powerful genetic and neurological pulls for certain behavior.  Got that, but still, there is an aspect of role theory that gives us great potential for change, for shifting roles.  For example, though the eternal struggle between Nature and Nurture is a delightful battle ground for social scientists, the research usually comes down to percentages:  there is a possibility/probability  given your genetic background, you will be a leader; and there is also the possibility/probability given your birth order, you will become a leader.  Kind of a crap shoot, I’d say.  One’s role is possible, perhaps probable, but not mandated. There is freedom in role choice.  Therein lies hope.  But that choice comes down to awareness of one’s role and whether we want to stay there.

Context:  after the Industrial Revolution, new roles developed.  Some were now paid, others not.  That added to the power issues between men and women: wage earner and housewife.  Throw in race.  Throw in class.  Throw in immigration status.  Throw in unemployment and the lack or benefit of ‘access.’  Some aspects of role are socially bound.  And this, of course, goes to what can we change, what we cannot, and what we have to fight for.  And against.

Some of the roles that seem to have surfaced in this pandemic and time of social crisis:

  1. The Guardian:  This is the one who is constantly checking the ‘north forty‘ to see if everything is safe.  Has the perimeter been breached?  In a covey of quail, there is one who sits on a fence post looking out for trouble, the vigilant one, the protector.  The strengths of this role include leadership, care for others, responsibility,  protectiveness. The weakness here can include a loss of empathy for other’s feelings, fear mongering, loss of self protection, and excessively controlling behavior. 
  2. The Opponent:  Here is the contrarian.  If you tell me what to do, even if it is in my interest, I’ll fight it.  Instead of- I think therefore I am, the rule is – I rebel therefore we are (thank you, Camus).  Here we may have the counter-dependent, and at worst, the oppositional personality.  If there is going to be a fight between the different people in the family, roommate, work group, it will be between The Guardian and The Opponent- ‘That’s not safe’ versus ‘You can’t tell me what to do.’  Not fun.  The strengths of this role include a critical thinking about the situation, a push toward returning to normalcy.  The weaknesses lie in knee jerk reactions, an undermining of the direction of the whole group, and inattention to potential dangers.
  3. The Isolate:  When there are so many dangerous winds blowing, some will simply retreat.  Back in the 50’s, school children were told if the school gets hit with an atom bomb, the best thing to do is to ‘duck and cover.’  Hide under your desk, or crouch down directly below the classroom window (the blast will blow the glass over you… yeah, right…). Here retreat is the solution.  Decrease in contact with friends and family as well as community connections.  The idea behind this is that one is safer out of contact with the ongoing pandemic threat and the societal crisis.  The strengths of this role include a certain self sufficiency, an effort to access one’s own resources.  The dangers are loss of support, loss of long term resilience, and depression.

There seems to be ancillary roles also:  The Placater (working to avoid conflict, people pleasing, ignoring one’s own needs); The Egoist (it’s all about me, what can I get out of this; the Chaos Creator (can’t stand calmness, stirs up anything that can be stirred up).  

The key issue here is that roles are not absolute.  They can change.  We are not stuck;  there is the opportunity for growth.  For example, families and groups (roommates, work partners)  are not static.  The group can form over years (family) or can be created spontaneously (police squad or a demonstrators’ cohort).  The point here is that as the group develops, various roles come and go as well as leadership styles. More on group development next….

If you can, stop for a bit.  Do an inventory:

  1. Does this role fit?  Is there something uncomfortable about what I’m doing…is there anxiety, guilt, shame?  A touch too much pride?
  2. Does this match up with what my dreams were when I was younger? What’s the difference?
  3. Am I drinking too much, other addictive behaviors, numbing something important?
  4. Are the conflicts I’m getting into seem ridiculous after I settle down?  (I’ve been there, done that!)

Go easy, folks.

Posted on by Dr. William Vlach

Resilience in the Pandemic

Earlier I wrote about the stages of the first responder’s career.  For the police it seems to be a journey from the heroic to the cynic to, hopefully, the resilient.  Fire fighters, doctors, nurses also follow a similar pattern.  This pattern tends to be parallel to the psychological stages of reaction to a disaster, such as this pandemic. So let’s take a look at resilience.

When I first heard the term I thought it was like a football player who takes an enormous hit, doesn’t even feel it and keeps going. Nope, that’s not resilience, that’s being a refrigerator.

The  word resilience came into use in the 17th century, came from the Latin resili, meaning to spring back, to rebound.  The Latin roots of the word offers a clue to a deeper meaning:  re and salire.  ‘Re’ in Latin means again; salire means jump.  Resilire: jump again, spring back.  From that word came the word resile, Now here is the crux of the matter.  Resile is defined as: to abandon a position or a course of action.  For example, ‘can he resile from the agreement? And from there, resilience.

So the way I see it, being resilient is— do, abandon that position and then jump back, rebound.  Stephan Curry shoots with the intent that the ball will go in.  He drops that plan when the ball bounces off the rim. Then he leaps, grabs the ball, and shoots again.  In it goes  (Yay, Steph).  He has abandoned the first plan, regained his composure about the loss, and shoots.  Here is resilience: do, fail, do again differently.

This pandemic is a long term crisis that will continue until there is a vaccine, prophylactic drugs, or, as in HIV- a cocktail of meds that will ameliorate disastrous results.  Epidemiologists say that ‘herd immunity’ is not a viable options because by the time that is reached  the mortality rate would be far too high (tens of thousands of deaths just in the Bay Area).  In other words, resilience in the pandemic is less 100 yard dash and more marathon.

In the flush of adrenaline, in fight/flight mode, the basketball player, the ER nurse, cop,  doesn’t have the mental space to consider our reactions of ‘well, that didn’t work, how do I feel about that?’  Far too busy dealing with death and destruction.  This has nothing to do with resilience.  This is athleticism.  This is warrior mode.  This is override for the greater good.  

The danger, of course, is that this is a potential set up for more problems down the road.  If the deep emotional reactions to the  ‘abandon the position‘ step is denied, there is the potential for long term consequences.  Running over the top of pain and grief by denial, numbing, re-entering the fray without acknowledgement can bring trouble.  I know how this works.  After my mom’s awful and sudden death, I quickly went back to work.  The irony, was of course, my work has to do with helping folks process the very emotions I was running from.  That glossed over grief turned into depression and ultimately got me back into therapy.  Thankfully.

This three part scheme of resilience (do, fail, do again differently) includes a very human reaction to the the fail-loss part. This can include anger, self blame, shame, and all kinds of other nasties. For some, there is a denial that can create psychological stress, and others a paralysis about the loss. And others: an acceptance and increased tolerance for that loss. A healthy resilience, I’d argue, in this pandemic, means to acknowledge the losses (a family member, patient; loss of social connection and touch; loss of economic stability, etc). Ideally, one grieves that loss, then takes the next shot. Doesn’t have to be in exact sequence. But, without that pause, this resilience may be short lived. That crucial ingredient has been glossed over. Burn out, irritability, depression may easily follow. And then attempts to fix that problem rather than the original one can lead to alcohol, drugs, sexual acting out, etc. Fall out from the not dealing with the grieving.

I’m not suggesting in the middle of the shift. Maybe not even when one gets home after shift. Or at the end of the week. But at some point— acknowledge the losses. Dealing with this damn pandemic takes a lot of control…letting go of that in a safe place helps. This sets in motion a healing process that will pay off as the crisis eases.

Building resilience is not rocket science… it’s mostly common sense.  Going back over almost a thousand years, Arabic medicine recommended a healthy diet, exercise and fresh air.  Sounds good to me.  These are basics to building resilience.

What to do/what not to do:

What doesn’t kill you, MAY make you stronger— if you do something about it.  If not, it will make you weaker.  For example here’s a recipe for doing damage to yourself:

  1. Get angry, resentful, ‘it’s their fault,’ I deserved so much better than this.
  2. It is my fault. I shoulda woulda coulda, etc. etc. etc.
  3. My life is turning into an ongoing streaming of “The Lord of the Flies.’ No one gets along. We’re an episode of Ozarks, without the pretty lake.
  4. Everybody is toxic: stay away. I am alone, and I want to stay alone.
  5. I’ll watch everything on Covid on the TV… that’ll help my nerves.
  6. Numbness to the fear is a good thing—bring on the booze and drugs.
  7. Do not laugh at anything. People are dying.

In fact, none of these are bad, simply in and of themselves.  For example, the first one, anger, if turned into positive political action can help recreate this damaged world.  Even the self blaming second one, with a little thought, can lead to alternative strategies going forward.

Remember the ancient Arabs’ recommendations : a healthy diet, exercise and fresh air.  Here are some more ways to build resiliency:

  1. The jangled body needs to slow down and rest. I don’t think I’ve ever seen so many people fishing the ocean here before. Maybe build something in the garage. Try a meditation app. Yoga if you like; go birding. Get yr partner to give you a bad ass massage.
  2. It would be sweet if building resilience could be done on our own. Not so much. In a safe place with safe friends, a partner, open up. The emotional build up from the fail-loss part of do, fail, try again, is toxic. This is the key moment of healing.
  3. Laugh. Yeah, it’s awful. And it may look, if you’re not in a safe environment, that you are cold and inhuman. In a safe place: Feel free. The grief, love, care, frustration, and pure pain can come out this way. Try not to get fired. (I’ll deny I ever met you…)
  4. I’ve a couple of friends who are on a mission through this. Their goal: Spot one kind thing a day. Probably not on TV which can be pretty cheesy and gamey. At work. In the neighborhood. Believe it or not, on the road. It’s there…. if you look for it.
  5. Meaning- see the earlier blog.

Go easy, folks

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check out these for more info:

http://www.apa.org/topics/resilience

https://www.mayoclinic.org/tests-procedures/resilience-training/in-depth/resilience/art-20046311

https://greatergood.berkeley.edu/article/item/five_science_backed_strategies_to_build_resilience

Posted on by Dr. William Vlach

Moral Injury and Morale in the Pandemic

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: