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

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: