From: The American Funeral Director 120 (4): 26, 30, 32, 34, 54, 56, 58. 1997 April.

AFD SPECIAL REPORT

Critical Incident Stress Among Funeral Directors

BY JOHN M. KROSHUS, PH.D. AND STEVEN TIBBETTS, M.A.

Fast Facts Funeral directors must cope with a high level of work-related stress, but the issue is ignored and unaddressed in funeral service, a study conducted by the University of Minnesota mortuary science program found. In a survey of Minnesota licensees, funeral directors reported they had experienced irritability, frustration, and apathy - all symptoms of critical incident stress that the survey's authors say are cumulative and ultimately devastating. In an article in the quarterly Journal of Mental Health Counseling, John Kroshus, of the Minnesota mortuary science program, and his collaborators wrote: "The [survey] results indicate that a relatively high percentage of respondents reported moderate to severe levels of symptoms commonly associated with critical incident stress following exposure to events that were outside the range of human experience." Among the authors' recommendations: Support networks should be set up within funeral service to provide funeral directors opportunities to talk about the stress in their work. Funeral service families with one or both parents involved in stressful work should have access to therapy. Funeral service education should inform students about the stress associated with being a funeral director and tell them about resources

The involvement of funeral professionals in the aftermath of disasters has been extensive and important, but at what price?

Funeral directors have been identified as one group whose exposure to critical incidents can be frequent enough to cause the development of symptoms of stress and/or illness (Curley and Curley, 1991). It stands to reason that when critical incidents are frequent, stress levels can be expected to be higher. Post-traumatic stress disorder might also be higher in funeral service.

Recognizing these implications, the Program of Mortuary Science at the University of Minnesota gathered statistical data on critical incident stress among funeral directors.


Questionnaire:
Methods and Procedures

Methods and Procedures: A questionnaire was developed after a review of the literature on stress, critical incident stress, and post-traumatic stress disorder. Data gathered from the questionnaire enabled researchers to analyze how critical incident stress affects funeral directors.

The questionnaire included an explanation of the term critical incident in order to focus responses toward particular events respondents had experienced, and several questions were intended to gather demographic data.

Funeral directors were asked to indicate the number of times they had been involved in specific types of critical incidents. They were given a list of 14 events (for example, homicide, suicide, accidents) considered to be critical and stressful, and asked to report the frequency they encountered them.

Funeral directors were also asked to report the frequency they experienced symptoms associated with critical incident stress. They were given a list of 25 symptoms (nightmares, irritability apathy, for example) and were asked to respond via a frequency scale (1 = very seldom; 2 = seldom; 3 = undecided; 4 = often; 5 = very often).

The questionnaire was sent to 1,325 persons licensed as morticians by the Minnesota Department of Health, and 762 usable surveys were returned, for a 57.51% response rate. Anonymity was guaranteed by coding data in a manner to protect respondents' identities.


Results

Respondents were predominantly male (93.7%) and ranged in age from 23 to 88 years, with slightly over half (50.39%) between 30 and 50. Three hundred six respondents (40.16%) identified themselves as working in a "metropolitan" area, and 428 (56.17%) worked in a "rural" area. Twenty-eight respondent (3.68%) did not clearly identify themselves as either metropolitan or rural.

Metropolitan funeral directors reported higher exposure to industrial accidents, explosions, boating accidents, SIDS deaths, airplane accidents, motorcycle deaths, and homicides. Rural funeral directors reported higher exposure to auto accidents and farm accidents.

As might be predicted, all responding funeral directors with over 20 years of experience reported a higher exposure to all variables, with two notable exceptions. Funeral directors with over 20 years of experience did not report a higher exposure to SIDS deaths and suicide. Also, some with fewer than 10 years' experience reported as high an exposure to suicide as those in practice for 20 and 30 years.

Differences were noted in symptomatology reported by funeral directors in the survey. A higher incident of symptoms was reported by a subgroup of 100 funeral directors, or 7.6% of the 1,325 funeral directors who received a mailing, and 13.1% of the 762 funeral directors who responded.

Demographic characteristics of the 100 funeral directors in the subgroup paralleled the core group of 762 respondents, with the exception increased symptomatology 30- to 39-year age group.

The subgroup was 95% male and 66% rural. For those who had in the funeral business for more than 20years, irritability (94.4%) and frustration (94%) were reported most often.

Both symptoms are commonly associated with critical incident stress. Among this same group, sexual impotence was reported least often, although it is a symptom commonly associated with critical incident stress.

Further analysis showed that in the subset of 100, those funeral directors with 20 and fewer years' experience had significantly higher mean scores for: fear of being abandoned by others, feelings of isolation, and excessive concern over their physical well-being, when compared to funeral directors with more than 20 years of experience.

For funeral directors in the subset of 100 with more than 20 years of experience, a significantly higher mean score was recorded for apathy compared to those with 20 years or less.


A Model for Intervention

The results of the survey indicate that a relatively high percentage of respondents can be considered to display moderate to severe levels of symptoms commonly associated with critical incident stress, following exposure to stressful events at work.

Ironically, longitudinal data collected from salary studies conducted by the Program of Mortuary Science at the University of Minnesota reveal that funeral directors ages 30 to 39 (the age range of those indicating higher levels of symptoms associated with critical incident stress) are more likely to "drop out" of the funeral business than any other group (University of Minnesota. 1991). One can speculate that this "drop out" rate agrees with the authors' assertion concerning the stress experienced by this group

No direct cause-effect relationship can be drawn from these data, but they suggest that for some funeral directors stress may have an effect on their lives. And if vulnerable groups of individuals can be identified, they can be targeted for help.

CRITICAL INCIDENT STRESS SYMPTOMS

Insomnia	Unresolved grief
Frustration	Loss of objectivity
Nightmares	Apathy
Disturbed memory	Sexual impotence
Withdrawal	Anger
Depression	Deteriorating relationships
Irritability	Phobias
Emotional callousness	Fear of being abandoned by others
Apprehension	Meaninglessness
Survivor guilt	Confusion / disorganization
Hopelessness	Excessive concern about one's physical well being
Loss of appetite	Resentment that others fared better
Isolation	Increased drinking/ smoking

While additional research needs to be conducted to ascertain whether the survey findings are general, we believe mental health counselors should structure their intervention and educational programs to focus on the following issues: irritability, frustration, fear of abandonment, feelings of isolation, excessive concern over physical health, and apathy.

In order to provide counseling assistance for such clients, the following intervention strategies are recommended:

(1) Funeral directors should have access to ongoing open group therapy, providing an opportunity to discuss and explore the stressors in their lives.

These groups should be patterned after what we already know. In response to earlier studies of emergency personnel and their exposure to critical incident stressors, critical incident stress debriefing teams have been organized in many metropolitan areas.

These teams meet following an emergency situation and provide an opportunity for all members to "unload" their reactions, fears, and memories, and to affirm the enormous impact such events can have. Such sessions can be immensely helpful, and may also serve to identify those who need more in-depth mental health counseling. The authors recommend that group interventions for funeral directors follow the same pattern used by critical incident stress debriefing teams.

(2) Funeral service needs to establish networks of support for funeral directors whose work is emotionally demanding and whose profession requires that a "strong image" be portrayed to the community at large. Support networks can serve as an important adjunct to group counseling, because they also provide the opportunity for funeral directors to probe and share their concerns. The creation of networks can be facilitated by bringing funeral directors together with other interested parties, such as priests, ministers, rabbis, psychologists, physicians, and nurses, to work toward mutual support and respect for those in stressful careers.

If professionals are reluctant to establish such networks, an initial step may be to offer workshops on critical incident stress that would require group interaction. This could be a first step toward cooperation in the future. Workshop participants could explore how networks could be set up.

(3) The profession should be particularly aware of families in which one or both parents are in stressful occupations. The importance of family therapy techniques in treating people strongly affected by work-related stress cannot be overestimated. Funeral directors do not live in a vacuum: they have family contacts, social contacts, and business contacts. When a funeral director's ability to function is affected by one or more critical incident, the impact is manifested on many different levels. Family therapy techniques that advocate the inclusion of people on these different levels are, in the authors' opinions, essential in many cases.

(4) Finally, funeral service must consider developing a curriculum that addresses the stressful nature of the profession by teaching prospective funeral directors about the potential hazards of their work and providing the means to get necessary support at the beginning of their careers. This preventive strategy is consistent with the general aims of good mental health.

Conclusion
The emotional cost borne by funeral directors as they prepare individuals for burial and guide bereaved families through the beginning phases of grief is too often unrecognized. The job exacts a toll frequently manifested by a reduced ability to work and can become serious enough to cause disease, dysfunction, and ultimately death. It is the authors' opinion that the funeral service profession can provide the needed expertise to enable funeral directors affected by stress to cope effectively with the demands of their career.

Finally, there is a need for community education to demystify the funeral profession. The funeral director is a multitalented person, subject to the full range of human emotions - feelings of sadness, hurt, and loneliness. Education can promote a greater understanding within a community of the various stressors confronting funeral directors. Promoting this type of understanding can ease the use of mental health services by funeral directors, while avoiding the stigma that might have otherwise been associated with seeking help.

CRITICAL INCIDENT STRESS DEFINED

A 1988 U. S. Surgeon General's report predicted that 80% of people who do not die from traumatic causes will die from a stress-related disease. While this estimate may appear high, studies linking stress and the subsequent development of symptoms and/or illness have generated a significant body work on this subject. (Lazarus, Delongis, Folkman, & Gruen, 1985; Rathus, 1990.) As a result, several theories and models have been developed to illustrate the link between the pathological nature of stress and the development of disease.

The concept of critical incident stress arose while those theories and models were being applied to studies of emergency workers. Researchers began to differentiate normal life stress from the stress encountered because of critical incidents experienced by emergency workers. (Everly, 1989.)

According to Mitchell and Bray, critical incidents are experiences that produce major "distress" within the individual. "...They are so powerful that they can easily overcome a person's normal ability to cope with the stress of the job." (Mitchell & Bray, 1990, page 29.)

Anecdotal evidence indicates 80-85% of emergency workers develop acute or delayed symptoms commonly associated with critical incident stress. (Mitchell & Bray, 1990.) Symptoms can occur in many different forms.

Some forms common to the experiences of funeral directors would include intrusive and unwanted mental images or thoughts that affect attention span and disrupt concentration. There is mounting evidence that traumatic events may be powerful enough to imprint themselves in the biochemistry of the brain. A slight stimulus (unrelated to the critical incident) may trigger a biochemical reaction in the brain, which in turn initiates all the thoughts and emotions and, sometimes, even the physical responses that were present during the actual incident.

FACTORS THAT CONTRIBUTE TO POST-TRAUMATIC STRESS DISORDER 1. The closer an individual is to the actual event, the greater the chance that they will be affected. A majority of torture victims develop PTSD, but only a small percentage of those who witness the torture will develop PTSD. 2. Those who have no experience dealing with excessively stressful events are more prone to develop PTSD. 3. Stess is a cumulative phenomenon. If a person has other significant stressors in his life (death or illness of a loved one, pregnancy, etc.), a critical incident may set the stage for the development of PTSD. 4. What hidden meaning does a particular incident have for the emergency worker? Frightening memories and experiences, or unresolved losses from the past may resurface after a traumatic event. 5. Past difficulty in dealing with anxiety/pressure will be compounded in response to a traumatic event. 6. The amount of help available immediately following the event, how receptive the individual is to that help and the level of support available from co-workers and supervisors may impact the outcome. 7. Inability to communicate with and receive support from family members, significant others and friends will complicate the person's coping mechanisms.

Mitchell and Bray (1990) found that 3-4% of the emergency workers they surveyed experienced ongoing problems and were diagnosed as having post-traumatic stress disorder (PTSD). PTSD is characterized by the development of symptoms following a psychologically distressing event that is outside the range of usual human experience - such as, seeing another person who has been seriously injured or killed as a result of an accident or physical violence. (American Psychiatric Association, 1987, p. 247-248.)

Like emergency personnel, funeral directors can also be called to the scene of a murder, suicide, auto accident, drowning, fatal fire, childhood/infant (SIDS) death, farm/motorcycle accident, explosion, electrocution, plane crash, boat accident, natural disaster, or industrial accident.

Symptoms of a reaction to stress may not occur for some time. Delayed stress reactions are recognized by the existence of intrusive images and bothersome thoughts that come into the mind without being invited. They distract the individual, affecting attention span, concentration, and other cerebral functions. These thoughts are generally ruminative and focus on the past incident.

When the thoughts enter into the mind, they reenact the anxiety and discomfort that was present at the scene of the accident. Such intrusive images slip into awareness via nightmares and daydreams, or through auditory, visual, and olfactory impulses. People who have been present at a traumatic scene may re-experience smells, such as the odor of death, blood, feces, gun powder, jet fuel, or other noxious reminders without stimulation from another exposure. (Mitchell & Bray, 1990.)

From the information regarding acute and delayed stress reactions, Mitchell and Resnik (1981) developed a list of symptoms that are commonly associated with critical incident stress. Critical incident stress is characterized by self-reported symptoms that may include any or all of symptoms that appear in the box on page 34.

Delayed onset of PTSD is very difficult to predict, particularly in this culture where "big boys don't cry" and grizzly national and international atrocities are considered prime time entertainment.

Updated August 23, 1999 by Webmaster