From March 2020, psychologists began to publish warnings that medical staff working through the height of the pandemic, perhaps faced with difficult choices and almost certainly higher patient mortality than usual, should watch for and guard against the symptoms of what they called ‘moral injury’. They warned that if left unchecked, it could lead to longer-term mental health issues.

Moral injury can be defined as psychological distress resulting from an action, or inaction, that the individual perceives as being against their own moral or ethical code. The concept originates in the military, with the term itself being coined in the 1990s by psychiatrists working with Vietnam War veterans. More recently, even pre-COVID-19, it has started to be applied to the healthcare profession, for example to junior doctors working in an under-resourced NHS, and other professions including police and firefighters.

Might it be time to consider whether, with the unprecedented challenges 2020 has brought, those in the funeral profession might also be experiencing moral injury – and if they are, what can be done to alleviate it?

The symptoms

The first thing to say when considering moral injury is, despite the somewhat dramatic sound of the term, do not panic. The symptoms that it describes are actually a normal response to extraordinary circumstances. That’s not to say they aren’t very distressing they can include, but are not limited to, feelings of guilt or shame about something the person did or didn’t do, or observed; feelings of anger or directing blame; self-doubt and low self-esteem; feeling haunted and anxious; withdrawing socially; possible misuse of drugs or alcohol. Although some of the symptoms are similar to those of PTSD, it does differ as PTSD is largely a fear-based condition, a sort of severe anxiety relating to a past trauma. Moral injury is more about processing the judgment of one’s own conscience, and it is not currently classified as a mental illness or a clinical diagnosis. However, it can have some profound effects and early intervention is a good idea.

The impact on staff

We know that funeral directors and their staff have been severely tested by the pandemic. Their ways of working have had to undergo fundamental changes meaning they could not offer the full service they would normally take such pride in; funeral arrangement meetings taking place remotely; loved ones not able to view the deceased or touch the coffin; an increase in direct cremations; no limousines or family funeral cars; restricted numbers present at the funeral or no funeral service at all.

While funeral staff and others who work alongside death are no strangers to difficult emotions, supporting families during stressful and upsetting times, their role usually involves making a terrible situation more bearable in whatever ways they can. Under the restrictions of COVID-19 it has fallen to them often to break bad news to an already grieving family; rather than ‘we’ll do everything we can’ to give them the send-off they want for their loved one, the conversation has had to cover all the things they couldn’t do.

Most independent funeral directors would say their work is a vocation rather than a career, certainly, it is far more than a job. They are passionate about providing excellent care and doing their very best for every family they serve. COVID-19 has stripped some of their capacity to do that. What’s more, they have likely been exceptionally busy over the last few months, leaving them at greater risk of the effects of stress and burnout – which can skew our perception even more and add to that sense of never quite being or doing enough.

What can employers do?

So, some funeral staff could naturally be left feeling that they could, or should, have done more, even if in reality they couldn’t. Employers can help prevent or assuage these feelings with regular supervision and peer support. Being around others in a similar situation, with whom you can have honest and open conversations and a regular informal ‘debrief’, is one of the best guards against work-related stresses – of which moral injury is simply a very particular type. Feeling well supported and understood by your peers is so valuable at any time but especially right now.

The nature of moral injury however, and it’s implicit in the name, is that it can feel intensely personal (it’s about your own moral compass, and your behavioural expectations of yourself) and can quickly progress to shame rather than guilt. Whereas guilty feelings present as ‘I did something bad’, shame presents as ‘I am bad’. It is inherently more problematic and by its nature more secretive.

So the supportive employer may need to turn detective: look for the regular signs of somebody struggling at work (e.g. persistent absenteeism), but also be aware of ‘presenteeism’ – which is characterised as being at work a lot, maybe more than usual or than is required, perhaps as an attempt to assuage feelings of guilt or shame or not being good enough.

It is a good idea to have some sort of external employee support or assistance programme that your team can access in confidence if they need to. Some of the negative feelings that present with moral injury (commonly anger and blame) may be directed towards the employer or colleagues, so it can be helpful to acquire an external, neutral perspective, such as the SAIF Support helpline.

Most people will emerge from the difficulties of the last year without any long-lasting effects. In fact, although there has been nothing totally comparable to this pandemic in our lifetime, in the aftermath of previous large-scale traumatic events such as terrorist incidents or massive accidents, many frontline responders and professionals involved have been found to experience ‘traumatic growth’ – so out of terrible events, they might learn or develop something positive. However, if individuals and organisations can be aware of the symptoms of moral injury and seek help quickly if they seem to linger or dramatically worsen, then with care, it’s an injury from which it’s very possible to recover.

Steps to reduce symptoms

Before

Use of frank, open and honest dialogue to prepare staff for the challenge ahead of them. This will help manage their expectations and avoid disillusionment. Encourage emotional ‘offloading’ and self-disclosure of experiences of moral challenges garnered from caring for families. Make staff aware of moral injuries and encourage the use of a support network or peer support programmes.

During

Ensure staff are not avoiding discussions of emotionally challenging instances, as this can be a sign of trauma, e.g. avoiding or not attending meetings. Support (or refer to a team leader) if staff become overly distressed as this can be a sign that other things have been building up below the surface. In more severe cases a specialist may be more appropriate to support them. In larger set-ups, senior management should be particularly mindful of the health and wellbeing of managers who are supporting frontline staff, as they themselves may start to experience moral injury.

After

Offer a positive reframing of the crisis, where it is reflected on and learned from, as opposed to being a traumatic event better forgotten. Active monitoring of staff enables quick identification of those experiencing moral injury. This allows efficient signposting for early interventions. Treatment for moral injuries should include discussion of shame and guilt; topics which the patient may try to avoid

Written by Joanna Williams, Head of Counselling at Professional Help Ltd for SAIF Insight Magazine October 2020