Climbing out of the Valley

On a trip out West many years ago, I sat across the aisle from a man who described himself as a “change-management professional.” He worked for a Fortune 100 company and would be sent to locations all over the world where fundamental change to work-life was anticipated — a new factory opening, the implementation of a novel mechanization process, or the sale of a business sector. His role was to help the employees adapt to the new reality of their professional life. In many cases, the people who were undergoing the change had little control over the initiation of that change.

It is a testament to his articulate and thoughtful nature that I still remember, more than a decade later, one of his fundamental lessons. He told me that change has three phases. First there is uninformed optimism; next, informed pessimism; and finally, acceptance. “Think about it,” he said. “Doesn't this pattern explain so many things? Think of your last relationship, your new job, or even going through chemotherapy.”

While my airplane neighbor articulated only three phases, I've since come to know that he was summarizing the work of two psychologists who published in the 1970s. Drs. Don Kelley and Daryl Conner described five emotional stages of voluntary change, and hopefully I am not being too reductionist by summarizing their work: Following 1) uninformed optimism and 2) informed pessimism, one can next detect 3) the valley of despair, 4) informed optimism, and finally 5) success and fulfillment. The chronology is important, and not everyone gets to the end. Notably, from what I understand, this model was developed to describe voluntary change, not necessarily the changes that arise from events that are out of our control. Nevertheless, it recently occurred to me that one could easily apply this model to partially illustrate our course through the past 20 months of the pandemic. And if we do try to fit the events into this model, what can we learn about ways to emerge from these events productively and with fulfillment?

Clearly, the initial months of 2020 were the time during which we defined the problem. We all learned what a coronavirus was. We had the phrase “flatten the curve” drilled into our collective consciousness and came to realize that it wasn't just the tragedy of death that we needed to confront but the critical lack of medical resources and community coordination. And yet, I might argue, that this was also a period of uninformed optimism. What else but hope can explain the phenomenal number of clinical trials that were introduced; the deluge of signs supporting postal, health care, or civic workers; and the anecdotes about surviving the blitz and successfully emerging on the other side. These are all acts of optimism and hope. Despite the fear and the anxiety, I remember very clearly thinking, “Well, it's just three months of lockdown, and then things will get back to normal.” In these very pages, I wrote about buckling down and “getting to work,” as though the pandemic were a problem that could be worked away.

At least in the United States, it was the fall of 2020 when informed pessimism set it. By autumn, we all knew what it felt like to watch patients die alone, to have to cancel weddings and reunions, to enforce draconian visitor policies, and to try to remain deaf to the frustrations of our young people. Even in regions of lesser impact, we all watched our patients die. And nothing seemed to work. Early hyperbole about potential treatments proved misguided, and it appeared that most patients had only luck, age, and the vagaries of fate to thank for their survival.

In my opinion, the final months of 2020 and the first months of 2021 have been our valley of despair. With a record-breaking number of deaths, fear and pessimism have led to what they often produce — the abrogation of charity and neighborly kindness and in its place, the adoption of nihilism. I think some of us “checked out” at this stage (perhaps a form of resilience). Others found hope in causes that felt more familiar such as voicing support for social or political change. I remember the day that I first read about the vaccine trials and pending approvals; for me, this was the first peek out of the valley.

So, have we emerged? I am writing this in early August, as the Delta variant burns through our Southern states and there is continuous resistance to vaccination in communities all over the country. Patients who are immunosuppressed and fail to respond to vaccination are especially vulnerable. While May and June were glorious days of opening up, now hospitals are beginning to fill again, disparities in care persist, and burnout is especially pronounced. Can we trek out of the valley of despair and move into informed optimism even now?

I think the answer to that is yes. What if we took what we learned about health disparities during the previous two months and really applied those lessons in the future? What if we were able, from now on, to run clinical trials with fewer barriers (e.g., allowing telephonic consents, local lab draws, fewer in-person trips to the trial hub)? What if we made permanent the logistical changes that allowed large groups to coordinate on research? Could we continue the stunning collaboration that we saw with the trials on convalescent plasma or registries on cancer patients? What if we were able to replicate the incredible speed that we saw in vaccine development? And what if we could learn from our mistakes in education and distribution and fix those the next time?

As I constructed this column, I remembered the final part of my conversation with the man on the plane. He said that while the initiation of change is often out of our control, the results of that change can be molded and controlled by our emotional response. In short, events happen to people, outcomes happen because of people. That seems like a lesson we can all use right now. It's time for some informed optimism and persistence. Let's start climbing out.