Doing Death Work: A Mixed Method Examination of Imprinted Events and Behavioral Responses of Medical Examiner O�ce Sta�

: This study provides a qualitative and quantitative analysis of data from interviews of current and former staff of medical examiner offices. The current and former positions of these staff members required that they arrive at the scene of natural, accidental, and intentional deaths, retrieve the body, and assist in the evisceration of the body to help a medical officer determine the cause of death. The authors interviewed 14 staff members of different medical examiner offices about what they liked, disliked, and struggled with in the job. Additionally, study participants answered questions about imprinted events, how they and colleagues responded to the job, behavioral adaptations to the profession, and views about treatment or programming to assist persons in handling this type of work. The study identified a range of imprinted events and reasons why certain circumstances are meaningful and memorable. These professionals personalize their experiences and utilize bluntness in their conversations with family and friends about life, risk, and parenting. These death workers become risk aversive, change their friendship dynamics, learn to not take life for granted, and parent and see children differently. Some participants indicated that they experience dreams and relationship difficulties. Although study participants expressed an openness for treatment and programming, this support was typically in the context of assistance for others who needed help to cope.

take calls for service where death did not occur, or a member of a medical services team who saves a life despite trauma to the body, in every case where medical examiner staff responds, there is a death. As a constant element of the medical examiner office staff's state of existence, "death work" may be more intense and consequential than other professions. Medical examiner office staff are necessary to study as a population because, as laypersons, they are uninfluenced by strong professional cultural norms of the sort that police, doctors, or nurses experience. This study reports qualitative data from interviews with medical examiner offices staff members. In addition, following Casas and Benuto (2021), the study also presents quantitative results by applying the Language Inquiry and Word Count (LIWC) framework to identify language structure and psychological states through content analysis of the text.

PROFESSIONALS' RESPONSES TO DEATH WORK AND TRAUMA SCENES
We identified nine studies that qualitatively examine different professionals' (police, medical personnel, first responders, and journalists) reactions to death work and careers that exposed study participants to trauma. Table 1 provides an overview of these nine studies. These studies are diverse in the populations they target and the scope of the findings. Some qualitative studies address professionals' views of the profession and job stressors (Dabney, Copes, Tewksbury, & Hawk-Tourtelot, 2013).
Professional and organizational culture can impact job-related performance, work stressors, and responses of death work professionals in various ways. Loftus (2010) defined police culture as craving crime-oriented work and excitement, a persona of cynicism/pessimism and social isolation, and suspicion and intolerance of those who challenge the status quo. Skolnick (1994) noted that embedded in police culture are notions of solidarity, brotherhood and sisterhood, and bravery. Police professional culture provides "the container within which officers operate, determining how they should behave, think, and feel" (Koch, 2010, p. 92). The impact of police culture on officers is not uniformly positive or negative and appears context-specific. In terms of routine death work cases, since a high proportion of death work does not involve a crime that advances to a criminal investigation, it is not a high-status job event for police officers, and senior-level officers may relegate these cases to those new to the profession with little experience (Carpenter, Tait, Quandrelli, & Thompson, 2016).
Moreover, police officers who work on these routine cases sometimes lack sensitivity when asking questions and interacting with the decedent's family or social network members (Carpenter, Tait, Quandrelli, & Thompson, 2016).
Similarly, because police culture emphasizes an action orientation and police training is lacking, officers are ill-equipped to handle the emotion of cases (Howard, Tuffin, & Stephens, 2000;Koch, 2010). However, aspects of police culture can have positive outcomes for police officers who work during major national disasters such as Hurricane Katrina, owing to the brother-and sisterhood inherent in the profession (Adams, Anderson, Turner, & Armstrong, 2011). Concerning organizational or "unit" culture in a homicide department, Dabney, Copes, Tewksbury, & Hawk-Tourtelot (2013) identified internal and organizational demands as an omnipresent feature of the culture but cautioned against a "rush to remove such visible components of homicide investigator culture" (p. 832) because of potential positive cultural impacts on enhanced police performance. While the influence of professional and organizational culture may be more pronounced for police officers compared to other death workers (Carpenter, Tait, Quandrelli, & Thompson, 2016), it contextually remains a crucial factor for others. Buchanan, & Keats (2011) draw attention to the "ways in which the culture of journalism has exacerbated the distress that journalists experience" (p. 134) in covering traumatic events. These authors further urge that "The stress of witnessing and reporting on traumatic events coupled with the practices of silencing and stigma that exist within the culture of journalism must be considered when discussing journalists' coping strategies." (p. 134) Prior studies suggest that death professionals use various behavioral, adaptive, and maladaptive techniques in response to the work they perform (Adams, Anderson, Turner, & Armstrong, 2011;Buchanan & Keats, 2011;Koch, 2010). Any particular behavioral response a person employs to deal with trauma can be either adaptive or maladaptive depending on the circumstance (Kirby, Shakespeare-Finch, & Palk, 2011).
Therefore, labeling many behavioral responses to trauma as adaptive or maladaptive is imprecise. Synthesizing the response types across the empirical studies reveals ten different behavioral strategies that death workers employ: 1) professionalism: emphasis on the occupational role and technical, mechanical, and practical aspects; 2) investment and engagement; 3) disinvestment, disengagement, and detachment; 4) communication with or storytelling to coworkers; 5) communication with a spouse or a family member; 6) physical stimulation and hyperactivity; 7) spiritual beliefs and practices; 8) humor; 9) negative emotions (anger); and 10) use of substances.
To date, the most comprehensive conceptual framework concerning death worker views of their professions, job-related stressors, and adaptive and maladaptive behavioral responses comes from Casas and Benuto (2021). Their mixed method, qualitative and quantitative analysis, noted that many first responders idealize the job, particularly by conceiving it as a public service profession ("helping others") that places the person in the middle of the action (especially for young, new to the job, professionals). Yet, there is a powerful disillusionment with the job that sets in for many, characterized by a recognition of an inability to help or save others, burnout, compassion fatigue, and lack of organizational support. In their study, these authors also sought to examine the nature of traumatic experiences by first responders. They found that early-career exposure to human suffering is particularly acute, that first responders personalize the trauma exposure, and they experience feelings of guilt, shame, and helplessness. Trauma exposure in the Casas and Benuto framework leads to psychopathology, poor quality of life, and social withdrawal. In coping with trauma, first responders rely on adaptive and maladaptive behavioral strategies and often experience a stigma toward treatment-seeking as an alternative.
Prior research identified the presence of secondary trauma on family members of first responders (Duarte, Hoven, Wu, Fin, Cotel, Mandell, Nagasawa, Balaban, Wernikoff, & Markensen, 2006). However, notably absent from these featured qualitative studies (see Table 1) is attention to how these lived experiences impact relations with family and friends. There is reason to believe death work influences relationships with family and friends. Agocs, Langan, and Sanders (2015) studied women police officers who are also parents and found that the professional lives of policewomen translate to "danger protection parenting practices" to "prevent their children from becoming victims or offenders" (p. 265). These authors noted that for policewomen, these concerns are omnipresent due to their exposure to "dangerous, gory, sad, frightening and/or traumatic situations that often have long-term emotional repercussions." (p. 278). The heightened concern for their child's well-being occurs because policewomen "see more, know more, worry more, and warn more." (p. 278) Work-place exposure influences how policewomen construct and deploy harm prevention strategies in the home. These authors found that "in contrast to intensive mothering approaches that rely on the advice of external experts" (p. 279), policewomen in the study relied on their own experiences and expertise. These women strategically approached how they "verbally account for their work experiences, always with their children's welfare in mind." (p. 279). The policewomen used a "teachable moment" strategy to discuss uncomfortable matters that many in society may deem inappropriate for children.
A related factor of interest to the current study is how these professionals personalize their experiences. Prior research on first responders gives scant attention to this issue.
Certainly, linkage of a traumatic event to one's children carries an element of personalization. Yet one may experience an event or circumstance and relate it to oneself and not one's child. The study to most directly address the personalization of trauma is Casas and Benuto (2021). They defined "personalization of trauma" as "familiarity with the victim, finding resemblances of one's own family in the victim" (p. 6). Conversely, other studies suggest that cultural norms and professional practices develop to prevent first responders from personalizing an event, particularly when the professional is in the throes of the case (Adams, Anderson, Turner, & Armstrong, 2011;Buchanan & Keats, 2011;Carpenter, Tait, Quandrelli, & Thompson, 2016;Howard, Tuffin, & Stephens, 2000;Koch, 2010). and employ open and axial coding of the qualitative data. In addition, we use the LIWC software to understand the structure of the text and the psychological processes used by medical examiner staff to describe their profession and its impacts.

PLAN FOR THE CURRENT STUDY
Broadly stated, the research questions for the current study are as follows.

Data
The data come from interviews with medical examiner staff members employed by or previously employed by an urban medical examiner office in a southern state. The istudy participants did not all work for the same medical examiner office, nor were they employed in this capacity all at the same time. The first author of this study previously worked as a medical examiner office staff member. She utilized her contacts to set up interviews with persons she knew in the field and used snowball sampling to identify other potential interviewees. participant. The study's first author made the contacts, set up a face-to-face interview at a place chosen by the interviewee, obtained permission to audio record, conducted the interview, took detailed notes, and transcribed the session. Each interview session lasted between 30 and 45 minutes. The first author collected body language and verbal cues (such as a laugh) data that a traditional transcript could not otherwise capture. In the transcript data, the authors note these body movements and verbal cues through the use of asterisks (* ____ *) embedded in the transcript text.
The positionality of the first author as a prior staff member of a medical examiner's office enabled her to establish rapport with those contacted for an interview. In addition, her previous work as a child forensic interviewer potentially reduced bias in the structure, format, and content of the questions during the interview. Each study participant got asked five questions (as well as follow-up questions): 1) things you like or dislike or personal struggles related to the profession; 2) standard and unusual ways coworkers react to the profession; 3) top two to three job-related events, incidents, or scenes that imprinted in your mind, and why; 4) how the profession impacted personal life, behavior, and interactions with friends and family; and 5) are programs or interventions needed to assist professionals in this work?

Qualitative Content Analysis
The second author read and coded the interviews. Initially

Description of Sample
The average age of the sample is thirty-nine years. Sample respondents spent, on average, nearly eight years in the profession. Males comprise a little over one-half of the sample (n=8, 57.1 percent), while females (n=8) represent forty-three percent of the interviewees. Forty-three percent of the study participants are Hispanic. The remainder of the sample is nearly equally divided between White, non-Hispanic (n=4, 28.6 percent) and Black, non-Hispanic participants (n=3, 21.4 percent). One participant (7.1 percent) reported a White, Hispanic racial and ethnic classification.
Half of the sample (n=7) were in the profession at the time of the interview. The remaining half (n=7) already exited the profession but were interviewed about their prior experiences. Eleven participants (35.7 percent) were married. Twenty-one percent of the respondents responded that they were single (n=3) and living with a partner (n=3), respectively. Two of the participants reported a divorced status at the time of the interview (14.3 percent). One participant reported separation from a spouse at the time of the interview (7.1 percent). The article provides sample descriptive statistics in Table 2. Table 3 identifies the themes and subthemes from the open and axial coding process and provides a description for each subtheme. The study participants describe their approach to the job as "being a professional" and are quick to dispel common assumptions that they are different or the job is distinct.
Just instead of being in an office and wearing high heels and a skirt, I am in a morgue, and I wear scrubs and a face shield. Well, and there is a case we are working on. But a case, I mean, that's like an IT team working together to fix a bug or something. It's no different. We are there to do a job. We are just like Well, I mean, we didn't walk around work all day saying, "oh, this is sad" and "oh, that is really scary" or "that's a really awful way to have to go," right? But you can tell people think it. You can see it in their faces and stuff. (Participant 14)  the two identified cases are events that "I remember like they were yesterday." Some were memorable due to a personal reaction. Others were memorable because of specific abnormal aspects of the scene, sensory perception details, or an unexpected case outcome.
Personal Reaction. One personal reason why respondents remember specific cases is they involve kids and the innocence of childhood. When participants referenced "kid cases," they sometimes talked about physical features of the decedent or factors that relate to youthfulness or how early the decedent was along in life (Respondent 1: "He was this handsome kid. Athletic looking … Barely old enough to drive."; Respondent 6: "She had the most beautiful head of hair."). In accident cases that involve kids, the respondents focused on randomness and the scene of the event (Participants 2 and 9).
In contrast, when the matter involved intentional infliction of abuse to a child, the focus was on what the child experienced in the time leading up to death (Participant 5).
And I guess that is one of the cases that really messed me up. I mean, kids now are rear-facing. You always see them asleep in the car seats, right? And there is a chance, I mean, it's a slim slim slim chance, but it is still possible that a kid could For three of the participants, there was a personal reaction to a fear of making a mistake (or "messing up") on the job. In each instance of this, the participant was careful to note that the case was a "first" of some sort. The instruction received from a more seasoned employee on the scene or upon arrival amplified this nervousness and fear for one participant. For a medical examiner staff member working a "first" case, the level of angst gets enhanced by the reality that (s)he must perform death work tasks in a public space.
I was sent out there when I was still really new, and I didn't really know what I was doing. I hadn't been out on a scene before … my partner is telling me stuff, like "let me tell you what to do, you just follow my lead when you get there" stuff like that … we get out of the van, and there is a bunch of people standing around and watching … I am so worried I am going to mess something up. I walk up to the body, and the investigator knows I am new and is telling me stuff like, "don't step over the body," "tape this bag on the hand on the wrist," and I am so nervous.

So I'll never forget that. (Participant 3)
Similar to the observation in the "kid cases" from above, even when the deceased is an adult, a dichotomy between intentional acts and accidental circumstances provides the basis for a distinction in personal reactions. Intentional acts that cause death prompt some to question their faith in humanity. Situations that involved an accidental death prompted an emotional response centered on the randomness of conditions that led to death. Consider below the reactions of two persons interviewed.
I remember my first homicide. It was a young woman. I think she was living on the streets, looked like a drug user. She was probably selling herself for money. And One respondent expressed concern with personal safety as a primary reason that the imprinted event was memorable. Participant 6 described feelings experienced on the first occasion that she worked nights.
This man had gotten run over on this little back road, kind of in the middle of nowhere. We had to take flashlights and go looking on this road to see if we could find anything related to this man…. I was out there on this road, and we kind of split up…. Like you couldn't see anything…. It was something out of a scary movie…. I had goosebumps and stuff. It was like you were waiting for something to jump out the woods at you. Even thinking about it now. (Participant 6) Lastly, a personal concern identified by a participant as a reason for remembering a particular case is the participant's fascination with the human body. For two participants, the abnormal context occurred in response to observations of the human body following trauma. Understanding the standard mechanics of an autopsy, one recalls concern with how to proceed in a case where the body was already in pieces. The other discussed the first occasion to smell burnt human flesh.
For some reason, he decided to run across the freeway. Crazy thing to do anytime, but he did it just as it was getting dark, in the fall when it was around rush hour. This is going to sound so creepy … but you know, a person whose remains are basically liked cooked, it doesn't smell much different than any other mammal that is cooked. It was so weird to me that the smell of someone burnt up smelled good. Awkwardness (or abnormality) of a scene can concern the person involved. In each of the following illustrations, the respondent identified the personal characteristics of the decedent. The first refers to the neighborhood, noting that the call was to a high social class neighborhood. The second and third are comments on abnormalcy in processing a decedent child scene.

Qualitative Findings: Behavioral/Significant Personal Change
The medical examiner field exposes professionals to a variety of difficult job-related circumstances. These professional situations impact their worldview and influence their relationships with others. In these interview data, we identified several behavioral responses. These professionals personalize their experiences and utilize bluntness in their conversations with family and friends about life, risk, and parenting.
These death workers become risk aversive, change their friendship dynamics, learn to not take life for granted, and parent and see children differently. Some participants indicated that they experience dreams and relationship difficulties. I know that I am more morbid than I was before. Surprise right? (laughs).
Meaning, I sometimes say things that really upsets people that are close to me, especially my mom. I slip up and say stuff like *pauses* let me give you an example. Like if I am driving a far distance, I will say something like, "I'll call you when I get there, if I don't get in a wreck and die." It's kind of a weird thing to say, but I guess the idea of death and of dying is something that you think about more, and so you mention it more. I know. It's weird. And that sort of talking really gets to people around me. They say I am messed up. (Participant 8).
Risk Aversive/Altered Friend Dynamics. Nine participants indicated that they became more risk aversive after working in the medical examiner's office. The participants mentioned several preventative things they now do (such as regular doctor check-ups and wearing seatbelts). Yet, most mentions were of behaviors they did once but didn't anymore because of the risk involved. In essence, the participants more liberally assess risk while more conservatively measuring reward. These include avoiding drinking, not engaging in activity that may lead to road rage, less speeding, avoiding holiday events where drugs and alcohol may be present, and eliminating unnecessary entertainment activities (such as cliff diving). Below are some textual illustrations.
Well, I am less likely to do things that might get me hurt. Like I don't really speed.
If someone gets mad at me when they are driving, like road rage, I can't even be bothered to get upset. I don't go out driving on holiday when people are drunk, Before I worked at the morgue, it was really only once in a while that I would sit back and think, whoa, I am lucky to be here. It was really only when some kind of crazy story hit the news, and it could have been you. And after like a day or two, you would kind of forget about it and go back to not really realizing how lucky you were to be alive. But after seeing that sort of stuff all the time, you really, really get an appreciation for living. (Participant 4) View Parenting or Kids Differently. Seven participants stated that they viewed parenting and kids differently because of the profession. Notably, this was not a phenomenon limited to those participants who are parents. One participant (7) expressly stated that (s)he is not a parent but that kids at family gatherings make the participant nervous. Very similar to the section above relating to being blunt with others on their behavior and parenting, this theme concerns parents who have pointed conversations with their kids, informed by the experiences of the participant's profession. In addition, this theme includes participants' self-reported aggressive parenting behavior (always knowing kids' location and what kids are doing). This behavioral response is not limited to female participants. Note that Participant 5 states he is a father. Tables 5, 6, and 7 contain language inquiry and word count findings reported by subtheme. In the tables, "JI" means job idealization, "JS" means job struggles, "IE" means imprinted event, "B/PC" means behavioral or personal change, and "ATS" means attitude toward treatment-seeking. The "n" for each subtheme represents the number of study participants with coded content for the subtheme. The word count  (187), the stigma of treatment (132), and dismissive of treatment (37). Of the eight themes with 1,000 words or more, four relate to behavior or personal change, and two concern imprinted events.    In Tables 5, 6, and 7, the table cells are percentages with the range listed below. Study participants were most analytic in their word usage when discussing the public service orientation of the profession, unexpected case outcomes, learning opportunities in the profession, abnormalities of the scene or circumstances, and sensory perception.
Concerning cognitive processes, this was most prevalent in the treatment themes when participants were dismissive of treatment and claimed that others might benefit but not the study participant. The themes relating to physical demands/safety and imprinted events remembered due to sensory perception had the highest percentages for biological processes. Participants most prominently used positive emotion when describing the public service role, expressing how the profession led to a greater appreciation for life, and discussing professional learning opportunities. Negative emotion words appeared more frequently for the themes relating to the stigma of treatment and physical demands/safety. More specifically, anxiety as a negative emotional word appeared in the themes concerning changes in behavior relating to their children/kids in general, treatment stigma, partner talk, and physical demands/safety. As an emotional state, "anger" words were most prominent in the risk aversion/friend dynamic and unexpected outcome themes. Words related to sadness as a negative emotion most frequently occurred in blunt talk (with friends and family), partner talk, and personal memory themes.
Participants used perceptual processes (see, hear, etc.) more often when discussing treatment stigma and imprinted events relating to sensory perception, personal memory, abnormal scene, and unexpected outcomes. Social words (family, friends, etc.) appear more frequently in the themes relating to behavioral and personal change (blunt talk, parenting and kids, and partner talk) and treatment stigma. Study

Discussion and Recommendations for Future Research
Medical examiner office staff experience secondary trauma in their professional roles.
A primary mechanism through which secondary trauma occurs is the personalization of the event. The study participants recalled, often in vivid detail, traumatic events, describing events at the death scene and in the process of body evisceration that stays with them and influences them long-term. While this study did not identify the range of behavioral and adaptive responses that characterize much of the prior work on death and trauma effects on second responders, it expands current knowledge on the topic.
It confirms that some of Agocs, Langan, and Sanders (2015) findings on the protective behavior of policewomen toward children apply more broadly. Medical examiner staff, male and female, shared that their parenting and views of kids changed because of this profession. They became hyper-vigilant, informing their children of risks and dangers to people (in general) and children (in specific) based on experiences from their job.
They also acknowledged more aggressive parenting, which entailed more significant concern for children's whereabouts and knowledge of what children are doing and with whom they do it. Protective practices appear to extend to others as well. Study participants discussed at length their attempts to warn others about the risks of their behavior and parenting styles. Personalization of the event also involves understanding how risky behavior may impact the medical examiner staff member individually. Study participants discussed at length how they avoid events with alcohol and drugs, do not engage in conduct they once did, and see the doctor more regularly.
More qualitative and quantitative research should be conducted on how death and trauma work influences first responders and their family members. Future work can explore whether and to what extent police officers, EMS staff, and other first responders change their worldviews and parenting from on-the-job death and trauma experiences. A question that clearly emerges from this research concerns whether the parent-child relations amongst first responders produce positive, negative, or neutral outcomes for first responders' children. A protective orientation may keep first