Long-Term Sickness Absence Due to Burnout: Absentees’ Experiences

Qualitative Health Research Volume 18 Number 5 May 2008 620-632 © 2008 Sage Publications 10.1177/1049732308316024 http://qhr.sagepub.com hosted at http://online.sagepub.com

Ulla-Britt Eriksson Karlstad University, Karlstad, Sweden

Bengt Starrin Karlstad University, Karlstad, Sweden, and Lillehammer University College, Lillehammer, Norway

Staffan Janson Karlstad University, Karlstad, Sweden In the late 1990s, there was a marked increase in Sweden in long-term sickness absence with mental diagnoses. In the extensive research on burnout, little attention has been paid to the link with sickness absence. Our aim in this study was to discover what caused burnout, or such severe stress that it led to long-term sickness absence (> 28 days). We interviewed 32 individuals on long-term sickness absence with a diagnosis of burnout and used grounded theory to analyze the data. We believe that events prior to the sickness absence can be understood as a process of emotional deprivation, and we described the process in terms of a flight of stairs with eight steps: “The Burnout Stairs.” We argue that the emotion conveying the process of emotional deprivation is unacknowledged shame, which has its basis in poor social relations at work. We discuss the study’s limitations and the need for further research in this field. Keywords: burnout; sickness absence; shame; emotional deprivation

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rom 1997 to 2002 the number of persons on longterm (at least 29 days) sick leave in Sweden more than doubled. Both men and women showed an increase but it was greater for women. The three years from 2003 to 2005 showed a certain reduction in the numbers, but in 2005 they were still very high. Apart from a general increase in long-term sickness absence, there was also a shift in the diagnostic pattern in that the proportion on sick leave for mental illness rose dramatically. Among women, the most common reason for sickness absence is mental illness. In December 2005, 32% of the women on sick leave were diagnosed with a mental illness. Among men, mental illness was the second most common diagnosis (24%), after injuries to the locomotor organs (30%; Försäkringskassan, 2006). Burnout is classified as a mental illness in accordance with the ICD-10 medical classification system, and it was not until 1997 that it was accepted as a legitimate reason for sickness absence (Socialstyrelsen, 1997). Many of the diagnoses for mental illness are symptom diagnoses, and the lack of an internationally accepted, criterion-based diagnosis instrument for burnout means that symptoms that are sometimes classified as burnout are, on other occasions, classified under other types of mental illness such as depression, 620

stress reaction, and anxiety symptoms (RFV Analyserar, 2002). Burnout is not a well-defined concept. It is used in everyday language, in health care, and as a scientific concept with partially differing definitions (Starrin, Larsson, & Styrborn, 1990). When the concept was introduced in scientific contexts, it was described as a psychological condition primarily in those who worked in the caring professions, such as nurses, social welfare officers, social workers, and teachers (Freudenberger, 1974). Symptoms were frequent sick leave, anxiety, life crises, and physical disorders. The causes were thought to be low pay, great responsibility combined with little power, poor career opportunities, bad and bureaucratic management, and lack of support (Freudenberger, 1974). Burnout is also described as an expression of

Authors’ Note: This study was financed by the University of Karlstad, the Regional Social Insurance Office in Värmland, the Regional Unemployment Office in Värmland, and the Värmland County Council. The authors wish to thank the participants in the study. Correspondence concerning this article should be sent to Ulla-Britt Eriksson, Karlstad University Department of Health and Environmental Sciences, SE-651 88, Karlstad, Sweden; e-mail: [email protected].

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professional crisis, a syndrome consisting of three components: emotional exhaustion, depersonalization or cynicism, and reduced capacity (Maslach, 1998). The symptoms also include general stress symptoms such as anxiety, headaches, sleeplessness, restlessness, and resignation. They are accompanied by a range of physical symptoms such as increased sensitivity to pain, susceptibility to infection, muscle tension, dizziness, and stomach, heart, and vascular problems (Perski, 2000). Conditions at work, such as too much work as a result of staff reductions, and lack of recognition, can also cause burnout (Maslach & Leiter, 1997). Burnout might even occur when the individual is exposed to such stress that they can no longer perform a role that is central to their identity (Hallsten, 2001). Several studies have focused on the occurrence of burnout in different professions and different countries (Brown, Prashantham, & Abbott, 2003; Jamal, 2004; So-kum Tang, 1998). One Swedish study estimated that 7% of the Swedish population was in the risk zone for burnout (Hallsten, 2005). Few studies have linked burnout with sickness absence. However, in a study of burnout and health in tram drivers, van Dierendonck and Mevissen (2002) found a link between the component emotional exhaustion and sickness absence. Even though research on burnout has not directed so much attention to the link with sickness absence, there is considerable research on the relationship between the psychosocial conditions in working life in general and sickness absence. In their survey of research on the effect of working conditions on mental ill health and sickness absence, Michie and Williams (2003), for instance, found that job demands such as long hours, too much work under pressure, lack of opportunity to influence one’s work situation, and poor support from managers were of great importance. Their results correspond well with the extensive research which shows that psychosocial working conditions where high demands in combination with little opportunity to determine how and when the work will be carried out lead to increased stress, with negative consequences for health as a result (Karasek & Theorell, 1990). Michie and Williams’s survey also confirms previous research into the importance of social support, where great effort combined with small reward has proved to have unfavorable effects on health (Siegrist, 1996). The very large increase in sickness absence in Sweden followed the major changes which the Swedish labor market underwent in the 1990s. Unemployment

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rose rapidly in the early 1990s from a very low level (1% to 2%), and in 1994 was 13% to 14%. At the same time both the private and public sectors underwent major cutbacks. Reorganization became common. In 1998 alone, two thirds of the working population had experienced some form of change at their workplace (Yrkesmedicin, 1999). It is a well-known fact that extensive changes can, in certain circumstances, create a breeding ground for stress-related ill health. A study from Finland found, for example, that individuals who have recently been exposed to cutbacks and reorganization show symptoms of burnout (Kalimo, 2000). A Swedish study found that the risk of burnout was twice as great among those who had been exposed to organizational changes in the previous year, than among those who had not (Hallsten, 2005). That negative changes in the psychosocial work environment increased the risk of sickness absence was found in a study of effects of a recession in Finland lasting several years. This was particularly true among those who, prior to the changes, had an unfavorable psychosocial work environment, with little opportunity to influence their situation, and poor support from managers or colleagues (Vahtera, Kivimäki, Pentti, & Theorell, 2000). A Belgian study of hospital staff found that sickness absence was affected by organizational changes and cutbacks (Verhaeghe, Mak, Van Maele, Kornitzer, & De Bakker, 2003). Hallsten and Isaksson (2001) observed resignation, tiredness, depression, indifference, and reduced loyalty, and a range of symptoms of ill health among individuals who were still working in organizations which had been subjected to staff reductions. The number of employees on the Swedish labor market reporting a too-high workload increased during the 1990s by 20% (Arbetsmiljöverket & Centralbyrån, 2001). The working environment and sense of well-being showed a negative development for municipal and county administration employees in particular (Persson et al., 2001). It is not only the organization of work that has proved to be of importance for health; the quality of social relations is also significant for the occurrence of mental ill health. For instance, van Dierendonck and Mevissen’s study (2002) found that the health of tram drivers was negatively affected by aggressive behavior on the part of their passengers. A study by Almberg, Grafström, Krichbaum, and Winblad (2000) found that the feeling of not being involved in major decisions had a negative effect on the mental health of caring relatives. Other expressions of exclusion such as being frozen out or belittled, or having a low social status, are

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also related to mental ill health (Billeter-Koponen & Fredén, 2005; Lindberg, Josephson, Alfredsson, & Vingard, 2006; Schaufeli & Peeters, 2000). There are, then, various models at the community, organization, and individual levels for explaining the causes of burnout and other mental ill health. The aim of the present study is to determine what it is that causes the individual to suffer from burnout or such serious stress that the result is long-term sickness absence. We concentrate on the conditions at the workplace. The point of departure is the perspective of those on sick leave and their experiences.

Method Design and Procedure Data from individual interviews with 32 persons on long-term sick leave due to burnout or a stress-related mental illness diagnosis were analyzed qualitatively. A qualitative research design was selected because it allows the discovery of variations, structures, and processes of currently unknown or unsatisfactorily understood phenomena (Starrin, 1994). Qualitative research interviews also provide a way to understand the world from the perspective of the interviewee, and to develop the meaning of the individuals’ experiences (Kvale, 1996). In designing the study, we paid particular attention to ethical issues. Because the participants were sick-listed and were required to discuss emotionally charged events during the interview, the investigators thoroughly examined the risks and benefits of participation. The risks involved negative emotional reactions such as anger or sadness in response to the interview. The benefits involved emotional relief from talking about experiences. The interviewers had no relationship with the participants. The participants were also encouraged to contact the interviewer if they experienced excessive distress after the interview. We made preparations for referrals for psychological counseling if the interviews raised questions of such a sensitive nature that the informants needed further support; this situation did not occur. The recruitment of respondents, as well as the interviewing and reporting of results, have been conducted in line with the ethical code for social science research in Sweden (The Swedish Research Council for Humanistic and Social Sciences, 1999). Most interviewees were strategically recruited from the regional social insurance office, which is the regional branch of the National Social Insurance Agency that registers and administrates sickness allowances for all

inhabitants in Sweden. Moreover, municipal and county council employees were recruited directly from their personnel departments. The following inclusion criteria were used: employed woman or man who, in 1999, had an ongoing sick-leave period exceeding 28 days and with a physician’s (mostly general practitioners) diagnosis of burnout in accordance with the ICD-10 medical classification system (Socialstyrelsen, 1997). An introductory letter including information about the nature of the study, and stating that participation was voluntary, was mailed to individuals who fulfilled the inclusion criteria. One week later they were contacted by phone. Two individuals chose not to participate because of poor health. Interviews were conducted by five people. Openended questions were used and the participants were encouraged to use their own words to talk about the themes included in the interview guide. The participants themselves chose the locations for the interviews, to ensure a relaxed, open, positive atmosphere, and a comfortable interview situation. The interviewer explained the purpose of the study and emphasized that the interviewee could withdraw at any time. The interviews lasted approximately 1 to 3 hours, and were audiotaped. The data were collected from autumn 1999 to spring 2000.

Participants The interviewees were from the county of Värmland, Sweden. All respondents were on sick leave when interviewed. In all, 32 people were interviewed: 26 women and 6 men. The fact that the number of women was far greater than the number of men mirrors, partly, the higher level of sickness absence among women compared to men, especially with diagnoses because of mental illness. The higher number of women among participants can also be explained by the fact that most interviewees were recruited from the service sector. Though the participation of men and women at the Swedish labor market is almost equal, there is an imbalance in the service sector, with women constituting 69% of the workforce (Swedish Government, 2004). The participants’ ages ranged from 26 to 62, with a mean age of 47 years. The educational level among the participants was relatively high, with 23 of them having university education. Six had completed high school, and three had 9 years compulsory education. The majority (29 individuals) were employed in the public sector (municipality, county council, or state). Their occupations were classified according to the MOA classification system (Härenstam et al., 2003). Twenty three participants worked with “social relations” in occupations such as

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nurse, teacher, and welfare officer. Seven worked with figures or other “symbols,” as medical secretary, school secretary, data operator, and economist. Two participants worked in the manufacturing sector, with “things,” as cleaner and engineer. Twenty four participants were married or cohabitants. Fifteen of the married participants and two of the singles also had at least one child living with them. At the time of the interviews the participants had been on sick leave between 1 and 35 months. Most of the participants (21 individuals) were 100% sick-listed at the time of the interview. Of the 11 interviewees on part-time sick leave, all but two had previously been full-time sick-listed.

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Figure 1 The Burnout Stairs: A Step-by-Step Process to Sickness Absence Due to Burnout

Exit From Working Life

Return to Working Life

8. Sickness Absence 7. Collapse 6. Strong Emotions & Health Problems 5. Lack of Trust & Diminished Self-Esteem 4. Incompatible Expectations

Data Analysis

3. Increased Demands

The interview data has been analyzed using a grounded theory approach (Glaser, 1978; Glaser & Strauss, 1967; Starrin, Dahlgren, Larsson, & Styrborn, 1997). Our specific procedure was based on the approach used by Glaser (1978). This method involves a process of coding, categorization, and comparison of the interview data. The interviews were transcribed verbatim by the interviewer directly after the dialogue. Non-verbal markers were used to indicate long breaks, mumbling, fillers, quiet speech, and tears because these added descriptions of the interview situation facilitated a higher degree of authenticity. Each interview transcript was read repeatedly by the whole research group; selected sections of the text were compared and grouped under themes. During this process the researchers found Retzinger’s list of shame markers (1991) of value; this was translated into Swedish and used for the analysis. To structure the raw texts, we reproduced every interview in a chart describing relations between themes, events, and/or phenomena. The codes emerged from the data and as the coding progressed, the charts were compared, the titles of the themes were refined, and connections were made between clusters of themes to identify subordinate themes. The data coded under each theme was then re-examined to ensure that it was represented in the transcripts, thereby minimizing the risk of bias. Excerpts from the interview transcripts are presented below to support and illustrate our categorization.

Results The study revealed a number of critical phases and events relating to the work environment that all the participants faced. The emphasis is on significant

2. Insecure Social Bonds Fraught With Conflict 1. Extensive Changes

events that preceded the sickness absence. In our interpretation, these events represent important phases which contribute to an understanding of why the situation finally became so difficult that all that remained was sick-listing. The process that led to sicklisting and sickness absence can be described as a flight of stairs. We term the process the burnout stairs (see Figure 1). All the participants climbed the various steps depicted. Their stories became increasingly detailed the closer the individual came to sickness absence.

Step 1: Extensive Changes All the participants in the study were exposed to extensive changes in their workplace before they became ill. These changes form the first step on the burnout stairs. The changes described by the interviewees were of two kinds: organizational changes and cutbacks. Organizational changes primarily involved a new employer, new areas of work, and changes in the decision structure. For instance, preschool teachers and recreation instructors reported that their activities had been incorporated in the school system both spatially and organizationally. Municipalities became the new employers of nurses and other health care personnel, in connection with the transfer of the responsibility for health care for the elderly from the county administration in the early 1990s. One participant described what happened to her as a completely new situation, “coming from a hospital environment and

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working in a care team to working alone with increasingly ill people in their homes.” Another organizational change of which the participants had experience was the introduction of so-called lean organizations. This new form of organization meant that there was no longer an immediate (middle) manager to turn to when necessary. The participants indicated that when the middle managers disappeared, their functions of giving support and feedback, and as a vertical channel for information, disappeared with them. This resulted in a feeling among coworkers that the distance to management became greater. All public employees participating in the study had been exposed to extensive cutbacks. These were of various kinds; for instance, colleagues who had been given notice or positions which were left unfilled when their employment was terminated. The lack of temporary replacements when someone was ill, on leave, or on vacation was another form of cost reduction. In several cases, dismissals and cutbacks meant that certain professional groups such as remedial teachers and administrators were withdrawn from the workplace. The employees who remained had to take over the tasks of those groups which had left, and this meant that their roles changed and they had more to do. The participants reported irregular, extensive, and repeated changes over which they had no control. As one of them put it, “I don’t know how many times they have reorganized here.” They had greater responsibility and more work to do, but less opportunity to influence the situation, which in the long run affected their health situation. “No one feels good when living in a state of constant changes,” as one of the participants put it.

Step 2: Insecure Social Bonds Fraught With Conflict The changes described in step one led to a split of sound working groups and put the employees into new challenges. This led to tensions and put pressure on the social bonds, and is the second step in our model toward understanding the path to long-term sickness absence. In step two the interviewees described how their relations with colleagues, as well as with superiors and/or subordinates, deteriorated. In several of the workplaces serious conflicts occurred. Some had experienced severe harassment and they saw this as an effect of the changes in the workplace. One of the participants described it as “stabbing one another in the back because people are at breaking point.”

The serious conflicts were of two kinds, horizontal and vertical. Horizontal conflicts are conflicts between individuals at the same level in the organization, and with equal power. This might mean an individual being excluded from a work group and not being permitted to take part in meetings or general coffee breaks. One participant had a colleague who “did not talk to me for a year.” Another heard her colleagues slandering her and felt very hurt and humiliated by this. Vertical conflicts occur between superiors and subordinates and are characterized by an imbalance of power. This might concern individuals or groups, but could also involve the manager against one or more of the employees; or one or more pupils against a teacher. Several of the interviewees said that they had been treated without respect by a superior. “It is incredible to stand here as an adult and be scolded like a little child,” as one of the participants expressed it. This type of conflict could also involve withholding important information, as another participant reported. She found out that the manager had arranged information meetings on the days she was working in another department, and felt that he had done this deliberately to exclude her. She began to feel increasingly isolated because she was the only one in the department who did not know what was going on there. One participant reported on the experience of being neglected. She had repeatedly sought a meeting with the manager to find out what was going to happen to her position after the latest reorganization, but it was difficult to establish contact. “I was treated as if I was invisible. It was as if I had never been in the workplace.” Another participant, who was involved in a conflict with the manager, was punished by the latter and missed out on both a salary increase and promotion.

Steps 3 and 4: Increased Demands and Incompatible Expectations The third step on the burnout stairs concerns the problems that arose as a result of increased demands that individuals experienced at work. These increased demands, which all the participants felt, were noticeable both in the work itself and in relationships in the workplace. The problems were aggravated by the fact that the increased demands and expectations were often perceived as contradictory and incompatible. These contradictory demands form the fourth step. The increased demands and expectations were linked to the cutbacks and reorganizations. One of the participants, who had worked for the same public employer

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for almost 20 years before her sickness absence, reported how she experienced how the atmosphere deteriorated after the introduction of a new organization, where her field of activity was transferred to a separate company. The change meant that the company was in competition with other companies in the field, even when work was to be done for her previous employer. She felt herself under pressure from the increased demands. “We had to do more and more. What was required was that one person should do the work of two. After all, you are only human.” One consequence when people left but their jobs remained was that those who remained were expected to do the vacated jobs as well as their own. A woman who had worked as a nurse in a hospital for 12 years experienced this situation: When I started working as a nurse, I was a nurse. I didn’t have to be an assistant nurse, clerk, a nursing assistant, a cleaner, or kitchen staff. I am all that today. . . . The result is that you cannot do anything really well. You are supposed to be out in the wards, washing and dressing people, making beds, changing diapers. All this. And at the same time you have to do your nursing job as well. Medicines, injections, drip, suction. Then you have to help serve meals. Then there is the paperwork, which is more than twice as much today as before. . . . You are social worker, assistant nurse, kitchen staff. You are everything and then on top of all this you are supposed to be a supervisor.

Apart from her traditional nursing duties she was expected to carry out tasks that were beneath her level of competence, which she felt was frustrating. Participants who found themselves in the opposite situation—that is, who were required to carry out duties which were above their level of competence and too difficult for them—experienced the same kind of frustration. The increased demands also made it more difficult to maintain a high level of quality in social contacts. One woman who had worked in a health care center before her sickness absence described such a situation. Her duties included receiving all patients. On one occasion she counted and came to a total of 120 registered patients during a 4-hour period. She described the situation in the following terms: “They are living people I am working with. They are not machines where I can just push a button, receive the charge, and so thank you and next please.” The need for new forms of collaboration resulted in a deterioration in social cohesion in many of the participants’ workplaces. For many of them, the new forms of

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collaboration meant that established work teams were replaced by different short-term groups. In some cases this required cooperation between different professional groups in so-called teams; for instance, “care teams” or “teaching teams.” One female primary school teacher felt “alone and isolated” in her new teaching team. She was the only one with her background in the new group, and no longer had the support of her colleagues. It has been shown that the power imbalance between different members of a care team can lead to feelings of powerlessness (Rutman, 1996). Another participant, a male employee, had not been part of a permanent team during the last few years before his sickness absence. He had moved from team to team, “and I did not even learn the names of my colleagues who I had been working with for several months,” he noted. Teamwork culture weakened the social bonds and led to superficiality in social relations. The participants in the study generally liked their jobs and their duties. Several of them said that at the end of the working day they wanted to feel that they had done a good job and be proud of and satisfied with their efforts. But they felt that the expectations placed on them from various quarters were incompatible. Cuts, the need to economize, and staff reductions prevented them from carrying out their work as they wanted to, which led to a sense of inadequacy. The weakened social bonds meant that they had too much to do at the same time as they did not dare, or were unable to, “draw the line.” Despite the new situation, they all indicated that they tried in various ways to meet their own quality demands. The solution was that they worked more. “On certain days I sat at home and worked five hours after work until late at night,” reported one of the participants, who had been a teacher before the sickness absence. They missed or shortened the breaks, took work home, and worked overtime. “I used to train during the lunch break but I seldom have a lunch break these days,” was one comment. Some of the participants indicated that loyalty to their clients, pupils, or colleagues made it difficult to stay at home even when they were ill. Several of the participants from the health care and school sectors found themselves in a conflict situation, where they felt that they were forced to give priority to the management’s requirements rather than doing what they felt was more important, which was having direct contact with patients or teaching. One of the participants described this conflict as “sitting in front of the computer all the time and not having time for the patients.” It became more and more difficult under these circumstances to gain job satisfaction.

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They felt that they no longer provided care that was “fit for humans,” or that the children at school “suffered,” and this had a negative effect on their own health. In this phase the participants’ narratives contained many descriptions of how they put more and more pressure on themselves but still felt inadequate.

Step 5: Lack of Trust and Diminished Self-Esteem The new expectations fraught with conflict produced emotional stress and affected the participants’ trust in others and confidence in themselves. This is the fifth step in the flight of stairs leading to sickness absence. This lack of confidence was in the employer and/ or in colleagues. One of the participants reported that when she wanted to talk about her stressful working conditions with her superior, the answer she received was that “there were other jobs she could apply for.” She took this as a signal that her long professional experience was of no value and she lost confidence in her superior. A young female teacher provided an example of how trust in colleagues can be destroyed. Some of her colleagues had promised to help her put forward a proposal to divide classes in the hope that this would improve her work situation. But time passed, the term was coming to an end, and because the changes were supposed to be made during the vacation, she felt it was odd that she had not heard anything and that nothing had happened. She commented, Since it was the last day of term, I thought I would ask one of my colleagues. So I ask[ed] one after another and they had not done anything about it. Then I just ran completely out of steam.

Cooperation and solidarity were tested, and the “we” feeling was replaced by egoism, mistrust, and competition. Frequent unresolved conflicts at work gradually resulted in a loss of trust in others and, in the end, confidence in oneself. Lack of recognition and appreciation led to diminished self-esteem. One of the participants felt that she dared not rely on herself any longer. “It seemed to me that I had lost all my professional competence. There was nothing left. I felt I could no longer do my job.”

Step 6: Strong Emotions and Health Problems In step six we have reached the stage where feelings of tiredness and exhaustion have become increasingly

obvious. Powerful emotional experiences and psychosomatic and physical problems have preceded the path toward sickness absence. Feelings of shame. The participants expressed strong feelings of insufficiency, inferiority, and inadequacy. One of the participants felt that she was “treated as if she was nonexistent.” Another began “to doubt herself” and a third felt she was “going downhill.” One reported the fear of not even being able to manage the simplest of tasks, and the disappointment at never receiving praise for having done something well. Their reactions can be seen as expressions of feelings of shame. We concur with Scheff’s (1990) and Retzinger’s (1991) broad definition of shame, including everything from mild to painful forms. An example of mild shame is embarrassment, which has low intensity and is very temporary, whereas an example of painful shame would be humiliation, which is very intense and has long duration. For Scheff and Retzinger, shame contains a collective heading for a whole set of emotions which arise when individuals see themselves in negative terms through the eyes of others. Merely expecting such a reaction might be sufficient. In Scheff’s and Retzinger’s emotional and relational theory, the sense of shame is a signal of threatened and insecure social bonds. Scheff and Retzinger make a distinction between normal and pathological shame. Manifestations of normal shame are brief and last only a few seconds. Persistent and continuing shame is pathological. Pathological shame might arise in situations where an individual is repeatedly humiliated and slandered. Many of the participants talked about failure and the feeling of not being good enough. One said that she had prayed to God for support because of her fear of making a mistake at work. Another thought she was a poor teacher and avoided answering the telephone or going into town because she did not want to risk meeting a friend who might ask how work was. Feelings of anger. There is a clear link between shame and anger. Humiliation and degradation can be turned inward and result in silence, or turned outward in the form, for instance, of anger and aggression (Scheff, 1990). One of the participants, who prior to her sickness absence worked as a teacher, reported such aggressiveness. She spoke about a meeting that was meant to be about her future work situation, and in which she felt that she did not receive any support from either her colleagues or her headmaster; they talked about completely different things. She commented, with a sigh, that she started crying and ran out. She went on to say,

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For two weeks after that day, I cried and shouted. I was so angry. And time and again a terrible rage came over me that I had never felt before in my whole life. I was so angry, so terribly insulted. And it went on for two or three weeks like this and I couldn’t do anything about it except within me. I shouted and struck the table with my fist over and over again and I felt I needed a sandbag so that I could punch the rage out of me. There was no room for it in my body.

For another of the participants, anger almost became part of her daily life during this period: “I came to work and then went home; was angry and slept; ate, slept and shouted; was angry and wept—all the time.” A third participant, who worked in a municipal administrative office, reported that he increasingly “lost his temper.” When he thought back on the time before his sickness absence, he remembered that he had been very irritable and insulted several people in his vicinity. Various health problems. Furthermore, the participants began to suffer from various health problems. They all felt tired and had sleeping problems, described as “extreme exhaustion.” They slept but never felt rested, as one of the interviewees commented: I came home from work and was so exhausted that I was virtually asleep by the time I got home. . . . Then I dreamed about work and I was so tired in the morning when I had to get up . . . since I had already done a full day’s work.

Gradually, various health problems became apparent. The different symptoms led participants to worry that they were seriously ill. One of them reported that she “had a terrible headache all the time” and was worried whether she “had a brain tumor.” Two of the others thought they were developing Alzheimer’s disease, as they could not remember well-known names and telephone numbers. Several others associated certain symptoms, such as increased heart rate, cramp, or a lump in the throat and choking sensations, with serious heart disease. “I thought I had had a heart attack,” commented one, and went on, “I was in such pain that I thought I was going to die.” Several had had a high temperature and “suffered from continual colds.” Many also had stomach pains and several suffered attacks of dizziness. The joy of living disappeared. Several participants remembered a general feeling of sadness coming over them. One expressed it in the following terms: “I could

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become sad at the least thing and start crying.” Several witnessed that they no longer took any pleasure in their work. One even went as far as saying that her joy of living had disappeared and nothing was fun anymore. Laughter vanished, to be replaced by tears. At this stage, many of the participants also began to withdraw into themselves, spending less and less time with their colleagues at work and their friends in their free time. “In the end it was just me and work,” said one of the participants. As some of them expressed it, this withdrawal was because of the fact that they could no longer cope with social relations. Another observed that her friends could not cope with the fact that she was not her usual self, and “then I have to pretend or withdraw,” she said, and often chose the second alternative.

Step 7: Collapse All 32 individuals experienced some form of collapse before their long-term sickness absence. However, this collapse took different forms of expression. Several described dramatic collapses followed, in several instances, by shorter or longer memory gaps. Some were able to identify a single triggering factor. But far from all were able to indicate anything special. Suddenly one day, things just stopped. The body or brain ceased to function normally. The collapse was, in many cases, the culmination of a long process of deterioration. One of the participants reported that her collapse was triggered by her work situation during the summer, when many of her colleagues were on vacation or ill, and they had no replacements. She was one of two administrators where there were normally four. And then her colleague became ill and she had to do all the work herself. Her vacation was not sufficient to provide her with the necessary recuperation. When she started working again, she did not feel well and cried a lot. “As soon as somebody spoke to me and asked me how I felt, since they could see I was not well, I cried . . . just cried and cried. . . . I couldn’t stop.” These intensive crying fits signaled the approach of the collapse, which came after a week or so. It was impossible to talk to her and one of the doctors at her workplace sent her home. Several participants reported recurrent crying fits. One participant described her collapse in terms of not reacting normally or not reacting at all when she was driving home from work far too fast. Others reported that they had been panic-stricken and had anxiety attacks. One stated that in the middle of an ordinary blood test she suddenly felt that she could not cope with it. She said, “I had palpitations and I began to

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feel ill and the sweat poured off me and I felt that if I didn’t get away from there, I would faint.” In several of the narratives, the collapse came after a confrontation at the workplace; for instance, in connection with a staff meeting. The individual concerned felt derided, superfluous, called into question and/or insulted, and left the meeting in an agitated state. One of the participating teachers had had a difficult time at school over a long period. There was a whole succession of arguments and conflicts, and one day she had a confrontation with one of her pupils. She reported, And it was almost as if something snapped in my head. . . . My voice started to shake and I felt I was losing my self-control and I couldn’t cope with this and I felt beaten; I almost collapsed in the corridor and just wept and wept and I couldn’t speak and I felt that I had no resistance anymore; that I couldn’t do anything but was completely helpless.

One of the participants reported that she had come home late one evening after a long day at work, with overtime. On her way home she had felt extremely tired and almost fallen asleep at the wheel. The next day she did not have to start work until lunchtime and stayed in bed because she still felt tired. When her husband came in, she began to cry. After a while she needed to go to the toilet but her legs would not bear her and she fell. Her body would not obey her any longer. Her husband helped her back to bed and she called her workplace and said she would not be coming to work that day. Several of the participants described their collapse in great detail. One stated that his collapse came “on a beautiful autumn day at the beginning of term.” He had been getting ready to go to work, looked out of the window, and said to himself, “No, I’m not going back again, ever again, so I just sat down; it was all empty; everything was empty . . . all the energy had in some way flowed out of me.”

Step 8: Sickness Absence The collapse, which was described and experienced in various ways, was the beginning of a long sickness absence. It produced mixed feelings with both positive and negative experiences. Sickness absence made it legitimate to stay at home and avoid the conflicts at work, and the expectations of colleagues and supervisors. For many it was a relief not to have to think about going back to work. Sickness

absence also gave them an opportunity to wind down. For some of them it marked the beginning of a muchlonged-for change in their lives. This was the case for the male teacher in his 50s who, for a number of years, had wanted to do something other than teach, but had not seen any chance of changing jobs. At the time of the interview, it had just been decided that he would return to the school after his sickness absence as a resource person for the school management team. He was looking forward to that. When he received the information about the new job, he felt relieved, and it was as if “a huge weight had been lifted from my shoulders.” For most of the participants the negative aspects of sickness absence were predominant. Even though some saw positive elements in what had happened, they talked about the sickness absence—being ill—as a failure, as something shameful. Several of them accused themselves for getting sick and had a bad conscience at having left their job. One of them expressed this in the following terms: “I felt it was almost impossible to go home. . . . It was terrible. I felt like a real deserter.” One of the participants who accused herself for becoming ill showed several physical signs of shame, such as avoiding eye contact, looking down at the ground, talking very quietly and with long pauses. Sometimes she did not complete a sentence but simply fell silent. All these nonverbal signs signify shame (Retzinger, 1991). It was not just the sick-listing which the participants experienced as a defeat. Several of them reported that they felt ill for months at a time when on sick leave. They said they were restless, had no energy, were worried, and had difficulty concentrating. One described getting out of bed and getting dressed as a whole-day project. For her the first period of her sickness absence was a time of poor sleep and nightmares. The negative feelings were also associated with the diagnosis. Despite the fact that the doctor’s certificate indicated “burnout,” or “stress reaction with depression,” they did not see themselves as burned out or depressed. One of them said that it was the job that was at fault, not her. She did not want to see herself as “burned.” Another also objected to the diagnosis of burnout. “That word sounds so awful,” she said. Several of the participants saw the diagnosis of burnout as a stigma, because it could be linked with mental illness. This was the case of a woman who reported that she had the impression that those around her treated her as mentally ill, and thus even “suicidal,” but she did not see herself as mentally ill.

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The financial consequences of sickness absence varied. For some participants the reduction in income was serious. One participant, whose wife was unemployed, reported that the couple had sold their car and caravan, and that the continually poor financial situation was an extra burden during his sickness absence. Another participant pointed out that at the same time as the family’s financial situation deteriorated markedly because of his sickness absence, he also spent less. “I have no car journeys to work, I don’t go out and about, I eat much less and I have no desire to buy clothes.” The participants provided a number of examples of deteriorating social contacts because of their sickness absence. Several had been active in various associations and had had lots of friends and acquaintances, but their situation changed drastically in connection with their sickness absence. One of them said that he did not feel needed and did not seem to be part of any group anymore, not even within the family. Others experienced that the isolating effects of sickness absence can remain for a long time. One individual, for instance, spoke of the difficulties in making contact with other people he had experienced over a long period, even after his health improved. He simply said, “You become unsociable.” We can add to the list of negative experiences the feeling of “being a burden on someone.” As one participant said, she felt that “everybody” thought she would start working again as soon as possible, as she was “costing the community money.” This was hard on her and was an obstacle to her recovery. Several others had had similar experiences and the signals came from their employer, the health care system, and the social insurance office. One participant thought that many people viewed sickness absence in negative terms. Several of those interviewed had visited their workplace during their sickness absence, but with mixed feelings. One observed that one effect of her visit was that her symptoms, in the form of nausea and headaches, returned. Others reported that they had no wish whatsoever to visit their former workplace. This was particularly true at the beginning of their sick leave. One who had been on sick leave for a month at the time of the interview said that she could not even watch a television feature that reminded her of work. “If I see a desk or a table with papers on it, I leave the room,” she said. Another participant said he had anxiety attacks at the mere

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thought of going past the school where he had been a teacher. “My stomach tightened.”

Exit From or Return to Working Life? Virtually all the participants said that they had thought about their return to working life. Some believed they could return in one form or another after their sickness absence, and a few had even begun to reduce their level of sickness absence and work part time. Others were convinced that they would not return to work. Because all the interviewees were on sick leave at the time of the interviews, the presentation of our findings concludes with the unanswered question of whether there is a way back to working life for the participants in our study.

Discussion 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 that is revealed in joy, commitment, and empathy. Our interpretation of the causes of this process of emotional deprivation is that it began in connection with the fact that conflicts which arose as a result of radical organizational changes were not resolved, but escalated instead. We describe this process as a flight of stairs, where the various steps describe the different stages in the process (see Figure 1). Well-functioning work teams were split and the individuals were put together in looser groups, with more superficial contact. It is a known fact that working groups or teams can act as a buffer against the excessive demands of supervisors, colleagues, and patients (Lindgren, 2001). However, in the environments where the interviewees worked, the cement required for individuals to support one another was missing. The process of emotional deprivation resulted in serious psychosomatic disorders. Many began to withdraw into themselves and found it increasingly difficult to live up to the demands and expectations. Pleasure, interest, and commitment disappeared. Our description of emotional deprivation relates to Hochschild’s concept of emotive dissonance (Hochschild, 1983). In her study of flight attendants, she showed how emotive dissonance develops when the feeling one shows is not in harmony with the feeling one has inside. The interviewees in our study reported that they felt they were forced to hide their real feelings

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of, for instance, disappointment and anger. Instead they became silent and withdrawn. According to Hochschild, in situations like this individuals risk losing contact with their own feelings and this might lead to burnout (Hochschild, 1983). Emotional deprivation is also associated with Collins’s concept of emotional energy (Collins, 2003). Successful meetings with people charge those taking part with energy, whereas unpleasant meetings have the opposite effect of draining energy (Collins, 2003). The participants in our study gave numerous examples of how the arenas where a high degree of emotional energy had previously been created no longer existed. Collins’s concept of emotional energy has clear connections with the meaning Scheff (1990) and Retzinger (1991) attach to the notions of shame and pride. Shame corresponds to low emotional energy, and pride to high emotional energy. Collins suggests that these emotions are subjective, self-oriented interpretations of what, in a collective aspect, might be termed emotional energy (Collins, 2001). For Scheff and Retzinger, both shame and pride are selfreflecting emotions which fulfill a major function in revealing the state of the social bonds between people. Shame is a signal of threatened and insecure social bonds and pride of secure and solid bonds. The sense of shame is two-sided. Scheff (1990) and Retzinger (1991) distinguish between normal shame and pathological shame. Shame is normal and constructive when it contributes to the reparation of social bonds, and pathological and destructive when it leads to the breaking of these bonds. Normal shame is recognized and acknowledged, whereas pathological shame is suppressed and unacknowledged as shame. Self-esteem might play an important role for understanding why individuals manage shame differently. As suggested by Scheff (1990), persons with high selfesteem would be those with the experience of managing shame such that it was acknowledged and discharged. Persons with low self-esteem, on the other hand, would be unable to manage shame in a way that leads to acknowledgement and discharge. It implies that individuals have different susceptibilities to shame. The role of self-esteem needs to be tested directly in future studies. Being part of a group or community is one of the most fundamental of human needs (MacDonald & Leary, 2005; Scheff, 1990). Being abandoned, excluded, and not forming part of a group seems to be just as painful as physical pain (Eisenberger, Lieberman, & Williams, 2003). In our study the social bonds at the

workplaces had been severely threatened and the participants expressed feelings of isolation. The results from our study support Scheff’s and Retzinger’s theories of shame. The social bonds with colleagues, superiors, and subordinates of those on sick leave had been damaged, and the latter showed marked signs of shame, both verbally and nonverbally. Consequently, in this framework, if shame and being exposed to shaming causes mental ill health, it must by definition be toxic. Some authors have suggested that this toxic shame might be crucial to the understanding of the link between stressful external circumstances and illhealth (Dickerson, Gruenewald, & Kemeny, 2004; Scheff, 1992, 2001; Wilkinson, 1999, 2002, 2005). Our study suggests that the emotional deprivation that characterizes the group we examined is, to a significant extent, a result of social processes as well as relational and emotional ones. We suggest that the emotion that conveys the process of emotional deprivation is unacknowledged shame, which in its turn has its basis in social relations at the workplace that are insecure and fraught with conflict. Mental ill health in the form of burnout would then be a matter of shamerelated processes where the self is subjected to an attack which it cannot cope with or defend itself against. However, the role of insecure bonds and shame in developing burnout must be further explored in future studies. The study and the model we have presented rely entirely on the narratives of those on sick leave. One limitation is that we do not have any independent data on the working environments where our interviewees were active before becoming ill. Nor have we been able to take the individuals’ total life situations into account.

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Ulla-Britt Eriksson, BA, MPH, is a PhD student of public health sciences at Karlstad University, Karlstad, Sweden. Bengt Starrin, PhD, is professor of social work at Karlstad University, Karlstad, Sweden, and professor on the Faculty of Health and Social Studies, Lillehammer University College, Lillehammer, Norway. Staffan Janson, MD, PhD, is professor of public health sciences at Karlstad University, Karlstad, Sweden.