 Bereavement professionals such as funeral directors, embalmers, cemetery workers, crematorium operators, and their support staff may regularly engage with diverse, potentially psychologically traumatic events. These exposures can lead to a variety of mental health injuries, including post-traumatic stress disorder, major depressive disorder, panic disorder, and alcohol use disorder. Recent research has provided important information about those experiences, such as the scope of the challenges, the potential impacts on mental health, factors impacting health, and some of the opportunities to help protect mental health and provide support. Dr. R. Nicholas Carleton, a professor of psychology at the University of Regina and a registered clinical psychologist in Saskatchewan, introduced his discussion on challenges, strategies, and coping by emphasizing that it was really an introduction to mental health. MENTAL HEALTH EXISTS ON A CONTINUUM“There’s a long-standing notion that we are either mentally healthy or mentally unhealthy and none of the data bears that out,” Dr. Carleton explained. “It’s simply not the case. Most of us, throughout the course of a day—and certainly throughout the courses of weeks or months on end—we shift along a continuum from healthy, to having reactions, to possibly being injured, to being ill or meeting diagnostic criteria for one or more mental health disorders. And this is normal.” Odds are that people probably experience changes in their mental health throughout the entire day. Dr. Carleton described a scenario where someone wakes up in the morning and everything is fine and that’s terrific, only to move on and have somebody cut them off in traffic, and for a few minutes, they might be reacting—might even be “injured” for a few moments—but they recover very quickly and then they’re at work and moving on with their day.  environmental backdropRight now, all of us are sharing a massive significant environmental variable that’s impacting our mental health—and that’s COVID-19. The impact of the pandemic is underlying all of the other things that impact us, including our biology. If we’re sick, if we have a flu, if we have a cold, that impacts our mental health. If we’re healthy and we’re exercising regularly, we’re active, that impacts our mental health and our mental health impacts our physical health as well. If we’re not feeling very happy about something, if we’re worried, if we’re depressed or down, that has a reflection in our physical capacities. We also see those same kinds of challenges with respect to our social environment. If everything is going well with our friends and our family and we’re regularly engaged, that also serves a protective function so that we’re more likely to feel physically healthy and we’re also more likely to feel psychologically healthy. Our biology, our psychology, and our social environment all come together on an overlapping Venn diagram that sits on top of our environmental stressors. it's not weaknessDr. Carleton informed listeners that it’s also important to remember that mental health has nothing to do with inherent weakness. “We have no evidence that says that there’s one gene or one feeling or one thought or one behavior or one experience that is solely responsible for our mental health or mental state. And certainly not for having difficulties with mental health,” he said. “When we talk about people who are having difficulties with mental health in most cases it’s a function of high stress or chronic strain or physical exhaustion and maladaptive coping all coming together to challenge an individual’s experience.” He pointed out that anyone can develop symptoms, saying, “At the end of the day, even the most resilient of us is still human. We still experience all kinds of highs and lows in our lives.” DEATHCARE AND MENTAL STRAINMoving on to talk about potentially psychologically traumatic events that might apply specifically to some of the work that deathcare professionals perform, Dr. Carleton spoke of experiencing, witnessing, or learning about something potentially injurious to a close relative or a friend that may cause mental health injury. He said that other potential events include repeated exposures to distressing details of significant threats such as exposure to war, threatened or actual physical assault or sexual violence, kidnapping, hostage-taking, torture, and mechanisms of severe physical injuries, like motor vehicle accidents and industrial accidents. “You’re exposed to these things because if someone dies as the function of one of these events, the last responder is you and so you are exposed to these on a regular basis,” he said. “As a species humans are generally resilient and adaptable. So even these kinds of events, when we’re exposed to them, we can bounce back, we can recover. Most stressors—even repeated exposures to these kinds of events—are not typically overwhelming. But you have to remember that our experience of whether something is overwhelming is influenced by our biology, our psychology, and our social environment, as well as what’s happening behind the scenes in our broader environmental variables.” Dr. Carleton was talking specifically about events that are potentially psychologically traumatic. He said that the most common thing we think of is post-traumatic stress disorder (PTSD) when we think about a mental health injury. PTSD can be one thing that happens following exposure to one or more potentially psychologically traumatic events where we don’t bounce back, where we aren’t able to be as resilient in that moment because of any number of things that have come together. It’s a mental health injury for which there are effective treatments that can provide symptom relief for a great many people and it’s one of the disorders that can follow exposure to the kinds of traumatic events Dr. Carleton listed. It’s also not the only mental health injury or disorder. Major depressive disorder is actually more common, even among people exposed to these ongoing potentially psychologically traumatic events. “There are also difficulties with substance abuse and dependence disorder,” Dr. Carleton explained. “You’re taking the substance for longer than you expected. You’re taking the substance in order to avoid or manage symptoms that you’re having or to change your emotional status. The problem isn’t necessarily volume. It can be the amount that someone’s consuming. But more often than not, the challenge can be that one drink might be too many and ten might not necessarily mean there’s a problem. It depends on how you’re using and what you’re using for. And if you’re using as a function of trying to manage other symptoms, that’s a good indicator that you can probably benefit from some additional support. It’s not the only indicator, but it’s certainly one of them.” Dr. Carleton underscored that only licensed qualified experienced persons can and should diagnose disorders or imply diagnosis. “Dr. Google gets us part of the way there in some cases, but that’s not super reliable,” he said. “If you’re looking for help with mental health or you’re concerned about your mental health, you want to talk to a registered, licensed, evidence-based mental health care provider who can provide you with information about where you’re at and possible solutions to get you to where you’d like to be.” SYMPTOMS AND WARNING SIGNSDr. Carleton turned to discussing some of the urgent warning signs and symptoms. First, he pointed out that if any symptom lasts longer than a week, at that point it’s a warning sign that your symptoms may benefit from some intervention, particularly difficulties with falling or staying asleep, intrusions, numbing, changes in your behavior, or sudden increases in substance use. Those are also potentially urgent warning signs and symptoms. Suicidality, homicidality, violence, or sudden dramatic increases in substance use should all be taken as urgent warning signs where it’s time to get in to see somebody soon. “It doesn’t mean necessarily that we need to call 911, although that is a possibility,” Dr. Carleton said. “It does mean that help is needed sooner rather than later.” HOW CAN MANAGERS AND COLLEAGUES SPOT SIGNS OF BURNOUT AND ENCOURAGE PEOPLE TO SEEK HELP? According to Dr. Carleton, the more open you keep communications, that peer connection, can help. But if you identify big behavior changes—someone normally jovial now lashes out, as an example—it’s a good indication that you should check in with them. The more engaged you are with your team with regular communication, the better positioned you are to support them. mental health is a journey“What can you do? Well, I think first and foremost it’s important to keep in mind that mental health is a journey, not a destination,” Dr. Carleton advised. “It’s not something you check off as a tick box because you did it well today, any more than physical health is.” He encourages deathcare professionals to monitor both their physical and their mental health. “We have tools that we make publicly and freely and anonymously available on our website for our public safety personnel, and those tools might be beneficial for you as well,” he offered. “They allow you to compare your responses to the general population, and, in doing so, you get immediate anonymous feedback that you can use to see where you are sitting relative to everybody else.” Because changing mental health requires culture change because of stigma and misinformation, it’s extremely difficult and takes a long time to accomplish. Dr. Carleton believes it’s important that we all pay attention to the idea that mental health is something we’re trying to change at a population level, but he pointed out that for people who are regularly exposed to potentially psychologically traumatic events, they may very well be forced to engage with culture change more directly than everybody else. He encouraged listeners to engage in ongoing monitoring regularly and get help sooner rather than later. self-careWhat can we do in addition to the monitoring? The doctor advised people to look to their social support. “Talk about your experiences. Not necessarily about the details of what happened in your job and specific day, but how you’re feeling and what else you’re doing in order to manage those feelings. If you’re having difficulties with the symptoms we’ve discussed, talk to family or friends. Make sure that you keep a regular diary so that you can watch what changes for you that supports or undermines your mental health.” “As cliche as this sounds—and it sounds cliche in part because we all keep saying it—engaging in regular healthy behaviors enhances your coping ability and helps to maintain your mental health,” he continued. “So, exercising regularly, even light exercise: simple walks, getting outdoors, 20 minutes. Any exercise at all tends to be beneficial as long as it’s regular.” Dr. Carleton added that people should watch what they eat. Eating healthy is important because the highs and lows of sugar affect your biology, which impacts your mental health as well. Substance use and misuse is much more problematic and a much more slippery slope than most people realize. If, for example, you’re using alcohol to manage your emotions, that’s a good indication that there’s a better set of skills you can access to manage those emotions. He also emphasized that, where possible, it was important to maintain routines, even in the face of COVID-19. “The more routines that you can build in, probably the better off you’re going to be, as long as those routines include strict work-life balance where possible,” Dr. Carleton said. “As a professor, I can tell you that the boundaries between my work and my life are permeable at times. They’re permeable most of the time, but it’s important to try and manage those separations because that’s what’s helping to protect and sustain your mental health. So making sure that you’re managing that is an important part of living an ongoing happy, healthy career.” Last but not least, Dr. Carleton addressed early evidence-based interventions. “Evidence-based interventions are evidence-based for a reason. It’s because they’re helpful. It’s because they’re beneficial and there’s proof, there’s research that says that they work.” He spoke of the importance of finding the right type of practitioner to offer those interventions. “Psychologists is a protected term. So is psychiatrist. But counselor, therapist, and healer are not protected, which means that anyone can take them—and there is a lot of variability among them. That doesn’t mean there’s not good counselors, therapists, and healers. It’s just that there are a lot fewer restrictions on those names and titles than there are on things like psychologist or psychiatrist. So I recommend you demand registered and licensed, experienced, evidence-based, empirically-supported mental health care (which is a mouthful!), but you can find that from colleges, registered provincial associations, and registered state associations.” HOW CAN WE SUPPORT EACH OTHER IN OUR OWN GRIEF?Dr. Carleton said that grief is a unique thing and shared the work of Dr. Katherine Shear on Complicated Grief. Grief is not something that’s clearly defined—you don’t have clear phases or end-point. Grief can last an entire lifetime, ebbing and flowing throughout, and in many cases it does. Grief in and of itself isn’t a problem, it’s not something to cure since it’s part of the human experience. If grief is leading to difficulties with destructive behaviors or debilitating, interfering with your job, then maybe seek help to better manage the symptoms of grief from an evidence-based professional. But grief is part of the human experience. While it’s not a pleasant emotion, it does also remind us to value all of the things we have right now because of the things we’ve lost before. With shorter days, family obligations, and a job that doesn’t recognize the change in seasons, the holidays can be the biggest strain on our profession. Combine that with a global pandemic and a surge in cases and taking care of yourself and your colleagues is more important than ever. With that in mind, Funeral Professionals Peer Support (FPPS) and CANA came together in mid-December of 2020 to help deathcare professionals gather the tools needed to keep working by offering a free webinar with expert presenters who shared strategies to address the challenges faced on the front lines during the winter months. CANA’s President W. Scott Smith addressed his experiences with the high number of COVID-19 cases in Texas. Dr. R. Nicholas Carleton, an expert on mental health on the front lines, highlighted strategies to identify problematic symptoms, suggested coping skills to help, and provided recommendations for engaging professional supports when needed. Visit goCANA.org/webinars to view a free, on-demand version of the complete webinar. Now, CANA and FPPS are coming together again to host a peer support meeting for deathcare professionals of all roles and experiences. Learn more about this meeting and mark June 22, 2021 on your calendar for this valuable meeting.
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