"Man är ju inte mer än människa" : Långtidssjukskrivning ur ett emotionellt, relationellt och strukturellt perspektiv

The background to this thesis is the dramatic increase of the long-term sickness absence that took place in Sweden from the late 1990s. There was also a shift in the diagnostic pattern with rising mental diagnoses. The overall purpose was to describe and try to understand the process leading to long-term sickness absence from the perspective of the sickness absentees, in order to get a better knowledge base for preventive and rehabilitative actions. The thesis comprises four studies (I-IV). Research methods have been both qualitative and quantitative. In study I data from individual interviews with 32 persons on long-term sick leave due to burnout was analyzed using a grounded theory approach. In study II the study population comprised of 2064 employed sick-listed persons, a sub sample derived from the 2002 national Swedish survey on health, working conditions, life situation and sick-listing. It was analyzed if persons with burnout had higher probability of having experienced the steps in the burnout staircase compared to other diagnostic groups in accordance with the previously suggested hypothesis of "the burnout staircase". Study III comprised of 2521 employed persons, a sub sample derived from the same national survey as in study II. It was analyzed if psychosocial work environment and conflicts and losses in private life independently or in combination were more strongly associated to sickness absence with mental diagnoses as compared to a healthy population. In study IV individual interviews with 25 professional rehabilitation actors and 14 unemployed sick-listed persons were conducted. Data were analyzed according to grounded theory method. The process that led to sicknes absence can be described as an emotional deprivation process, illustrated as a flight of stairs (the burnout staircase) describing a sequence of steps toward sickness absence (I). In accordance with the tested hypothesis persons with burnout to a noticeable higher extent reported expereince of being in the different steps in the burnout staircase compared to sickness absentees with other diagnoses. The model seemed to be valid also for persons with other mental diagnoses (II). Reorganization and conflicts at work as well as adding adverse private life events were associated with increased risk for sickness absence with mental diagnosis (III). Three significant factors behind the weak co-operation between local social insurance and employment agencies were identified: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies (IV). In this thesis it has been suggested that the course of events preceding sickness absence might be understood as a process of emotional deprivation, where the individual is gradually emptied of the life-giving emotional energy revealed in joy, commitment, and empathy. This life-giving force finds its nourishment in safe and secure social relations with others and in a social structure that promotes this type of social relations. The profound changes in the Swedish labour market during the 1990s influenced not just the psychosocial work climate but also the rehabilitation efforts for unemployed sick-listed persons. When the political goal of reducing the unemployment level came to the forefront the indistinct regulation and the conflicting goals in addition were factors that impaired co-ordinated rehabilitation. In this process also the physicians were involved. A labour market problem was turned into a medical problem