Mortuary Work: The Risks
The anticipation of stress by a mortuary worker before handling remains is influenced by three factors: the condition of the remains, the emotional link between the viewer and the remains, and any perceived personal threat to the worker, such as physical occupational hazards. It has been established that both experienced and inexperienced workers exhibit higher levels of distress when anticipating handling remains.
Exposure to remains is a risk factor for experiencing intrusion and avoidance symptoms associated with PTSD. Pre-post responses of military men and women mortuary workers from the Persian Gulf War revealed that symptoms worsened for both experienced and inexperienced workers who had the most exposure. When exposed to the dead for extended periods of time, inexperienced workers developed somatization symptoms (a physical manifestation of stress through emotional responses, via the mind-body connection).
According to one study involving Holocaust Museum workers, contact with the deceased's personal effects can mediate the period and type of exposure to death. Workers’ adaptive strategy of remaining impersonal fails when they humanise the dead, increasing their personal distress. This is also true for workers who must accept personal effects in hospital mortuaries. Items must be meticulously recorded and accounted for during admission/release, and are typically either released with the body or claimed as a dutiable item from cashiers. At times, various departments on behalf of families (such as social work and counseling services) request that certain items of clothing, heirlooms, and other keepsakes be placed with the decedent; however, due to a lack of understanding, little regard is given to mortuary staff, who must maintain an impartial and emotionally impersonal mindset.
The nature of stress from exposure to traumatic death at Dover Air Force Base Mortuary following a military air disaster in 1985 revealed that exposure to sensory stimuli, children’s bodies, female combat deaths, natural-looking bodies, and so on increased post-traumatic stress for workers. Workers’ coping strategies changed depending on their level of exposure and experience. Most workers considered therapeutic assistance “unacceptable” after being exposed, fearing negative consequences such as job loss. In general, this appears to be the case in Australia as well. When speaking with paramedics, it was implied informally (to myself) that if one was unable to maintain emotional composure, they should not be employed in their vocation.
In one study, it was determined that anticipatory stress increased among inexperienced workers and women prior to handling remains. This suggests the need for “inoculation” training to deal with emotional attachment, personal threats, and the gruesome nature of autopsy procedures. As a result, a similar concept of “gradual exposure” is considered in Australia. However, this concept is frequently overlooked when considering the availability of staffing resources in relation to the ebb and flow of workloads.
The long-term effects of stress on mortuary workers after a disaster are a factor that is more frequently discussed, as disaster victim identification (D.V.I.) operations typically employ those who are not ‘seasoned’ mortuary workers. The high levels of distress experienced following D.V.I. operations are more frequently reported; perhaps to provide additional coverage of an event by the journalists involved? Some operatives continued to report disaster stress after 20 months, implying that post-disaster body handling involves a complex interaction between environmental and task stressors, job competency, perceptual and/or emotional defenses, management, and follow-up support. Psychological support in the form of grief counseling and other forms of debriefing is well provided for those participating in these multi-national operations. In comparison, piecemeal services are provided to those who experience exposure. The conundrum lies in the fact that most mortuary workers see little value in the practical application of these services due to a lack of academic research in this niche area, and the lack of credibility of those implementing such services.
As indicated in other research, because of the nature of their work and their exposure to deceased victims of violent deaths, forensic mortuary workers are at a high risk of depression and other psychiatric disorders. A study conducted in South African mortuaries provides important context here, considering the high murder rate. Here, it was shown that inexperienced mortuary workers have a higher risk of depression than experienced workers, but PTSD prevalence remains similar. The question remains whether the overall quotient of stress experienced by the worker comes from the work itself or whether additional personal factors involving stress outside of the workplace (for example, stressful home life, financial stress, etc.) may affect the overall propensity for PTSD, anxiety, and other psychiatric conditions. It is no surprise that promoting mental health awareness and providing mental health preparatory training for inexperienced mortuary workers could be beneficial. However, government and privately run mortuary environments are rarely resourced with the means to address such issues, and it is rare that others outside of the environment would even consider such factors.
The stigmatisation of clinical and funerary mortuary workers by those outside their working environment is another factor that can have an impact on mental health. Due to a lack of understanding from family members, friends, and the community at large, they are frequently forced to use practices such as role-distance, dark humour, and their own sense of professionalism to overcome the social stigma associated with their work.
Cultural marginalisation may also occur in certain racial groups, depending on their cultural beliefs, attitudes, and, more broadly, their superstitions about death. Many cultures consider dealing with deceased individuals to be ‘taboo,’ and may label those who show care for the dead as “unclean.” Unfortunately, stigmas like these, combined with the general public’s misunderstanding of the psychological needs of those who work in the mortuary environment on a daily basis, frequently result in self-medication through pharmaceutical and recreational drug use, alcoholism; leading to other forms of addiction.
The lack of mental health support highlights the need for future programs and genuine, comprehensive mental health treatment services for mortuary workers. It has been proposed that by utilising Critical Incident Stress Teams and behavioural interventions to address traumatic stress experienced by mortuary and healthcare workers, a reasonable level of mental sobriety may be achieved. However, those who have no familiarity with the mortuary setting, no prior exposure to frequent death, or no comprehension of the general psyche of the target population typically implement these recommendations. Then, of course, traumatic stimuli must first be identified to be managed; the complexity of this concept increases with the fact that each individual has different triggering factors.
It has been proposed that the importance of mental health support for mortuary workers be approached through a three-tier model focusing on personal, logistical, and organisational guidelines. In Australia, little effort is being made to implement any form of preventative mental health care for mortuary workers. Simplified mental health programs are usually only available as a form of mitigation in government health facilities. During my career, I have witnessed a high percentage of staff experiencing mental disturbance, including my own episodes. When considering administration of post-care, each have lacked one fundamental aspect: the inability of those charged with the authority to implement required resources to either understand the issues enabling accurate recommendation of programs and services, and/or the failure to recognise that the workplace-culture itself is a major contributor to stressors. All issues have been dealt with in a reactive rather than proactive/preventative manner, often exacerbating the issues.
Effective mortuary technicians are observant individuals who are adept at detecting variations and inconsistencies. In this regard, they are often hesitant to participate in any form of preventative program due to the following factors:
- The perception of generalised preventative programs being overly simplistic, uncontextualised, and therefore, inappropriately futile,
2. The foreknowledge of the mitigating nature of such implementations,
3. Concerns about confidentiality,
4. Stigmatism that may arise when participating in such programs. Their colleagues and/or other stakeholders, may perceive them as unwell and unable to adequately perform their duties.
Mortuary work is fraught with health risks that cannot be engineered away for the environment. Infections, exposure to dangerous, foreign objects, chemicals, and the multitude of potential psychological risks mentioned previously, insist that efforts be made to foster greater awareness, regulation, and standardisations in the mortuary environment.
Although more needs to be done to address many of the factors previously addressed in this article, positive advances have been made in the mortuary space. For example, hospital scrubs are now the unofficial uniform of the modern clinical mortuary worker, and the provision of adequate equipment across all forensic and anatomical pathology departments contributes to the safety and health of mortuary workers. To complement these measures, immunisations are freely offered, and adequate equipment is available across all forensic and anatomical pathology departments to contribute to the safety and health of mortuary workers. When considering the implemented response to the COVID-19 pandemic, the aspects surrounding the immunization/vaccination of workers have become polarizing and have led to a greater stress burden for mortuary workers.
Mortuary waste management has also been shown to be a source of stress for some mortuary workers. However, with the National Association of Testing Authorities (NATA) accreditation of government mortuary operations in Australia, this issue would be limited to mortuary workers in lower socioeconomic settings. Laboratories work very hard to maintain their accreditation status, and there is often a strong desire to comply in order to remain legally operational. While waste management is only one aspect of the rigorous accreditation process, proper management and disposal of mortuary waste are critical for controlling disease transmission (data can be found for both India and Bangladesh, in this respect). Some Indian mortuaries were discovered to have a high proportion of inadequately processed hazardous biological waste, a lack of adequate storage facilities for bodies and waste, and untrained workers who were not adequately educated to process such waste.
Conclusively, there is a critical need for independent and confidential counseling practices for mortuary staff, as well as awareness programs and mental health support to address the risks, hazards, and challenges associated with their work. Since the COVID-19 pandemic, many Australians have relocated to locales perceived to have more temperately controlled pandemic responses. As a result, spike populations have formed, resulting in increased mortuary workloads in these general areas; simply put, more people equates to more deaths. With the well-known overbudgeting aspects of the COVID-19 response, mortuary workers in these now heavily overpopulated areas are now also suffering burnout due to a lack of staffing. “Just get more staff,” one might think, is the obvious solution. However, this is never a simple solution. New mortuary personnel are a critical investment. Multitudes of people express a strong interest and enthusiasm for mortuary technician roles, but it is rare to find those who can deliver.
To be an accomplished mortuary technician in Australia, one must have:
- the ability to work autonomously in small teams that are frequently understaffed,
- a meticulous eye for detail,
- exemplary dexterity and a reasonable level of physical strength and stamina
- a recognition of jurisprudence and levels of confidentiality
- a high level of discretion
- an array of specialised techniques at their disposal that may only be used occasionally,
- exemplary customer service skills when dealing with the bereaved and other stakeholders,
- the ability to cultivate their own psychological coping strategies and techniques for identifying, coping with, and monitoring their own levels of mental health.
Overall, despite the fact that forensic and anatomical pathology departments are well funded, technical clinical staff are underpaid, frequently face staffing and other resource supply issues, and bear the burden of substandard facility maintenance without the availability of adequate monetary allowances for on-the-job risks.
Despite the foregoing information, mortuary workers continue to provide an essential service in an environment where the rules have been developed without an adequate understanding of stark realities, often at the expense of their own psychological detriment.
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