Why Nurses Commit Suicide: Mobbing in Health Care Institutions 0773400680, 9780773400689

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WHY NURSES COMMIT SUICIDE Mobbing in Health Care Institutions HEINZ LEYMANN AND ANNEUE GUSTAFSSON

W HY NURSES C OMMIT SUICIDE

Mobbing in Health Care Institutions

WHY NURSES COMMIT SUICIDE

Mobbing in Health Care Institutions

Heinz Leymann and

Annelie Gustafsson Translated by

Sue Baxter With a Preface by

Kenneth Westhues General Editor, The Leymann Translation Project

The Edwin Mellen Press Lewiston'"Queenston• Lampeter

Library of Congress Cataloging-in-Publication Data

Library of Congress Control Number: 2013955670 Leymann, Heinz. Why nurses commit suicide : mobbing in health care institutions I Heinz Leymann, Annelie Gustafsson ; translated by Sue Baxter ; with a preface by Kenneth Westhues.

1. Medical--administration. 2. Medical--nursing--general. 3. Nursing-issues. 4. Psychology--suicide. 4. Gustafsson, Annelie. 5. Baxter, Sue. p.cm. Includes bibliographical references and index. ISBN-13: 978-0-7734-0068-9 (hardcover) ISBN- I 0: 0-7734-0068-0 (hardcover) I. Title. hors serie.

A CIP catalog record for this book is available from the British Library. By permission of the authors and publisher of the original Swedish edition: Sjtilvmordfabriken: om de stora risker sam sjukskoterskor utstittsfor I arbetslivetl

Heinz Leymann, Annelie Gustatlson, ISBN 91-39-10198-3, Stockholm, Sweden. Svenska: Norstedts juridik, 1998.

Copyright © 2014 Sue Baxter and Noa Zanolli, literary executors, estate of Heinz Leymann All rights reserved. For information contact The Edwin Mellen Press Box450 Lewiston, New York USA 14092-0450

The Edwin Mellen Press Box67 Queenston, Ontario CANADA LOS ILO

The Edwin Mellen Press, Ltd. Lampeter, Ceredigion, Wales UNITED KINGDOM SA48 8LT Printed in the United States of America

Table of Contents

Preface. The Leymann Translation Project, by Kenneth Westhues ........................................................................ v Authors' Note to Readers outside Sweden, and Dedication .............xiv

Introduction ........................................................................................ 1 Chapter 1. Working Life: A Central Manifestation ofLife ............... .4 Chapter 2. Existing Knowledge about Work-Related Suicides .......... 9 Epidemiological Studies .................................................................... 9 Connection Study I : Situations in Working Life and Suicide .................................................................................. 14 Connection Study 2: Suicidal Thoughts in Nurses .......................... l 6 Qualitative Experiences ................................................................... 18 The Picture ofMental Strain during Rejection ............................... 21 Permanent Personality Changes as a Consequence of Extreme Stress ................................................ 24 A Summary of the Existing Knowledge .......................................... 27 Chapter 3. A Presentation of the Research ....................................... 29 Method ............................................................................................. 29 Results ............................................................................................. 33 Chapter 4. A Theoretical Background for our Results ..................... 42 A Phase Model of Mobbing and Elimination Processes, International Research .................................................................. 44

iv A Phase Model According to the Whistleblower Research ........... .47 Attribution Research within Psychology, Blaming the Victim ...................................................................... 48 Work Environmental Studies within Healthcare and the Swedish Legislation ......................................................... 56 "Should Be" Situations according to Swedish Law ....................... 57 "Are" Inventories about Nurses ...................................................... 64 SHSTF's Response ......................................................................... 74 NSO's Studies ................................................................................ 77 A Summary and Comparison between "Shou ld Be" and "Is" ........ 88

Chapter 5. Case Studies .................................................................... 90 Introduction ..................................................................................... 90 Sarah's Golgatha - An Occupational-Social Anamnesis .............. 92 Union Handling of a Mobbing Case .............................................. 161 Poorly Treated at the Workplace - Hung Out in the Media ........ l 93 A Discussion Based on the Three Case Studies ............................ 204 \Vhy Suicide? ................................................................................. 213

Chapter 6. Suicide Prevention in Working Lifea Basis for Discussion ................................................................ 22 1 The National Council on Suicide Prevention ................................ 221 Special Possibilities for Suicide Prevention in Working Life .......................................................................... 223 The Swedish Regulations and their Shortcomings: Implementation ........................................................................... 225 Suggestions for Suicide Prevention in Working Life .................... 236 A Final Word About Suicide Prevention ...................................... 247 Appendix. An Exemplary Company Policy for an Anti-Mobbing Agreement ................................................... 250 Literature ........................................................................................ 255

Preface The Leymann Translation Project Kenneth Westhues General Editor

Mastery of a scientific field requires reading books by the founding scientists. Subsequent research may have gone beyond the founders · ideas. superseded or even disproven some of them. In pursuit of knowledge. one rightly climbs up on the shoulders of those who have stood on the shoulders of giants. Even so, the serious student of evolution has to read Danvin, of psychoanalys is Freud and Jung, or of IQ Stern and Binet. For the field of workplace mobbing, a ll paths lead back to a single scientist. Heinz Leymann conceptualized and named this distinct form of collective aggression in 1984, when he was 52 years old, and spent the remaining fifteen years of his life researching it. By now, ten more years have passed. The number of specialists in the scientific study of mobbing is in the hundreds, if not thousands. So is the num ber of published books and research reports. The word mobbing. defined as the ganging up of peers and managers against a workmate. is lodged by now in dozens of languages, also in laws, policies, medical lexicons, and textbooks of human resource management. All this can be traced in one way or another to Leymann. That is why publ ication in English of his main books. which he wrote and published originally in Swedish. is so important an event. Its effect is to multiply their prospective readership a hundredfold. Whoever would understand workplace mobbing, its nature, correlates,

vi antecedents and consequences, can now access the founding scientist's views in the main language of the scientific world. Provided only that they know English. serious students of mobbing can henceforth read the foundational concepts and hypotheses in their original formulation - so to speak, from the horse· s mouth. The Leymann Translation Project has requ ired the cooperation of many organizations and individuals, among which the Edwin Mellen Press should be acknowledged here at the outset. Out of its unwavering commitment to the advancement of scholarship, above and apart from financial priorities, the press has undertaken to publish four volumes, as follows: • The first volume, published by Mellen in 2010, Workplace Mobbing as Psvchological Terrorism. Leymann · s introduction to and summary of the field as he had shaped it by 1992; • The present volume, The Suicide Factory, co-authored with Annelie Gustafsson in 1998. a provocative expose and analysis of nurses in Sweden who committed suicide after being mobbed at work (including, as an appendix, statistical analyses of Posttraumatic Stress Disorder among mobbing victims): • 1·Vhen Life Strikes. Leymann·s critica l exam ination, published in 1989, of what it means to be victimized - raped, held hostage. robbed, tortured, or otherwise humil iated utterly (this book is crucial for understanding the larger theoretical frame Leymann brought to his research on mobbing); and • Adult ,\fobbing: on Mental Violence in Working L[le, published in 1986, Leymann ' s first book-length effort to conceptualize mobbing, distinguish it from other workplace pathologies like sexism and racism, identify the main types of it and describe ways of dealing with it. Also in th is volume is No Other Way Out. Leymann's analysis in 1988, of the diary of a mobbing target who took her own life.

Trajectory of Leymann 's Life A straight and narrow path through life seldom leads to invention and discovery. Heinz Leymann's biography had plenty of jarring

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twists and turns. He was born in Germany to a working-class family . His father had little appreciation for Heinz·s intellectual propensities. The boy grew up amidst the turmoil and devastation of World War II. then witnessed at the age of thirteen the defeat of the Nazi d ictatorship and the occupation of his homeland by its erstwhi le enemies. Leymann moved to Sweden in 1955, at the age of 23 , and \vorked as an interior decorator. There he married a Finnish woman and fathered two chi ldren. The couple divorced in !974. Leymann never remarried. It was only after his migration to Sweden that Leymann embarked on an academic career. Taking advantage of a national program that opened university schooling to adults over the age of 25 who had four years of work experience. Leymann began taking courses in economics, sociology, and psychology/pedagogy. In 1978, at the age of 42, Leymann became the first immigrant to complete a Ph.D. under this program . His thesis was entitled, Can Working Life Be Democratized~' He then worked as a researcher in the Office of Occupational Health and Safety, At the age of 50, he won appointment to the faculty of the University of Stockholm. Even then, Leymann continued his schooling, earning a doctorate in medical sciences, with specialization in psychiatry, in 1989. at the age of 57, from the University of Umea, a day's drive or overnight train j ourney north of Stockholm. From 1992 until his death in 1999, Leymann held a professorial chair at Umeii in the scientific study of work. He also established a private clin ic for treating victims of workplace mobbing. This was at Karlskrona, on Sweden's south coast. American mobbing researcher Joan Friedenberg has hypothesized that professors mobbed in universities are disproportionately hom backgrounds far down the scale of income, prestige, and power. Not surprisingly. her point applies also to the scholar who established workplace mobbing as a field of scientific inquiry. In the modal case, a professor is born to affluent, university-educated parents, embarks early on a standard academ ic career, and carries into it a world-view shaped by privilege. Leymann had no such '"'odd-view. His belief in democracy and human equality went beyond lip-service. His commitment to dignity and fairness in the workplace was visceral. He was not a prudent, temperate professional, a Caspar Milquetoast of the ivory tower. He was outspoken, abrasive, brazen. adventurous.

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Intellectual Origins He was also. however a scientist. His writing bespeaks not just repugnance to nastiness at work but an accepted vocation to make sense of it by disciplined appl ication of reason to evidence. and only on this basis propose remedial and preventive measures . The beginning of scientific study of any field is separating from the blur of complex experience a definable something, giving a name to it, and then proceeding to map relations between this something and other ones. It was this all-important first step toward a science of workplace mobbing that Leymann was the first to take. Yet as he readily acknowledged. others had brought him to his point of depar1ure. Ch ief among them was Nobel Laureate Konrad Lorenz. the founder of ethology. who introduced the word mobbing as a scientific term in h is 1963 book, On Aggrl!ssion. about the ··fighting instinct" in birds and mammals that is sometimes directed against members of the same species. In writing that book, Lorenz had searched for the best word by which to describe the form of col lective aggression wherein members of a species normally dispersed and unorganized ··gang up." form themselves into a cohesive group for attacking and eliminati ng a target. For this phenomenon Lorenz settled on the English word mobbing. By now. a substantial ethological literature has accumulated on mobbing among songbirds. In 1972, the German-Swedish physician and child psychologist Peter-Paul Heinemann published an article applying Lorenz"s concept of mobbing to the behavior of schoolchildren, who sometimes gang up on one of their number and torment that ch ild even to the point of suicide. Heinemann's article generated w idespread discussion in Swed ish media, and was the most prox imate inspiration for Leymann"s application of Lorenz's term to human behavior in workplaces. The title of Leymann ' s first book o n the subject, Adult Afobhing .... was presumably chosen to dist inguish its subject matter from the child and adolescent behavior Heinemann was concerned about. In two additional ways, Leymann ' s scholarship can be seen as following coherently from that of Lorenz. The first is its method. Lorenz came up wit h his ideas mainly on the basis of close. intense field observations, as opposed, for instance, to formal experiments.

ix

Similarly, Leymann produced knowledge on workplace mobbing from intense. extended interviews with mobbing targets and from systematic personal observation of their working conditions. Leymann was not opposed in principle to experimental and quantitative techniques of inquiry . Numerous of his articles report the resu lts of survey research. His books amply demonstrate. however. that the case study was his favored method, and that most of his hypotheses were hammered out through a process of analytic induction, with each successive case used to refine and revise prior hypotheses. Leymann was also similar to Lorenz in avoiding technical jargon and in directing his work to public readerships equally as to specialists and professionals. Konrad Lorenz is on ly the most direct antecedent to the nevi field of study Leymann invented . Collective aggression of the many against the few, even just one. is endemic to our species and has been studied in many forms and from many angles. By the time Leymann conceptualized workplace mobbing, large bodies of research had already been amassed on scapegoating, crowd behavior, witch hunts, massacres, shunn ing, lynching, torture, and moral panics, as well as on major historical instances. like the Inquisition, the Terror. and the Holocaust. of an institution or collective wreaking ruin on targeted minorities. Leymann's basic contribution was to discern in the ostensibly decent, rational workplaces of civil ized societies the same horrific process that was and is widely recognized in its more barbaric, violent forms.

After Leymarm's Death The initial reception to Leymann's discovery was not uniformly enthusiastic. Targets of workplace mobbing were overjoyed, of course, to learn a name for their ordeal. Ordinary workers and the public at large could recall from their own and friends ' workplace experience episodes of the process Leymann descri bed. Workplace authorities, on the other hand, including union officials. were loath to admit that such collective villainy regularly occurs on their watch. The very concept of mobbing calls into question certain exclusionary or pumt1ve workplace decisions: the main decision makers understandably looked

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askance at Leymann·s research. He was throughout his life a controversial tigure in Sv,:eden. and when he died. no academic or governmental organization leapt at the chance to memorialize and institutionalize his work. In I 996. at the age of 64, Leymann was diagnosed with colon cancer. Far from surrendering to the disease. he worked with more urgency. Two years earl ier, he had had the good fortune to meet Sue Baxter, an American-born dentist then working in Sweden's far north. She had come across Leymann's work by chance while browsing in a public library. She had liked what she read and contacted the author. Leymann. whose command of English was limited. enl isted Baxter to translate his main work into her fi rst language. She agreed. But time was short. In September I998. Leymann asked Baxter to come down from the north and help him continue worki ng even as his health declined. She did so. When he died on 26 February 1999, Baxter was one of the two women to whom he entrusted his legacy, naming them as literary executors in his will. The other was Noa Zanolli Davenport, a Swiss anthropologist living in Iowa but working as an international consultant in dispute resolution. Zanolli had learned of Leymann's work and been so taken with it she visited him and Baxter in Sweden a few months before he died. With two colleagues in Iowa, Ruth Distler Schwartz and Gail Pursell Ell iott, Zanolli was at work on what would become the first American book in this area, :\fobbing: Emotional Abuse in the American Workplace (Ames, lA : Civil Society Publishing). This lucid paperback was publ ished less than six months after Leymann 's death and was dedicated to his memory. L meanwhile, had been introduced to Leymann ' s research by my wife Anne, a social work professor, in 1994. Bowled over by its insight and explanatory power, I made ample use of the concept of mobbing in my 1998 book, Eliminating Professors, about certain kinds of conflict in universities. More than that. [ had begun to study additional mobbing cases within and outside of univers ities, and was forming a relationsh ip with the Edwin Mellen Press for publication of my research. To my regret, however, l did not write to Leymann himse lf until about a month after he had died. Baxter read my letter. informed Zanolli of my interest, and in that way made the in itial connections that have resulted in this series of books.

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Baxter, Zanolli, and I met in person at what turned out to be a seminal conference on workplace mobbing and bullying organized by Gary and Ruth Namie, US psychologists who would go on to found the \Vorkplace Bu llying Institute and to lead the movement fo r antibullying legislation in American states. The conference took place in Oakland, California, in January 2000. Baxter arrived at the hotel carrying a large box of Leymann · s articles and books. She more or less infl icted that box on me. I brought it back to Canada. For the next eight years. work tovvard English-language publication of Leymann's books progressed very slowly. Out of respect for Leymann's work and fidelity to his request as death approached, Baxter plodded away painstakingly at her translations. amidst many other demands on her time. She sent me the products of her labor of love but I lacked time to do much w ith them, preoccupied as I was with my classes and \Vith my own research agenda on mobbing in academe, vvhich won appreciative reactions and left me overwhelmed with inquiries and invitations from beleaguered professors far and >vide, as well as from journalists, university administrators, labor unions, and researchers of many stripes. Then. in 2008, the Un iversity of \Vaterloo received a bequest in suppott of my research from the estate of the late Hector Hammerly, Professor of Applied Linguistics at Simon Fraser University in British Columbia. Hammerly had used my work to make sense of the onslaught of hostility he had faced at SFU . In 2001 ,1 had traveled to Vancouver at his request to give court testimony in his legal battle with the SFU administration. As his health spiraled downward, undoubtedly due in part to the stress of that interm inable conflict, he resolved to do what he could to support sound scholarship on mobbing in academe. Hammerly died in 2006, having made clear his wi sh that part of his modest estate shou ld go toward furthering my research agenda. The time at last was right for bringing the Leymann Translation Project to fruition. In the summer of 2008, !used Hammerly's bequest to hire two extraordinari ly talented and diligent research assistants, Hannah Masterman and Rachel Morrison . Masterman set to work editing Baxter's translations for readability and prose style. She also designed and wrote copy f{:>r the Leymann Memorial Website, which we incorporated into the larger mobbingportal website that was

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Morrison ' s chief responsibility . All three of us worked hard that summer. with an exhilarating sense of common purpose and shared commitment to the body of knowledge Leymann had begun. Masterman did most of the editing. Morrison did some of it. We then sent the edited versions of the books back to Baxter for further checking. and to ensure that nowhere had we distorted Leymann·s meaning. In response. Baxter did a great deal more work in an etf01t to reconcile our priority on fl uent. smooth-flowing prose with her priority on close adherence to the original Swedish text. Knowledge is produced in different ways. At one extreme is the large. well-funded bureaucracy staffed by careerist professionals. At the other is the solitary scholar working without institutional support. The Leymann Translation Project falls between these extremes, but closer to the latter. It has been fueled less by money than personal conviction of the importance of Leymann · s research. and of the ever expanding literature on workplace mobbing. For me. working on this project with Baxter, Zanol li. Masterman. Morrison. and the editors at Mellen Press. all of us in the shadows of Leymann and Hammerly. has been among the more satist)'ing and fun projects of my academic life. Thanks to ail these scholars. as also. for the necessary permissions. to the pub! is hers of the original Swedish versions and to Leymann · s coauthor, Annelie Gustafsson.

Current Scholarship on Workplace Mobbing For bringing oneself up to date on research in th is area, thereby discovering where Leymann's foundational studies have led. the single best procedure is to put the terms '"Heinz Leymann•· or '"workplace mobbing'' in standard search engines for research databases and the web. Leymann himself recognized the power of electronic media for dissemi nating research results, uploading his ·'mobbing encyclopedia" in 1996: it remains onl ine. and I am committed to keeping it accessible. in conjunction with the Leymann Memorial Website.

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Authors' Note to Readers outside Sweden The laws governing work env ironmental issues are different in every country. The first health issue t hat was looked at by any legislation was organic diseases caused by conditions in the labor market. Most European nations have laws governing these. but few have laws concern ing mental stress and its hazardous effects on hea lth. Therefore. the reader must be aware of the differences which exist from country to country. The discussion in this book is based on the Swedish laws and regulations. Nevertheless. our hope is that every European country wi ll soon aim at ach ieving improved healthcare legislation and resources for employees in the labor market. Extensive mobbing or bullying (as it is called in England) undoubtedly constitutes the most health-hazardous stress factor in working life. The contents of this book, which has been written based on the Swedish conditions. is also valid in all other industrialized countries - a fact which is supported by existing research from all around the world.

Authors' Dedication This hook is dedicated to all of the nurses who haw? taken their lives ji)l/owing rejection processes v.·hich we know they never could have thought of wishing even their worst enemies.

Introduction

Working life is a very important part of people' s lives. Sweden has been prominent - from an international point of view - in mapping mental strain factors. The \\"ork Environmental Commission (SOL: I()90:49 l provides a good summary of this research \Yhere. among other th ings. light is shed on suicide risks in various occupational groups. Working life research around the ·world has only dealt with suicides to a very modest extent. In this research. a connection to conditions in working life can be suspected. however. The research that has been carried out thus far has had, simplistically speaking. only two angles of approach: One has been of epidemiological nature where signi ticant differences in excessive mortality in suicide has been established among various occupations and where certain occupations show extrenl!! mortality. This research does not allow any conclusions to be drawn about causes. Another more qualitative approach has more concretely strengthened the assumption that certain conditions in working life can trigger su icides. However. ceitain analysts have suspected bias on the part of the interviewed individuals in these studies. A number of qua litative experiences connected to interventions in severe anxietal conditions which have been recognized as industrial injuries also point toward a connection with very specific causal conditions in work situations. We will account for these research results. In order to further advance the knowledge about suicidal behavior and suicide risks. it is important to obtain more detailed and chronological descriptions of the social situations which people have been subjected to before they comm itted suicide. or attempted to. In Sweden. a research program was initiated by RCC (the Research Counc il Commission) which comprised 4 1 individual research projects ( Bil!e--Brahe & Uinnqvist. 1996) during a period of time from 1988 to 1996.

Our aims \\ith the present research are mainly the fo llowing: I. The overa ll goal is to study if and to what extent suic ides can be linked to causal conditions in working life. One main method here has been to develop very accurate and comprehensive social anamneses \vhich are analyzed with a '"critical incident" method. 2. Another goal is to present a number of ideas tor prevention on the basis of estab lished and assumed causal conditions. With regard to the existing structura l conditions in the work environment, these w il l be d iv ided into preventive interventions. eal"iy interventions during confl icts and crises. and late interventions of rehabi litative nature. The effectiveness o f these preventive measures wi ll not be eYal uated in the present study, however. T he research has been financed by the Research Council Commission ( RCC). There were two reasons for applying for grants from RCC. One was that RCC had become engaged in financ ing a special suicide program v,: ithin the fram ework of WHO' s international program on suic ide prevention. There were hopes of being able to obtain contact w ith other suicide projects in the country w ithin this framework. Unfortunately, thi s hope was crushed since the fe male professor who was in charge of the WHO project in Sweden refused to have any contact with us since ne ither one of us was a licensed doctor. T his was also the reason why she advised the Physician's Un ion against supporting our research which meant that \\e had to decline from study ing the female doctors· problems w hich are even greater than the nurses' (see table I). \Vith that. our hope o f be ing able to obtain a more effective distribution of our research results through an affi liation with \VHO ' s suicide program was crushed. To cap it all oft the National Board of Occupational Safety and Health. who has its own publishing business. refused to distri bute our book. They felt uncomfortable with our "'provocative" title. We hope to reach the intended d istribution of L)lll" book despite this. In the following, we will describe the existing k110 H1 She would have presumably gotten antidepressant drugs for a long period of time and, with any luck. she would have gotten to ·'go for counseling." These conversations wouldn't have dealt with what she should do to actualize her civil rights which men with power had taken from her. No, the conversations would have dealt with how she could activate her coping mechanisms in order to adjust to this insult and --get over it." If this wasn't successful straight oft~ which it naturally can't be either when a person has been mentally abused and deprived of his civil rights, what would have happened in the conversations then° Well, the conversation would have perhaps begun to deal with Sarah's earlier experiences in life during her ch ildhood, and how these experiences had perhaps blocked certain ''mature" coping resources which would have meant that she, in her present situation, "wasn't getting anywhere." Because what psychiatrist would call Sarah's Primary Care manager and tell him off? We don't know anyone. In this manner, no suicide is prevented. In this manner, it is stimulated. Our three cases have been driven into becoming a type of dissident in a capitalistic, democratic, westernized country fo unded on the rule of law

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where the democratic. legal structures have been ''point"-annulled for their part. These women· s views about their rights and about what their authorities should do are labeled as ..deviating viev.•s'' and as having "'cooperative problems." The authorities· actions aim at getting these women to decl ine from these '·deviating views." to get them to ''listen to reason" and to adjust. When they don't give up but persist in their demands for justice. the authorities - who lay claim to the right of interpretation-·· label these women's behavior as socially deviating. They are punished because they are of the opinion that a country governed by law should guarantee them their legal rights. And this is exactly what the definition of the term ..dissident" comprises. Those affected are systematica!ly driven into a life as a dissident. Why don't psychiatrists cooperate in teams with the unemployment office, social assistants and jurists 0 Why has the social psychiatry w hich we saw such good examples of during the !960' s and !970' s disappeared? The answer is probably that society's healthcare resources are less strained if mental symptoms are treated with psycho-pharmaceuticals and psychologists are used to "bring a person to reason.'" A genuine social psychiatric method of working is too cost-demanding- and besides, far too uncomfortable for the power-holders.

How Serious are the Mental Problems as a Consequence of Mobbing? If the degree of difficulty in the diagnoses which deeply insulted individuals have received (Leymann & Gustafsson. 1996) is compared with, for example, that which people who have run over and killed suicidal individuals on train or subway tracks have received (Malt, Leymann et al.. 1993; Theorell, Leymann et aL. 1994), significant differences are seen. In general. people seem to intuitively be able to imagine how it must feel to try to stop a train weighing hundreds of tons and how the driver, despite these desperate attempts, finally runs over the person who has laid himself on the tracks to die. Yet, the drivers' PTSDreaction is - from a statistical point of view - much milder than the reaction that people affected by mobbing show. It is also a considerably smaller portion of the train drivers who contract a PTSD-react ion. The share of severe PTSD-diagnoses is therefore much less compared with the case for severely mobbed individuals where al most all who have been examined in Leymann ' s & Gustafsson's study have received very grave

209 diagnoses. This comparison can illustrate what these latter-mentioned patients must have gone through in the form of mental torment, anxiety. degradation and helplessness for long periods of time in order to develop these much more extensive PTSD-injuries. Similarly severe and frequent PTSD-injuries have been observed in raped women (Dahl, 1989). Our present hypothesis is that the examined group of individuals shows a much more serious mental development if the traumatic situations are maintainedfor a long period oltime and are followed by violations (~lthe individual's rights for a long period of time. In 1989, Leymann carried out a comprehensive review of the literature based on 25000 pages of scientific texts regarding psychiatry and victimology in order to study the disappointments, insults and renewed trauma following an in itial •·commencing trauma" - - which in this study were called ·'traumatizing consequential events.'' Many of these were triggered by administrative elements in society's handl ing (or '·not handling") of the •·cases." It's possible to speak about a traumatic environment for the mobbed employee. Psychiatries. the social insurance office, the personnel department, superiors, co-workers, the labor union, doctors in general practice. and company healthcare can, if the subjected individual is reanv unlucky, produce worse and worse consequential trauma. Our l~;ypothesis is that it is this never-ceasing stream of life problems started by the "commencing trauma" that is responsible for the development (?f chronic PTSD and which can. in afinal stage. result in suicide. In this manner. these individuals find themselves in a prolonged condition of stress and in a prolonged trauma-creating life situation. Instead of a short-term, acute (and normal!) PTSD-reaction which is able to subside after a few days or weeks, it is constantly repeated. New trauma and additional anxiety supervene in a constant stream at the same time as the experienced and objectively demonstrable violations of the individual's rights undermine the subjected individual' s self-confidence and mental health. Thus, the grave social situation for these [ndividuals consists not only of severe mental trauma but also of extremely prolonged conditions of stress which serious~v threaten and destroy the individual's socioeconomic existence. lfthey are torn out of their social situation, most are threatened by an existence of permanent unemployment or premature retirement with permanent mental injuries. Why does this avalanche of consequential events occur? We have tried to focus on this in our study. The situation is developed so catastrophically for the affected because

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the structure in the organization where he is employed has certain deficient qualities (see the English studies in Chapter 4, pp. 64ff.). society allows the employers, the labor unions and other participants to violate existing laws, prejudices with functional effects are allowed to spread themselves unrestrained (which is described in our chapter about attribution psychology). The situation which we must unfortunately verity in many of the cases we have studied is thus characterized by severe legal violations by authorities, who according to the norms in countries governed by law, are actually supposed to protect the subjected individual' s legal rights. Therefore, the situation appears to us to be a civil rights problem. We can see in these cases that even countries governed by law create their own dissident groups where those subjected show a high rate of suicide. Yet, just this group of suicide backgrounds could be easily overcome. Because due to the labor legislative laws, the regulations that focus on the work environment and the many professional authorities involved, it would probably be possible to develop effective suicide prevention "vith regard to working life. This will be dealt with in an upcoming chapter. Before then, we will analyze a typical representative from the suicide research where a hot subject of debate is whether there is a one-causesuicide or if all suicides depend on a diffuse multi-causality.

Do Suicides Depend on Many, Often Diffuse Causes? Why Did Sarah and Marie Die?

Multicausality as an assumed cause ofsuicide (O'Carroll, 1993)- this article is appreciated by the advocates of the view that a suicide is always multi-causaL i.e. that the real cause of a suicide can never be discovered such as we claim in this book. In fact, we find it difficult to understand why this article has received such attention since the author argues quite banally by comparing a su icide with starting a car motor (! ). We '>''ill discuss the article here not because it contributes anything important to our analysis, but only because O'Carroll is so highly praised by our opponents of another opinion. The author argues that the car maybe doesn 't start and that it would perhaps be possible to find a reason for this. Maybe the car doesn't have any gas or the battery is dead? Maybe the cause is even more multi-varied since maybe I had thought of titling the tank with gas but forgot to?

2! l

O'Carro!l debates in this manner in order to claim that the reason why the motor doesn't start may depend on many different things which are partially dependent on one another, in other words, are multi-varied. O'Carroll calls the colleague who can 't see the situation in the same way as he does himself ''naive,'' and he calls the debates for or against multicausality dishannonious, unproductive and disturbing. One colleague's model which he is enchanted with is praised in this ·'scientific'' article as being "elegant" (p. 29). This model (Rothman, 1986) argues that the various factors in a suicide cohere and cannot be separated to explain a su icide based on one of them as a cause. O ' Carroll argues that ''decisive to start the car is not that nothing happens when the ignition key is used, but rather that the ignition key is used in a car where the battery is dead, the gas tank isn't completely empty and the car motor doesn't have any other greater problems (p 29). All of these parts function to start the car, but it doesn't start because one of the parts doesn 't work. If the battery were to be connected to another car's charged battery (prevention !), the car would start. The problem with the so-called multi-causality can also be demonstrated on the basis of Beskow's ( 1996) study. A number of factors, of which each one multiplied the risk of suicide. were accounted for there (see pp. l6ff. in this book). We will account for this list one more time: Mobbing at work (risk factor 8.4 ). Loneliness (social isolation) as a consequence of mobbing (risk factor 3.5 is stated only for divorcees and would probably be higher during more extensive social isolation). Poor fitness with physical and mental exhaustion as a consequence of mobbing (risk factors 3. 7 and l 0.9 respectively). Very poor health as a consequence of mobbing (risk factor 6.4 ). Dissatisfaction and feelings of discomfort before work as a consequence of mobbing (risk factors 7. 1 and 8.4 respectivelydiscomfort often turns into sheer anxiety in mobbing victims). Psychiatric illness (most often depression and PTSD) as a consequence of mobbing (risk factor 8. 1). Eight increased risks of suicide which can be thought to represent a ''multicausality'" are thus accounted for here. On the basis of our own studies (see the three occupational-social anamneses earlier in this chapter), we can j ust as well claim that these factors in themselves are consequences of one single circumstance. Namely, that the individual has been mobbed and that this mobbing was not the consequence of

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personality problems in the victim (research on adult mobbing has thus far not given any reason \\hatsoever to suspect a causal connection with the victim's personality) but can be claimed to have a connection with the organizational characteristics that existed at the victim' s workplace which led to severe social and emotional losses for the victim. (See also our discussion about the victim's loss of autonomy in the next chapter.) However ---· transferred to the debate about causes of suicides ··-· O'Carroll is ofthe opinion that a depression alone cannot be considered to be a cause of suicide. There must also be other elements that are criticaL His conclusion is that multi-causality cannot be excluded. If we want to. we can naturally characterize Sarah' s suicide as being dependent on many different causes: that she didn't receive the proper help, that she had a severe depression, that she felt abandoned. that she felt listlessness in her career in her last years or that she had been afraid of losing a decisive court proceeding. If Sarah is seen as one of the respondents in a statistical study, we are of the opin ion that O' Carroll's argument can be of use because Sarah, in this situation, becomes a statistical factor. However, we have shown in this book how an epidemio logical, social anamnesis, which covers many years, can reveal a course of events that, sooner or later, ends in a suicide. The anamnesis clearly shows that the fact that Sarah had been mobbed by her managers, been persecuted and deprived of her civil rights, sooner or later, results in a total elimination from the labor market and should be seen as the cause of Sarah's suicide. Later on in the book, we will argue that suicide prevention with regard to I 00-300 suicides in working life consists of all participants observing and respecting the \Vork Environment Act and its additional regu lations. The structurally effective measure is to ensure that existing laws are respected in the work environment. Why does this strange debate about the causes of suicide exist at all? There are several conceivable reasons. One reason may be that suicide researchers mainly work on the basis of statistical information and not, as we do, on the basis of courses of events in people' s lives, i.e. their occupational-social anamneses. Another explanation may be that psychiatries, which on the whole has the worst success rate within medicine, finds self-criticism difficult. It is in fact so that one of the most reliable prognoses of suicide is that a person has been treated within psychiatries. Another reason is naturally the circumstance which we have discussed under the heading "attribution psychology," where modern research shows that even psychiatrists and psychologists can't safeguard

2!3

themselves from the human psyche's inherent tendency of placing, if not all, at least a great deal of the blame on the victim . If you are of the opinion that a desperate person can't become more desperate because psychiatries gives the wrong treatment, there must be causes which shov.' that the individual who commits suicide differed from other citizens. Sarah's problem could never have been '·broken at its weakest point in the multi-variable chain.'' as O'Carroll boldly claims (p. 35). Sarah's weakest point having been bull ied by power-holders for many years, is her occupational-social anamnesis' strongest point if the situation is j udged from an aspect of power. The ''weakest" point would have been to bring her managers to reason. However, this is not possible because this, her ''weakest point," constitutes certain power-holders' brutal abuse of power which no psychiatrist could master. Sarah's '·weakest point'' coincides with the power-holders' ·•strongest point" which cannot be taken care of without resorting to structured measures, e.g. making inspections and taking legal measures against rights violations. Both the National Board of Occupational Safety and Health and a legal system would have been able to intervene preventively - if they had chosen to. Thus, we recommend (see later on) structural measures stipulated by law with regard to far-reaching reforms in the psychosocial work environment. People who feel well at work and who feel commitment and recognition don't commit suicide. Naturally, the reader must not think that we in this way reject O ' Carroll's theses. There is a real possibility that they can be used for specific mental illnesses, e.g. schizophrenia. However, if it's a question of suicides on account of conditions in the work environment, we consider O' Carroll's theses to be totally incorrect.

Why Suicide? As readers of the grave fates which encounter us in the three case descriptions, we can intuitively identify with the affected individual and intuitively ·'understand" some of the reasons for taking one' s life, t o no longer be able to go on living. In the following, we will let two people speak who have experienced the strange situations that arise for victims of assault. One of them is Jan Philipp Reemtsma, who was abducted by a group of gangsters and held isolated for 33 days in a basement while the criminals demanded a ransom. Reemtsma has in a touching and at the same time intellectually admirable way portrayed his encounter with total

2!4 subjection and powerlessness. The other is Hannah Arendt, a well-known sociologist who has written important works about the human being' s degradation and ce1tain social systems' malice. We believe that both of these testimonies can convey a deepened understanding surrounding the question '·but why suicide?" About Powerlessness and Superiority

Jan Philipp Reemtsma was assaulted and abducted in March 1996. The kidnapping occuned for the purpose of blackmail and the criminals demanded a very large ransom from his family. After several attempts to hand over the ransom wh ich were said to be disturbed by police activities and led to Reemtsma spending a considerably longer period of time as a hostage than what was intended from the beginning, his release occurred 33 days later in April. Reemtsma gives a touching portrayal of his abduction and time in captivity chained in a basement. His analyses of his condition during and after the kidnapping and the experiences that led him to the edge of existence are, in my opinion, even enormously important in understanding the suffering and the actions of people severely affected by mobbing such as they appear in our three case descriptions. In order to concentrate on the understanding of the individual rejected through mobbing, l will allow myself to give a selection of quotations from this book (Reemtsma, 1997). However, l won't recount his story, l will allow myself in the fo llowing to be inspired by his clear-sightedness, but transfer his interpretations to the mobbing victims' situation. I will give a page reference when I quote directly from the book. There is much in a hostage situation which naturally can't be transferred at all to the s ituation for a person rejected by society - and vice versa. I have, for example. among 1400 mobbing patients, never experienced that the so-called Stockholm syndrome has occurred (i .e. where the victim seems to begin to ally himself with his captors, see Leymann, 1989). which is so common in hostages. The reason is tairly clear to me: they aren't forced to live day and night under threat together with their captors as their only human contact. Many mobbing victims no longer have any human contact at all on account of the self-isolation they are driven into. Reemtsma describes his struggle to preserve his subjectivity, to remain as a subject even in his captors ' perception of him. He didn 't want to be regarded as an object, an object exchangeable for money. These lines remind me of a similar struggle led by the people who were rejected by society through mass mobbing. They wanted to remain as subjects. They

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suffered from the objectification which the surrounding had trapped them into. Like Reemtsma. the mobbing victims experienced an unequivocal relationship to power: no division of power but a brutal "side by side'' omnipotence in the surrounding and total powerlessness in themselves. They lived in constant attempts. ·which Reemtsma also portrays, to achieve just a little autonomy, not to see themselves as totally dependent and extinguished as subjects and individuals. One's soul becomes severely injured and this injury affects a mobbed individual in a special way since the power-holder has the pO\ver to distort the victim's intentions and interpret them as insubordination. inability to cooperate or that the individual was subjected on account of a "malicious character. ·• Reemtsma discusses the situation which implies that the matter of deciding on a feeling or an action basically means that the subjected has a choice of possibilities to decide on one thing or the other. In a victim situation, the choices are forced. provoked. In the end, there may be only one choice left - the choice between continuing to fare poorly as one does or committing suicide. The advantage with the latter is that the victim can demonstrate the last remnant of autonomy he has left. How can a person ··manage" such an experience? This question presupposes that he has an idea of what "manage" means. Reemtsma discusses the difference between ..managing" and "not managing.'' The idea of ''managing" or ..not managing'' builds on a notion about a point in time in which the individual shifts from "managing" to "not managing any longer." In his way of exercising absolute power over a victim, the individual as a wielder of power must also have a notion that the victim can give up. (Reemtsma mentions that this is probably easiest to understand during torture since torture is most often used in situations where it is intended to break down the victim's resistance.) ''It is probable that something, you don't know what it is, is coming to an end. You endure and then no more. And thereafter? What happens then? You speak if it is the captor's goal to get the victim to speak. Or you scream if you had clenched your teeth before then. But what happens if there aren't any of these determined moments') A hostage can't give up even if he wants to since this possibility has been taken from him. It is others who decide what is and what will be \vithout the hostage being able to influence this by giving up or not giving up." (p. 190) For a victim like Sarah, it is a question of giving up, i.e submitting to the slayer's will . Accepting his dictate, his version of the situation, his interpretation of what is counted as good or evil, giving up one's human dignity which consists of a little

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piece of autonomy. a smalL small breathing hole that can give one' s selfrespect a smal L small volume of oxygen. The employer (or other immediate power-holder in society) never sees himself as a perpetrator. He sees himself as a benevolent boss who is dealing with an unruly child and he waits·-·- and here there is a structural similarity to torture situations - for the child to fi nally ''yield." I have never met one of these organizational perpetrators, men or women, who have had the slightest idea that this ..yie ld'' means that the victim relinquishes even the last drop of his feeling of autonomy. In real ity, the perpetrator, man or woman. demands that the victim give up his claim of being a human being, that he degrade himself to an apathetic being. As Reemtsma writes: What notion does the person who says "I wouldn't have managed it" have? Or what mobbing victims often have to hear: ''I would have certainly managed that mobbing." And then the horrid condemnation: "Since he or she didn't manage. he or she must have mental character defects!" How do fantasies about the victim 's possibilities of managing or not managing in th is situation arise? The fact is that even the victim's self-image will with time become dependent on the person who is exercising the violence. Sarah, for example, fought desperately so that her self-image would not be totally abducted. It was broken but she safeguarded the remnants. She took her life as the only remaining demonstration of her autonomy as a human being. "Subjection to superiority reduces the victim, makes him little, exposes him and is also always a desecration and insult even if an outsider doesn't discover anything that he wants to consider to be something embarrassing." (p. 191) For a mobbing victim as for a hostage, " it is easier to accept an evil fate than pure coincidences. You often hear that people whose lives have taken an evi l turn complain that they didn't deserve this evil and they ask what evil they could have done that should be punished here? It is often easier to accept an injustice than to accept an entire world that no longer provides the possibil ity of being able to be judged by ingrained measures like right and wrong." (p. !92) Mobbing victims can never understand the reasons why they are subjected to this stream of never-ceasing and desecrating actions, no matter what concept the involved individual, whose actions harm, follows. The situation becomes absurd, becomes a Kafkaesque situation that risks stripping the subjected individual of all worth as a human be ing, including his or her autonomy. ''Confronted with conditions in an extreme manner. you discover how much you up until then had believed that you could be your own life' s

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director.'' (p. 192) You think that the vvorid is an orderly place where everything proceeds in an orderly fashion after rules and rights and that you can depend on it. Until you, like Sarah, discover that the world can become a non-world, something that no longer can be foreseen, something that you no longer can rely on, a nightmare, a horror story. Can the surrounding that has never experienced anything similar on the whole come anywhere near empathy or even understanding? !, Leymann, don't th ink so any longer after my many meetings with people who have been launched into an airless orbit, into a non-world. Is it possible to imagine how it fee ls? No. You ''can probably not explain this to anyone who hasn't experienced something similar, that the real terrible thing is this absolute helplessness, this absolute extradition.·· (p. 193) Respect could be shown. Instead, blame is offered . Even psychology, that wants to be a science about people's emotional lives and whose professionals would perhaps be able to understand what goes on in the victim's soul, betrays the subjected - you have become a victim because your character is such, because the experiences in your childhood have meant that you have become the person you have become. If you had been different, you wouldn't have reacted as you did, then others wouldn ' t have treated you badly. But, Reemtsma objects: "The blame for a crime has the person who commits the act not the one who is subjected to it.'' (p. 192) In her poem, Sarah bears witness to how her individuality. her identity is reduced through the meaninglessness which the situation's power-holders (the employer, the social insurance office, psychologists, doctors, the labor union, managers etc.) actually demonstrate that she finds herself in. Sarah is a non-person for whom they discuss the profitability of an investment in a support person at a couple of hundred crowns a week. She is forced to experience herself as singular: "Individuality and identity with oneself or one· s own authenticity presuppose a complex relationship to the world around one, to the people's world. There must be social connections, communication, a minimum of power to dispose over something. Communication with the person who represents absolute power has therefore this very special degrading potential for the completely powerless human being.'' (p. 199) "Therefore, capturing the possibility of a suicide becomes such a triumph."(p. 199) "A suicide nevertheless means a possibility of remaining autonomous in this final act." (p.21 0) Marie experienced media exposure which was for the most part based on lies, journalistic bias and malicious gossip. Similarities can be

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observed here with, for example, people who have been hostages. Reemtsma was absolutely to be shown after his release. He was to be seen in newspapers. Furthermore, he was to comment on other's comments about his fate: "And then it happened. From one minute to the next. I was in the basement again. The feelings were there again and swelled up within me, everything else was shoved aside. There was no room for anything else, nothing else was there any longer. Only the basement. A mixture of paralysis, an extinguishing of strength, a draining of all other emotions like a deep depression that had bui lt itself up for days: at the same time, ail of the nerves were overstrung, an extreme, fumbling nervousness. A repeat of the combination of suffocating desperation and constant, nervous expectation." "The nervousness grew, the stronger the feeling of paralysis became. I can't manage this any longer! was the only thought that there was room for beside this flush of feelings." (p. 212) '·Sudden noises startled you, made you almost raging with anger; you react differently to usualness, are besides very easily vulnerable. The surrounding perceives that 'his nerves are finished.' You tolerate it at the beginning, but don't accept it in the long run." (p. 2 13) ''There are always certain irritations, certain stimuli that trigger this inner breakdown, sometimes also the sum of the irritations." "During this time, I felt worse day by day." (p. 214) Sarah wanted to see her slayers punished. They \Vould atone for everything that had happened to her of depression, existential anxiety. suicidal thoughts and powerlessness. But instead, these men were promoted, rose in the ranks, and were offered to build their own company through a healthcare agreement with the county council. "The person who has experienced injustice desires revenge. This need is not to be disregarded. Sometimes revenge is soothing, sometimes not. Revenge is not allowed by civilization since it can result in an escalatory dynamic which can end up out of all control.·· (p. 215) Sarah had the same impulses. On the one hand, an impulse for revenge, on the other, civilization ' s brakes. l know that she was very afraid that this brake would give way. She sought refuge in verbal attacks: ·'I'll scratch your eyes out, you bastard!" The employer used these outbursts of powerlessness for their claims of an objective illegal threat and there was a risk that society in its courts would say: ·'Dreadful. You are malicious, dangerous to yourself and your surrounding." Sarah was, as long as l knew her, afraid of being locked up in a mental hospital. I know that there are plenty of psychiatrists who, for lack of knowing better (a Swedish doctor receives less formal education in psychology for his degree thana social worker!),

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would have interpreted her boundless desperation in incorrect psychiatric terms. Her interpretation of the employer's activities against her and her experiences of the employer"s wickedness would have probably been interpreted as a manifestation of serious paranoia. She would have preferred suicide as the on ly remain ing expression of human autonomy instead of allowing herself to be drugged at a mental hospitaL I know that this yearning for autonomy would have been interpreted as •·not being aware of her illness.'' a diagnostic. cardinal criterion for psychosis. The women in our case descriptions were rejected from society. civilization and the world. The omnipotent surrounding had ''taken from them the right of being able to prove that they were right- because there was simply no longer a social, legal forum where their legal cases could be actualized." With this quotation from Hannah Arendt's works, we will go over to this philosopher's reflections on the rejected human being. About the Rejected Human Being's Degradation

Sarah's Golgatha is the story about a person whose entire dignity and world has been laid in ruins. Certainly, they meant her "well", but the limits for this "well-meaning" were put in adamant terms by a powerconscious employer. That he with his dictatorial "offers" found himself far outside the limits of the laws- that troubled him little. Sarah's poem of powerlessness reflects this cruelty. Sarah and many other people who are rejected from society and who, through this process, lose their civil rights become creatures without legal rights and lose their faces in this world of working life. The fact is that those who are rejected from intellectual fellowsh ip through mobbing don't only lose their moral existence. they are threatened more and more of losing even their physical existence. Among my, Heinz Leymann's patients, there are many who. even they, are on their way into a total economic elimination on account of legally repulsive actions from the surrounding. Their diagnoses are rejected by the social insurance system; industrial injuries are not av.·arded to them with claims in the courts that their labor legislative situation is not covered by the clauses in the industrial inj ury insurance law. On the political level, they have fe llow brothers and sisters in those who are banished from their civi l rights by dictatorial, political regimes. For these people and also for Sarah, there are social analyses worth considering by one of the greatest political philosophers, Hannah Arendt. Seibt ( 1995)

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devotes her analyses much space. We quote the section ti·om his compressed text which best touches on our report: '"The civilian cover is ripped away and the expelled human being is reduced to a destitute, physical existence. She is socially more naked than an animal because she has lost her place in life. She is forced to accept that only her physical skin remains as the border of her existence. What is more, she is without means and legal rights, referred to charity. She has lost her status as a citizen and her participation in a legal system." Hannah Arendt has chiseled out this latter-mentioned aspect emphatically in her epoch study 'Elements and Origin for the Total Exercise of Power. ' The human driven away, as Hannah Arendt has portrayed her, virtually becomes an abstract school object for the classic human rights doctrine. This human being has been deprived of her role as a citizen by a government that was thought to guarantee her a primary legal system. She has been deprived of her right of being able to prove that she is right because there is simply no longer a legal forum left for her where her legal case can be actualized."

6

Suicide Prevention in Working l ife, a Basis for Discussion

The National Council on Suicide Prevention In 1995, the National Council on Suicide Prevention. wh ich is supported by the National Board of Health and Welfare, the Institute of Public Health and the Center for Suicide Research and Prevention, published a so-called national program for the development of suicide prevention. The background to the national council's creation had been activities within WHO, who during a conference i Szeged, Hungary in 1989, demanded that its member countries establ ish national programs for suicide prevention. The starting-point for WHO's activities was a continuing negative development in suicide mortality. During another conference in Canada in 1993, the UN and WHO, who were the organizers, described how the goals for the national programs should look. A national counci l for suicide prevention was not set up in Sweden until 1994 - five years after WHO's request - an embarrassing delay for Sweden's part. Presumably as a consequence of remai ning prejudices about the causes of suicide, the goals, guidel ines and strategies were mainly concentrated on activities that aimed at influencing the individual. In the council's publication ( 1995), no lengthy discussion emerges about social structural conditions that destroy the citizens' social lives and provoke suicides. In

222 one section about background factors (p. 20). it is stated that behind suicides lie "in most cases a mental disturbance, predominantly depressions." Nothing is mentioned about the causes of these disturbances, so the reader must draw the conclusion that mental problems in individuals arise in a diffuse way from out of the blue. Furthermore, it is stated that of "those who commit suicide during a depression. almost all are untreated or insufficiently treated. It often deals with several interacting background factors," about which nothing is conveyed in the report, however. According to the council's publication. suicides, mental problems and depressions seem to affect mankind like epidemics from at present unknown, contagious matter. Moreover, it is stated that it is very difficult to predict a suicide risk based on personal, social and cultural factors (p. 21 ). Nothing is more incorrect than a statement like this which the case descriptions in this book show. If anything, it seems to be too painful for society's power-holders to accept the truth that it is just these structures in society that increase the risks of the citizens' suicides. The prejudices and taboos surrounding suicide still seem to be strong enough that it's not even possible to draw concrete conclusions from conditions in other areas of death risk. The council writes (p. 22) that cases of work-related accidents ''during the last 40 years [have] decreased from approximately 500 to I 00 cases per year (the counci l doesn't take into account that 20-40 of these fatal accidents occur in traffic to or from work, i.e. that only about 60-80 are direct, fatal accidents at the workplace). During a somewhat shorter period of time, the number of deaths in traffic accidents have almost been halved and now lie between 600-800 deaths per year." In addition, they state that "the methods (in these areas) which above all have been successful within the areas of the work and traffic environments have been so-called passive method5, i.e. methods that have a general effect and are not dependent on the individual's active decisions in each individual case." What does this comment mean? Indeed, a confession that structural intervention in specific life environments (here the work and traffic environments) is a very effective method. However, in the counci l's program ( 1995), they mainly talk about increasing awareness, educating, giving individual mental support in crisis etc. Certain ly, even these methods must be resorted to but why do they wave aside structural measures ("passive methods"- the mere term ''passive" as a description of active structural measures is disturbing)? We have shed light on this in

our book under the heading ·•attribution research." It is prejudices, taboos and the blaming of individuals. above all within psychiatry and cl inical psychology, that impede. This may haw led to what we will describe under the next heading which hasn't been mentioned in the council's program at all, the laws within the work environment.

Special Possibilities for Suicide Prevention in Working Life The governments in most of the western industrialized countries have established special laws for the purpose of protecting their citizens when they find themselves in certain organizations. These special organizations are either those where citizens are forced to participate by law (e.g. school children in school, military servicemen in the military) or where economic centers of power may be feared of exploiting ind ividuals in a manner which the country's constitutional laws don't intend (e.g. employees in a company). Despite that there are still schools within psychiatry that claim that biological or diffuse "multisocial" causes are the only causes of suicide, there can no longer hardly be any doubt in the informed researcher or even in the public that just these three types of organizations mentioned may put an individual, who is a member there, in such a social situation and such mental powerlessness that a termination of life may appear as a desirable alternative. Trends of events within the framework of a membership in any one of these three life environments are often the immediate causes of a development that may end in a suicide. When we discuss suicide prevention in working life in this concluding chapter. our assessments only apply to the group of situational causes which we have devoted this book to. We do not discuss suicide as a result of an incurable disease, for example, a painful cancer. We don't either discuss suicide for other reasons, we only discuss suicides that may occur on account of severe mobbing, mental terrorization or rejection which results in, among other things, deprivation of important civi l rights. In our study, we have found that this occupational social problem is highly credible as an explanation of the subjected individual' s escape from an intolerable situation. The evidence from the studies which are accounted for in our book (see even Leymann, 1987) indicate that a

224 considerable share of an industrialized country's annual suicide rate has these causal conditions as a background. Th is evidence indicates that I 0 percent, perhaps even 20 percent, of the annual suicides in Sweden belong to the group of suicides that we have devoted this book to. According to the study mentioned, it may namely be presumed that between 100-300 suicides per year - of in total 1600-1800 annual suicides in Sweden - may have psychosocial problems in working life as a cause. Since mobbing and rejection in other western industrialized countries seems to have a similar, if not greater distribution (Leymann & Zapf, 1996), there is also support for the hypothesis that these results may even apply to these countries. Our intention with this concluding chapter is thus to discuss suicide prevention with regard to conditions within working life. Naturally, we will only choose to emanate from the Swedish conditions. Based on the fact that society has special laws that concern terms of employment, among these the psychosocial ones at workplaces, there are also special and very effective possibilities of suicide prevention. We want to develop this conceptually. The Swedish legislation provides comprehensive regulations in order to avoid just the situations which we have been able to point out as risky from a suicide standpoint The Swedish Work Environment Act requires qualitative psychosocial standards in the companies' work environments. In order to guarantee this. it is required in another regulation, (AFS 1992:6), that the employers are obl igated to uphold a control organization, i.e. a safety committee. This is imposed by law for companies with more than 50 employees. Smaller companies are required to be inspected by union regional safety delegates on a regular basis. Furthermore, there is a law that requires labor union organizations to appoint safety delegates among their members who, according to law, are allotted extensive authority. These safety delegates must exist as soon as the company has more than five employees. Work with the supervision of the work environment is carried out according to AFS (1992:6) and applies to the contents and routines for the companies ' internal work environmental controls. During its recurrent inspections, the Labor Inspectorate - a national control agency under the National Board of Occupational Safety and Health - ensures that this internal control, above all, functions at the company. For surveys, improvements and maintenance of a good standard, the companies have access to an organization of experts: company health care. Among the personnel at

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company health care, there are company doctors, industrial engineers, industrial psychologists, company nurses, physiotherapists and other specialists. Their job is also to carry out medical examinations of the companies' personnel on a regular basis. Affiliation to company health care is mandatory for the company if there is an agreement with the employees' labor union organization to that effect. With regard to the quality of the psychosocial work environment, there is a special law (AFS 1993: 17) that forb ids mobbing and rejection at the workplaces (which in Swedish bureaucratic language is called ..victimization at work"). This regulation is very concretely worded and defines and exemplifies the problematic situations well. For employees who despite this regulation are subjected to these problems there is a regulation about occupational rehabilitation (AFS 1994: I) t o resort to. Indeed, this regulation applies to absence for every form of illness cause, even those causes that don't originate from working life. Special rehabilitative work, which the employers are responsible for and the social insurance office supervises, must be carried out as soon as an employee is absent for one month or has had a number of short-term absences within a one year period. It goes without saying that these regulations and their implementing organizations in themselves constitute very far-reaching suicide prevention with respect to our group of themes which could hardly be further improved. A better comprehensive supervision of the nature of the work environment, a better procedure for screening and identifying suicidal individuals and better access to rapid therapeutical measures of every imaginable type can hardly be achieved in our opinion. Yet, this system allows nearly I 0 to 20 percent of the country's annual suicides to be produced within its framework. How can this be possible?

The Swedish Regulations and Their Shortcomings: The Implementation The reason why the suicide rate as a consequence of psychosocial problems at the workplaces is so high is that there are serious shortcomings in the Swedish system of implementation. Furthermore, there is reason to assume that at least some of these shortcomings are purposely created on governmental and departmental levels in order to limit expenditures. These shortcomings have been assessed on the basis

226 of two qualitative aspects; on the one hand, the patients' accounts with respect to their own experiences were evaluated at our clinic and, on the other hand, Leymann · s ten year experience as a researcher and teacher at the Labor Inspectorate at the National Board of Occupational Safety and Health was taken into consideration. The problems in the various areas are the following:

Attribution psychology As the case anamneses show, there is a general tendency to ·'accuse the victim'' of his own fate even if this tendency, for example in Sarah's case. couldn't manifest itself totally since Sarah's company doctor had comprehensive knowledge and could hold his own against the attributers. Indirectly, the attribution can be traced. however. The behaviors and actions of the employer as well as the union harbored an unmistakable character of this. The three women in our case descript ions were "punished" because they showed signs of serious desperation which is a symptomatic element of chronic PTSD. In my clinical work, I, Leymann, have never met a single person among approximately 1700 patients of this type who has not been subjected to this attribution and subsequent elimination. This occurred because the dictatorial participants in the surrounding (above all the employer. the union and the social insurance offices) had been irritated by their symptoms and had therefore chosen to "punish" them by denying them correct handling. Naturally, this stigmatization and mental abuse leads to a constant worsening of a highly stress-induced behavior with at times in individual cases, purely absurd stress behaviors in the victim. The usual is that no one in the surrounding is capable of seeing this behavior as a tormented individual's symptoms and as a cry for help. Through attributions, the power-holders can justify severe insults and blame. These are very active elements which push a negative development in the individual's psychosocial situation and can in this way contribute to a suicide.

Internal control and conflict intervention There are a great number of inventory instruments and questionnaires for the physical work environment. It is also relatively easy to inspect since faults are often discovered .with the naked eye. It is at once more

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difficu lt with the psychosocial environment. Severe mobbing processes are easy to cover up. They aren't noticed as easily during an inspection. One of the work leader's roles is to intervene during conflicts. This shou!dn 't only occur for work environmental reasons but even for business reasons since confl icts can be costly for a business because they often lead to qualitative and quantitative production problems. In Sweden, these interventions are rather rare. Superiors in general lack social competence and/or management education in the area. In this way, conflicts have a breeding ground in secret. Furthermore, the Swedish mentality (see Daun, 1989} prevents an open intervention in other's conflicts since it is considered to be rude to "poke noses into other people' s business." Conflicts in themselves already belong to - in the Swedish mental environment ·-- the discrete and unmentionable. Thus, there are a number of reasons why confl icts and thereby commencing mobbing processes are not detected early enough. Added to this is one of the Labor Inspectorate's most common criticisms against the companies: that internal control is not carried out. For that reason, a problematic situation can easily be developed to such strength that a suicide occurs without it being discovered in time.

Union Support Labor union organ izations in Sweden have with few exceptions had great difficulty in accepting the mobbing concept. This doesn ' t only have to do with the Swedish mentality already mentioned. It has even more to do with union representatives who can receive complaints from a union member who is severely mobbed by other union members. In our case ana lyses, we therefore often see a ''pseudo-democratic" attitude in the union representative. If word stands against word among union members, the party who is ''in the maj ority" gets the right of interpretation. Logic states that mobbing processes - since there are often two or three or four who harass a single person - can seldom be stopped in time through an intervention by the union or a safety delegate, even if there are a lot of praiseworthy exceptions. For reasons which we can only presume, some labor unions decline all involvement in connection with ''victimization at work," even if there are exceptions that slip through the more general policy. This has most often been recounted by subjected individuals who belonged to the physicians' union, the psychologists' union, the nurses' union, SHSTF and the

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municipal civi l servants union. SKTF- i.e. labor unions that affiliate employees within hea!thcare occupations in particular. From the lattermentioned union, a number of those subjected have received information from the central quarters in Stockholm that "we don't work with victimization at work; you have to find a private lawyer." This observation must be made with discretion. When all is said and done. it is never the policymakers at the labor un ions who handle the cases. What is decisive is the moral of the individual union representative who stands by his member. Thus, there are even cases that are well managed and worthy of imitation in the unions mentioned because a union representative on a lower level had acted courageously. The situation is most problematic for the subjected un ion member when the case is lifted centrally to a legal level. Here, it is quite exceptional in certain unions to find an administrator who doesn't act according to the attribution theories. The most severely injured patients thus far have also always been those who haven 't received any support from their central union. The most insightful and competent union jurists in this connection are found within LO-Legal Protection AB. The problem is that labor union organizations relatively often shut out their members from a union legal solution since the union is forced to pay the legal costs for their member, something which they readily avoid, in particular if they can act on the basis of attribution psychology. The union's deceit is experienced by all who are affected by it as a severe and traumatizing shock which sheds a bright light on the loneliness and the loss of rights they have already begun to experience. The unions' alienating action is clearly suicide-provoking.

Incorrect Medical Diagnoses The DSM diagnostic manual has existed for almost two decades and WHO's manual, lCD, since the 1960's, even if the PTSD diagnosis wasn't described until the beginning of the 1980's. Despite this, the PTSD-diagnosis is unknown to most Swedish doctors including psychiatrists, not to mention the psychologists. With a starting-point that one as a doctor simply can't imagine that what the patient claims that he or she has experienced in the form of persecution could be true, the logical attribution follows that either the patient has made up the entire story himself, or that he or she is vehemently exaggerating. The risk is

229 that the patient receives a paranoia diagnosis (or even ·•cantankerous paranoia"), in particular when some of the symptoms that are found in PTSD can only be associated diagnostically through differential diagnostics. The diagnosis thus depends on whether the patient can get the doctor to believe that the stated events are true. If the doctor receives information from the employer and the union which contradicts the patient's account. the doctor can be quite convinced that his attribution diagnosis is reasonable (Yes, unfmtunately. It isn't at all unusual that a doctor has private contacts with the employer before he or she makes his or her diagnosis!) Some of our patients have been involuntarily admitted to institutionalized psychiatric care in connection with these incorrect diagnoses. One of the patients had been drugged with strong antipsychotic medicine for ten years after such an admission. Another example is a patient \vhere the employer, the County Council in Malmohus, attempted to label her insane a number of times. A final attempt was made days before her trial against the employer. This was portrayed in the verdict as a reprehensible assault by the employer (Leymann, 1989). Other incorrect diagnoses are manic-depressive illness, personalityrelated adjustment disorders and character weaknesses. During the conversations that I, Leymann, had with individuals at the employer in Sarah's case, I could often notice discreet insinuations whether it wasn't nevertheless possible to see "personality-related mental problems" in Sarah's background. For an employer, and often even for the labor union, an attribution with a psychosis diagnosis solves the problem for good - and thereby most likely pushes the patient closer to a suicide. For the incorrectly diagnosed individual, this situation is experienced as deeply insulting. Even this can be suicide-provoking.

The Labor Inspectorate's Role Society has a widespread network of Labor lnspectorates over the entire country. Their role is to ensure that the work environmental laws and regulations are observed. Many labor inspectors have chosen to work more intensively with psychosocial questions since they can see in their daily work which problems can be created here for the employees. During the time when !, Leymann, as an associate professor and employed at the National Board of Occupational Safety and Health's research department,

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lectured on the subject of industrial psychology during the education of the labor inspectors, there were often conflicts between the labor inspectors and the then manager of the Central Labor Inspectorate. The latter-mentioned was strictly against a work priority that paid more attention to the psychosocial questions. This situation has been improved (see the handbook for labor inspectors regarding psychosocial problems at work: Marklund, 1996 described earlier). When the National Board of Occupat ional Safety and Health introduced the law against victimization at work, they created a convention for the labor inspectors at the same time. They were not permitted to intervene on the basis of individual personal cases. However, this convention is only applied when it concerns psychosocial problems and mobbing at the workplace. In connection with physical accidents and cancer illnesses as a result of unsatisfactory conditions in the work environment, they intervene now as before even on the basis of single individual cases. In Marklund's ''Handbook for labor inspectors," this older attitude is substantially modified by the National Board of Occupational Safety and Health. It is true that they point out that a labor inspector should not become engrossed in an individual case of mobbing, but that he should take this individual situation as a starting-point for concrete demands on the employer. Thus, they should work with individual cases but this work should result in injunctions based on existing laws and regulations. They should not attempt to solve an acute conflict or act as the company's consultant in the situation that has arisen. However, it frequently occurs in the practical work that the Labor Inspectorate doesn't take up mobbing cases or similar severe confl icts at all by defining them as work with individual cases. The immediate work with this type of case can differ immensely from one Labor Inspectorate district to another. The prior instruction to the labor inspectors (which with Marklund's handbook are nullified) thus lives on. It came into existence in its time because the authorities feared that the number of cases that had to be handled promptly could hurl the Labor lnspectorates into a staffing crisis. In addition to that, they have received unanimous confirmation from the employer unions as well as the labor unions that psychosocial questions should have a low work priority. But still today. officials at the National Board of Occupational Safety and Health can imply that ·'nothing effective can actually be done against mobbing." This is naturally not the case unless the authorities systematically accept the employers' violations

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of the law. Suicides within the work environment are a subcategory of the ''psychosocial work environment" and thereby have a low priority. In that mobbing ----- ·'victimization at work'' - has a low priority, society declines from forcing necessary measures from the employer. Naturally. the Labor Inspectorate doesn't increase the number of suicides, however, it does risk, through lacking implementation of the regulations, helping to conceal the risk cases that arise.

The National .Board ofOccupationai Safety and Health's Ro~e This board's role is ambiguous to say the least. In Sweden. it is the only governmental authority outside of the parliament that is permitted to legislate laws. The democratic legislative process which exists in the parliament is replaced in this authority by a corporative cooperation between representatives of the government, the employer unions and the labor unions. The clarity in the laws which the National Board of Occupational Safety and Health draft in the form of regulations has improved significantly in recent years. The regulations from 1993 regarding victimization at work would have hardly gotten such concrete wording only four years earlier. The reason for this was that the National Board of Occupational Safety and Health at that time had a committee which only consisted of representatives from the employers and the labor unions who, without exception, were reluctant to take the psychosocial questions in working Iife into account at all - with the exception of those which had biological effects from a traditionaL occupationalmedical point of view, e.g. stress as a consequence of night work. In addition to the existing text in the regulations (which focuses on the employers), the National Board of Occupational Safety and Health issues internal policies about how the regulations/laws should be implemented. The committee's agency for this implementation is the Labor Inspectorate which controls the employer's observance of existing laws and regulations during its inspections. As has already been pointed out, the psychosocial issues in these connections have a low internal priority within the National Board of Occupational Safety and Health/Labor lnspectorates - with the consent of both the employer unions and the labor unions. On one occasion, Sarah had reported her employer to the Labor Inspectorate- which every employee can do. The report gave rise to an inspection which didn't result in any greater show of force against the

employer, however - totally in parity with the authority's internal priority. This internal problem becomes even more pronounced if the regulation about occupational rehabilitation ( 1994: l ) is focused on. Here. the National Board of Occupational Safety and Health has infringed upon its classic role and dictated the employer's obligations for rehabilitation, i.e. dictated measures that actually fall under the domain of the National Social Insurance Board. However, if we ignore the distinction between these two authorities, we can state that the National Board of Occupational Safety and Health has produced a regulation of legal character which is onzv applicable in individual cases. Despite this, they maintain their agreement that the Labor Inspectorate should not intervene in individual cases! This conscious role ambivalence contributes decisively to the fact that elimination processes can be driven so far that the individual subjected no longer suffices and takes his life. The National Board of Occupational Safety and Health doesn't increase the number of suicides of course, but it helps to conceal the risk that already exists - - and prevents effective suicide prevention.

The National Social Insurance Board's Role The regulation AFS 1994: I about occupational rehabilitation has central importance for this authority since their subordinate authorities, the provincial social insurance offices, supervise the rehabilitation law. which exists in addition to the National Board of Occupational Safety and Health ' s regulation, so that it is practiced correctly by the employers. In connection with rehabilitation, the Law of Industrial Injury Insurance (LAF), which regulates the employee's economic rights when he or she is inj ured at work, is usually also touched on. When is it judged that the employee has been injured at work? The Law of Industrial Injury Insurance provides information pertaining to that. It is rare that individuals who have contracted a PTSD-reaction through poor psychosocial conditions at their workplaces are granted industrial injury compensation by the insurance system. It is namely stipulated in the industrial injury insurance law that certain circumstances connected with work or work conditions may certainly give rise to mental problems in the employee, but should not be judged_to be of a nature that should be approved in an assessment of an industrial injury. Thus, a number of exemption clauses are pointed out:

Exemption clauses according to the Law of Industrial Inj ury Insurance when mental ill-health should not receive status as an industria l injury : e Company shutdowns. e Labor disputes. e Change of work assignments. e Failed promotion hopes. e Lacking appreciation for work efforts. e General dissatisfaction with working assignments. e Conflicts with co-workers. If the injury originates from one or several of these causes, compensation from the insurance will not be granted. There is. in our opinion, a clear need for these exemption clauses to exist in the law. Someone who feels mentally i [l following a conflict or who has differences of opinion with the management or the employer should naturally not be able to lay claim to industrial inj ury compensation . However, one throws the baby out with the bath water if these exemption clauses are used in all cases when psychosocial conditions involve a confl ict. Victimization at work is defined in the National Board of Occupational Safety and Health ·s regulation AFS 1993: 17. Victimization at vm rk refers to reprehensible behavior by the employer personally, by his representatives or by other employees which impl ies, among other things, slander and character assassination of the employee, deliberately withholding important information, deliberately sabotaging or obstructing work, freezing out, ignorant treatment, neglecting the employee, persecution in different forms, threatening and creating fear, deliberate insults, overly critica l or negative treatment, control of the employee without his knowledge, together with punishing administrative sanctions not grounded in fact and without an offer to mutually want to solve possible problems in the employment (e.g. taking away a work room or work assignments, unexplained transfers, obstructing actions when applying for education, leaves and the like). In both the Swedish as well as the international research, "normal confl icts" are distinguished from '·victimization at work" in that the latter-ment ioned must occur systematicallv and repetitively and for a long p eriod of time. According to the National Board of Occupational Safety and Health's examples. insulting actions include, among other things, the

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exact same actions that are excluded in the Law of Industrial Inj ury Insurance (LAF). In Sweden, it is not unusual that laws and regulations instituted in different areas of society contradict one another. Within industrial safety, certain psychosocial events are branded as being health hazardous at the same time as the exact same hazardous phenomena are excluded in the regulations that apply to the industrial injury insurance. However, it should be simple to solve this problem with the conflicting legislation if the knowledge that has existed for a decade within work science is used. The system of rules within the insurance only needs a brief addition: '· .. .Apart from these exemption clauses, those situations which can be slurwn to occur verv often and systematically and for a longer period qf time and which thereby meet the criteria fo r victimization at work, should be j udged to he entitled to an industrial injwy .. ." The National Board of Occupationa l Safety and Health's regulation namely points out the employer as being responsible if victimization at work occurs. Signs of this should be traced early via the industrial safety-oriented internal control (regulation AFS 1992:6). It goes without saying that employees who through unbearable and by law forbidden actions contract an extraordinarily serious mental illness with a risk of mental injul)' for life, should have these injuries approved as industrial injuries. There are usable definitions to differentiate one from the other. The National Social insurance Board and the country's social insurance offices contribute to the frequency of suicides because they manipulate the affected individual's legal rights.

The Role of the Labor Market Insurance System Certain groups of companies have access to labor market insurance which may apply and which has more generous requirements for its assessments than the social insurance offices which, in recent years, have been given an increasingly restrictive basis for assessments from the government - apart from the fact that the social insurance offices. in addition to that, seem to compete in usingtheir requirements as stingily as possible. In the last few years, even the administrators within the labor market insurance system have been requested to save money. Insurance cases with regard to industrial injuries are handed over to the social insurance office despite that there isn't any coordination

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whatsoever between both of these systems in this matter. The administrators know that the social insurance office has greater possibilities of rejecting a claim for industrial injury compensation based on the Law of Industrial Injury Insurance which isn't at all binding on labor market insurance. However, its administrators readily reject a claim for industrial insurance compensation if they can refer to the fact that the social insurance office ''has also done that." · It is most likely so that these rules of procedure increase the desperation of the severely mobbing-injured and therefore risk increasing the suicide tendency.

The Prosecutor General's Role When the former Prosecutor General \vas on the eve of his retirement ( 1994 ), he went out on a tour of the country together with personnel from the National Board of Occupational Safety and Health with the message that victimization at work would be prosecuted by the country's offices of the public prosecutors. He wanted to update the possibility that exists in Sweden's laws in the penal code with regard to various paragraphs which take up libel. mental abuse. subjection to a state of powerlessness, bodily injury (psychosomatics!) etc. He found no sympathy for this among his public officials around the country, which is surprising. Still today, no prosecutor has taken up a single case of mobbing in working life . On the other hand, some fifteen teenagers have been put on trial for the same crime - mobbing - although here in the school environment against schoolmates. Certainly, the burden of evidence on the basis of the penal code is difficult. but can with time and more distinct routines be overcome. However, this is probably not where the problem lies. In the beginning of the 1990's, l, Leymann. participated in a group of experts which the Department of Justice had put together to examine the need of tightening certain laws in the penal code in connection with mobbing and systematic harassment. Those who were knowledgeable in law never forwarded the argument about the difficult burden of evidence in the way I have experienced this in the German debate in the same matter (Strop, 1993 ). No, instead they were more worried that there were so many cases of mobbing involved: 120,000 cases per year in working Iife with at least one half a year's duration and I 0-20 percent of these who had had the problem for several years and developed PTSD-inj uries. The Department

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of Justice was afraid that a large work load (and with that extensive costs) could arise. Certainly, this standpoint affects the statistical suicide rate in the country in connection with mobbing and elim ination from the workplace. A couple of trials against co-workers, labor unions and employers would, more than anything else, make the seriousness in the situation clear.

Conclusion: Suicide Prevention in Working Life is Nonexistent, but Easy to Carry Out We stated earlier that Sweden - on the paper- has an unsurpassed possibly internationally when it concerns suic ide prevention in working life. With an emphatic application of the existing laws, regulations and agreements. a large number of the annual I 00-300 individuals dead in suicide could have been saved - if not all of them. A conscious and strengthened implementation throughout the industrial safety work would most likely provide better suicide prevention than any other models of prevention in society in these respects. This. in particular if the same energy would be spent on the suicides of teenagers where we bel ieve that the problems often depend on poor psychosocial cond itions like mobbing and severe rejection in schools and at the regiments. What concretely would need to be done? We will discuss this in the following.

Suggestions for Suicide Prevention in Working Life The phase model of mobbing and elimination courses of events is certainly generally applicable, however, there may be a variation in the course of events. The second phase, mobbing by co-workers, doesn't necessarily need to arise if the individual is subjected to a direct conflict with his superiors. The research on whistleblowers in Australia has e.g. specialized itself on these types of situations. But if we disregard this detail, the phase model has its general validity in that it also points out critical and structurally dependent phases in the development of the course of events. When making a choice of measures for prevention, intervention, rehabilitation and therapy, it is very important to analyze the subjected individual's position in the phase course of events. As it has become apparent. these measures are namely

dependent on the course of events (Becker & Groeblinghoff, I 996: Leymann, 1996). [n a discussion about suicide prevention. we can through detailed research with regard to psychosocial stress conditions provide very concrete suggestions of measures where the early measures naturally don't have anything to do with suicide prevention but can instead be seen as general measures for improved living environments in accordance with WHO's health declaration and definition. For these reasons, our suggestions are grouped under a number of headings: • prophylactic environmental protection, locally and socially, • communicative intervention during confl icts, • intermediary interventions when conflicts have gained legal contents, e professional support by, among others, PTSD-experienced doctors and therapists, • occupational rehabilitative intervention in collaboration with legal intervention. In addition to that, the laws and their implementation are of central importance for suicide prevention which the previous chapter should have demonstrated.

Prophylactic Environmental Prevention, Locally and Socially Since the 1960's, there is extensive research internationally on topics such as work satisfaction, psychosocial stressors, work climate etc. We won ' t by any means exemplify with these large numbers of research directions, all of wh ich have great importance for health but even for industrial productivity. Very little of this overwhelming evidence about the benefit of productional and organizational forms which prioritize health is firmly anchored in the western industrialized countries. Even in fairly successful industrialized countries like Germany, for example, the productional environments show, if anything, conditions contrary to those which almost 40 years of research have shown to be optimal. The psychosocial work environment in Germany is considerably worse than the Scandinavian. On a base leveL the work environments (and in particular the hospitals' which in study after study lie on a bottom level in the westem

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industrialized countries) must be refonned to correspond to demands on healthy life environments which WHO - within other areas than working environments- has called attention to. In order to make this possible, national and international legislation is required. As an example of necessary legislature, the Swedish legislature can be used even if considerable improvements can be achieved here. On the other hand, the Swedish habits of implementation can never function as international examples which we have probably demonstrated. Important work for humanitarian life environments thus lies on a general structural and politicallerel. The implementation of laws and agreements must be seriously intended. There are three important measures to take with reference to the companies' and the administrations' implementation of the law: e Knowledge about the structure and effects of mobbing and elimination in working life must be made available. Superiors and union representatives in particular should be target groups for this. • There must be a designated person in the company where the subjected individual can go and forward his matter. This person must be able to delegate and have the authority to represent the subjected. For the reasons already mentioned, this person should not be a union representative. • The company must work out a policy which is approved by the parties. These types of policies have been put together by a number of German corporations. We will present one of them in the appendix on page x. We hope that the Swedish companies and administrations will reflect on this policy example.

Communicative Intervention during Conmcts We have made it clear in this book how severe life problems can arise through deficient work environments that are led by incompetent leaders where even uninterested union representatives deliberately deny their members help, where administrative incompetence is permitted to prevail, where a humane climate is allowed to degenerate and result in mental, and sometimes even physical terror. The summary of the English hospital studies which we have referred to in this book speaks for itself. Much of the basic work which must be carried out here both legislatively and in implementing pertains to the previous section about environmental prevention. But conflicts even occur in good environments. Both for

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health reasons as well as even for economic organizationa l reasons, employees in work environments in general and their superiors and union representatives in particular, must be trained in conflict intervention. Even here. both the scientific and the practical literature is extensive. Instead of conflicts resulting in hate and hostility even in work environments, training and socialization, among other things, are needed so that a constructive conflict culture can be developed. Apart from these long-term developmental goals, companies must have routines and work methods to be able to intervene rapidly if one or several of their employees are subjected to mentally or socially destructive conflicts on a long-term basis. The most appropriate functionary is probably the immediate superior or a functionary at the personnel department.

Intermediary Interventions When Conflicts Have Gained Legal Contents Conflicts which have been allowed to exist too long tend to obtain contents of a legally insulting character for the party who has come into a weak position. The results from research on mobbing are fairly clear on this point. Naturally, the most reasonable solution is, through conflict intervention, not to let the situation get to the point where these destructive conflict processes can develop. Based on the analyses of the patients' cases, it is possible to draw the conclusion that conflict intervention must look totally different- as soon as it has become apparent that legal consequences have been established for one of the acting parties. The further th is progresses and derails. the more difficult it becomes for the functionaries mentioned earl ier to intervene. Even work with group dynamics under the supervision of a psychologist experienced in this technique can quickly w·orsen the situation if intervention or awareness techniques, which are purely communicative and aim at communicative insights, are used at this late stage. An employee, like e.g. Sarah in a late stage, when she will be deprived of certain work assignments or will be transferred as a consequence of other individuals "winning" a tug-of-war outside of the management's or the company's control, may risk finding himself sitting before a people's court where justice and law no longer apply if a traditional group dynamic method is used at this late stage.

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At the time this is being written, one of us, Leymann, is busy on behalf of a German university hospital in developing and introducing a mediation method according to the American "Third-Party-InterventionMethod." which aims at reconciling individuals who have gotten into a destructive conflict. This method requires delegating certain administrative powers. agreed upon by the parties, to people who will work professionally with the cases and it must build on common, sound, po licy elements in the personnel contract.

Professional Support by, Among Others, PTSD-Experienced Doctors and Therapists If a conflict cannot be handled step by step according to our description, which naturally can be varied and developed in many different ways, the subjected individual is at the latest following an unsuccessful effort by the functionary, deeply intricated in a mobbing course of events which is already on the point of eliminating him from the company. Our three cases show this very clearly. The intervention wh ich l, Leymann. was requested to carry out in Sarah' s case came about in too late a phase in the eliminatO!)' course of events. If a case has not been able to be handled correctly or if an attempt at correct handling has been unsuccessful, the time approaches in the phase course of events when the subjected individual has contracted such severe stress symptoms that treatment by a doctor may come into question. Our experiences from various cases (see e.g. Leymann, 1992a) show that the individual runs a high risk of receiving an incorrect diagnosis. Individuals who have ended up so deeply in their crisis also show suicidal tendencies to a considerable extent. This in turn increases the risk of an incorrect diagnosis which. according to our clinical experiences, again increases the tendency of suicidal thoughts. It is our firm conviction that suicides can be prevented qu ite generally even in individuals who are suicidal for other reasons than those that we are discussing here (namely the conditions in the work environment). What is needed is education of professionals, above all doctors, psychiatrists and psychologists. The distribution of WHO's psychiatric diagnostic manual, ICD-1 0, has taken far too long. Intensified activities should be put in place to increase the knowledge about, among other things, PTSD even as an effect of traumatizing violations of the individual's legal rights.

24! My suicide prognosis for Sarah \vould have been that if she at the time of her 50th birthday and her "occupation" of the primary care manager's office had been involuntarily admitted to institutionalized care because her acts of desperation could be judged to be psychotic in nature, that she would have committed suicide in connection with that. It was an honest and outspoken company doctor who saved her life at that j uncture. l believe that l know that the primary care management w ished an involuntary admission to institutionalized care at this point in time.

Occupational .Rehabilitative Intervention in Collaboration with Legal Intervention At the time this is being written, the most effective and rapid changes can be made in this phase. Patients in this situation need occupational rehabilitation in stationary form in a very relaxing and friendly environment. A new method of treatment was initially developed in Germany in co-operation with a German colleague and head of clinic where we, for more than a year, treated mobbed patients with severe PTSD-injuries using this method (Leymann, l995c: Becker & Groeblinghoff, 1996; Leymann, 1997). This method was further developed at my own clinic in Karlskrona where we, after sl ightly less than two years of work. reached good results in 90 percent of the cases ( Leymann & Gustafsson, 1996; Leymann, 1997 ). How should rehabilitation be organized so that it is suicide preventive and also opens the path back to an active working life? If we disregard the obvious accompanying medical-somatical control, three conditions must be focused on: e A mental rehabilitation and stabilization. • A legal support program to activate legal demands. e An occupational-social support program for an occupational return. Thus, the main emphasis must be placed on work with structural environmental factors. In order to understand the contents in the very brief description of the rehabilitation plan below, famil iarity with mental and physical functional impairments associated with chronic PTSD is required. It is these functions that will be stimulated through this holistic/societal, social program. We can only touch on this briefly within the framework of the account of the results from our research project.

242 It is our opmion that the rehabilitation specialties below must work intimately together so that they can adjust their respective work speeds to one another and support one another in the work with the client. We also want to emphasize that the subjected individual himself has to be the ·'project leader'• for his own life planning. We regard the four occupational groups' integrated support work around this life planning in a late phase of illness as the core of the suicide preventive work in this type of working life problem.

Mental rehabilitation and stabilization The therapeutic treatment should be seen in this context as a support function at the same time as it will restore the functional impairments which have arisen as a consequence of the PTSD-syndrome. It is important that therapy emanates from the individual's immediate social situation and that it supports the individual psychosocially since re-entry into an occupational situation will be extremely demanding mentally. The first goal of psychotherapy (of cognitive type) is to rehabilitate the severe loss of mental functions which the patient has been affected by and which make his own work with his future situation difficult. Only in the second stage does the long-term mental stabilization come into question.

General medical examinations and control Because most patients have psychosomatic conditions as a secondary diagnosis, a doctor who can diagnose incipient organic problems and provide adequate medication must be included in the team. One task is to control whether the symptoms originate from organic malfunctions which must be treated medically, or whether they belong to the group of "unspecified stress symptoms."

A legal support program to activate legal demands Based on what we could observe with regard to shortcomings in the union' s work, we don't consider it reasonable that labor unions should take over other social roles than what they were originally created for: negotiations with regard to questions that concern the employee collective. On the other hand, all individual legal work should be transferred where the knowledge exists: to law firms . A neutral jurist with

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a license to practice should investigate which economic tosses the subjected has suffered and to what extent society permits demanding damages. This legal work requires mental strength which the subjected individual - depending on the severity of the PTSD-injury - perhaps doesn 't possess for the occasion. The speed of the legal work must therefore be adjusted to the successes of the psychotherapeutic suppot1 work in its first phase. The first partial goal of the therapeutical work is also to stabilize the client enough so that he or she can manage the stress which the legal work implies.

An occupational-social support program for occupational re-entry The central goal of the occupational rehabilitation and thereby suicide prevention is the occupational planning which will open the path back to an active occupational situation . It is by no means implied here that the mentally abused individual should return to his prior workplace. A decision regarding a step like this is not relevant at all in the beginning of the planning and preparatory work. We have had a lot of success in our clinical work with a metaplan method. This method ailows the subjected individual to make a comprehensive overhaul of his resources, his general wishes in life and his general career experiences. This method makes a fundamental revision of the individual's present occupational picture and goals possible. By evaluating these goals step by step, the individual slowly pinpoints the ideas that are important to him or her. His former employer is only one of the future possibilities to evaluate here along side of other possibilities. If the individual were to be turned down, there may be reason to demand economic means through the legal part of the work program which thereafter can be used to finance new goals, i.e. a new occupational activity. The professional person who acts as a supervisor here must have genuine knowledge about occupational choices and the occupational possibilities in society several years ahead.

A Tightening of the Law is Needed It is evident from our analyses that it would be possible, without a doubt, to convict single individuals or authorities of activities that drive a subjected individual into committing suicide or attempting to. It is by no

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means alleged here that a desire for a person take his own life has to exist. Criminalizing this type of activity would defin itely be a suicide preventive measure. This idea is not new. In reality, there are a number of countries in Europe that have this type of legislation. There is only a minority of European countries that don't prosecute the situation as a crime when an individual drives another human being into commting suicide. According to Makinen ( 1997). the three main forbidden activities in certain European countries are:

1. Contributing activities Activities where the participant in some manner (by placing the means at the individual' s disposal, providing practical assistance, or technical advice) increases the risk of a suicide or a suicide attempt without himse(f actively influencing the affected individual to choose suicide. 2. Active influence Activities where the participant increases the possibility of a suicide or a suicide attempt by actively influencing/convincing the will of the affected individual to choose a suicidal behavior. 3. Driving a person to commit suicide Activities where the participant, without for that matter necessarily desiring a person ' s death, treats the subjected individual in such a way that the cause of the suicide or suicide attempt can be explained by this treatment. Driving someone to commit suicide may mean that the two previous activities are included in the criminal act. Within the framework of our analyses in this book, it is the third type of activity which is of the most interest. Which countries have criminalized this activity and how does the punishment look in different countries? In most of the Eastern European countries, there are laws which specifically punish '"driving someone to commit suicide or attempt suicide'' through varying types of insulting and terrorizing acts." The law is usually worded in such a manner that the crime can only be exercised toward someone in the criminal's family or other person who is dependent o n him or her in another way (working life, military service, school etc.). Countries where this legislation is pract iced are those who

245

previously belonged to the former Soviet Union or Yugoslavia, Poland. Bulgaria, Albania as well as 14 other European countries, see the table on page 246 .. Since it is not habitual criminals who, accord ing to our analyses, cause another human being's suicide but rather common people whose thinking and acting is blocked for the most part as a result of ignorance, legislation in this area could be expected to help bring attention to the conditions in the labor market. We believe that criminalizing the conditions described above would contribute in decreasing suicides. The law would have a suicide preventative character.

Reduction ofthe Union's Authority Our experiences from clinical work with mobbing VICtims shows anamnesis and case descriptions that put union work in a very poor light. When we suggest comprehensive changes here. which includes serious criticism. we have to emphasize what this criticism and what these suggestions of changes build on. They bui ld on experiences from the most d~fficult cases. We are fami liar with many cases that never developed into such severe fates that those subjected had to be admitted for treatment at a special clinic for mobbing victims. Even a smaller number of the difficult cases (a few percent) alluded to have shown good union support. There are individual union representatives around the country who, often w ith a risk of being subjected to mobbing themselves, do impressive work. However, on the \vhole, the experiences mentioned justify the j udgment that the subjected runs a considerable risk of having his career totally destroyed if the union deceives him. We estimate (see the statistical information in an earlier chapter in this book) that approximately I 0-20 percent of the mobbing cases develop into severe cases and that it is the lack of union support in these cases that is the main cause of this. The main causes are evident from earlier chapters in our book: c

Union representatives have a total lack of understanding that people who are severely abused mentally and who are deprived of their legal rights can show aggressiveness.

246 Suicide-related crimes in the European legislation: The extent of the crime and the penalty (Mllkinen, 1997)

T he maximal punishment

No punishment Finland Germany Luxemburg Monaco San Marino Scotland Sweden 5 years imprisonment

I

5 to 10 years

None

Limited (1 )

Extensive (2)

I Belgium

I

I I

A lbania Belorussia France Iceland Lithuania Moldova Russia Switzerland The Ukraine Estonia

More than 10 years

(1) Less than an explicit crime (2) An explicit crime without any motives being excepted

Ii A ustria 1

Denmark Hungary Holland

Croatia Czech Republic Portugal Slovakia

Bosnia Bulgaria England & Wales Greece Ireland Isle of Man Italy Macedonia Northern Ireland Poland Rumania Serbia/Montenegr Slovenia Spain

247 0

0

The subjected is often mobbed by his own co-workers. Union representatives. who are representatives for both groups. are unable to handle the situation - with the obvious risk that the mobbed is totally destroyed. Union representatives are bias when the situation is such that a mobbed individual is represented by his own superior, who mobs, but who is elected as a union representative. We have accounted for completely absurd situations in our case descriptions.

•

On a higher union level, the subjected individual is - in a situation where the union representative is bias and wants to maintain ··good cooperation" with the employer on \vage issues (i.e. during wage negotiations)- at a pronounced disadvantage.

•

Our case descriptions also point to the union jurists' work methods which don't exactly prioritize the subjected's legal rights.

We consider it is unreasonable that legal matters which concern the individual citizen's legal rights should be managed by union authorities whose main task lies on the level of the coHective. Society should, through its normal legal channels (private law firms, legal insurance at insurance companies etc), guarantee the individual's legal rights which the union is unable to work for. This involves new legislation so that individual citizens can raise their cases in the Labor Court without being forced to request union representation (which is the case at present). Sweden's membership in the EU will nevertheless in due time force such a reform, in particular because there is only one instans in the Labor Court in Sweden - a serious shortcoming in a country that wants to assert itself as a country governed by law.

A Final Word About Suicide Prevention We have studied a number of suicides and suicide attempts in hospital environments where there is an obvious connection with very poor psychosocial conditions in working life. We have carried out these studies mainly with qualitative scientific methods.

248 We have found crucial evidence that environmentally deficient conditions within the healthcare sector have a connection with ignorant decisions made by politicians, lacking organization, deficient staffing and incompetent leadership. In comparison with a number of other studies, we have to state that this is a recurrent problem in, among others, hospital environments. We have found evidence that these problems will be worsened in the foreseeable future as a consequence of (most likely) lacking economic competence. We have also found that the extreme stress which prevails in these environments creates many conflicts and that these in general seem to be handled in an incompetent manner by work and business leaders. from other research, we know that mismanaged conflicts in work environments with a high level of stress tend to culminate in mental abuse, stigmatization and rejection from the work situation. From th is research, it is also known that these rejection processes may take between two and six years and that the subjected individual during this period of time contracts severe posttraumatic stress injuries. In the analyzed cases, stigmatization, which has been structurally described both within attribution psychology and social psychology, can consistently be observed. This stigmatization impl ies burdening the victim w ith guilt. The analyses also show that victims of these processes are subjected to massive violations of their legal rights, above all by their employers and labor unions respectively, but that these violations oftheir legal rights also come from other authorities in society in the subsequent development. The probable explanation to this is that the employers and the labor unions seem to think that they categorically have the right of determination over their employees and members respectively, and that participants from other authorities in society fa ll victim to the attribution thinking already pointed out, which dehuman izes the victims and inflicts them with severe insults far beyond law and humanity. It's obvious that these experiences during the process, together with the process' ultimate consequence -- a totally destroyed life situation result in a high overrepresentation of suicide compared with the total population. We consider that basic suicide prevention lies in the fact that even working life must be subjected to a democratic process in the same way as this applies in society in other respects.

249

•

•

•

A first task for suicide prevention with regard to the work environments (and in particular the hospital environments where the problem is most pronounced) is thus to stimulate or fo rce qualitative psychosocial conditions. A second suicide preventive task is to demand complementary legislation and effective implementation of the existing industrial safety infrastructure in society. These efforts must result in the creation of special representatives or officials so that every person who is subjected to mobbing attacks, mental abuse and severe violations of his legal rights at his workplace can find a neutral person, independent of the employer. labor union and the social insurance office who takes over the victim ' s post as a representative. A third task for suicide prevention must be created in the form of specially assembled occupational rehabilitative teams whose job is not to "send off' the subjected individual to some second hand occupational position but who, based on modern knowledge and a humanitarian commitment. assists him so that he or she can once again become the worthy member of society he/she had been before incompetence and wickedness rejected him into the role of a dissident in the middle of a society with a basically democratic legal system. And this democratic legal system must be reflected in the company's policy (see the example in the appendix).

We are of the opin ion that the severe shortcomings in people' s work environments are the greatest single cause of suicides during a productive point in t ime in a perfectly competent individual's professional life. In order to continual ly provide information, a "Mobbing Encyclopedia" (Leymann, 1997) is currently being prepared. It wilt be complete with regard to all existing knowledge about mobbing and elimination in working life at the latest during the fall of 1997. The internet address (www. Leymann. se) or possibly at a later point in time (www.Leymann.a.se)- is already available.

Appendix An Exemplary Company Policy for an Anti-mobbing Agreement

During 1996 and 1997, I (Leymann) worked as a consulting professor at the University Hospital in Hamburg. Among other assignments, I led a project that aimed at presenting proposals for a company policy to prevent and act in connection with mobbing situations. In the summer of 1997, a pol icy document was agreed upon by both parties, the hospital management (the employer' s representative) as well as the unioncomposed company committee (Betriebsrat). The credit for the creation of th is document was entirely the hospital management's and the personnel representation's. The complete text is published below. It demonstrates that it is certainly possible to devote attention to a personnel policy at a hospital.

Agreement between the University Hospital Hamburg-Eppendorf and Its Personnel Committee (Betriebsrat) On the basis of § 83 in the Hamburger Personalven;,a/tungs Gesetz, the agreement applies to the establishment of a Consult Service for personnel conflicts at the workplace.

Introduction and Definition Mobbing and psychoterror are characterized as attacks and assaults directed against one or several employees which mean that the subjected employee's possibilities of communicating are disrupted, that his or her social relations with regard to his profession and work situation are

251

negatively affected, that the subjected employee's health is harmed and that there are considerable risks of being rejected from employment or even from the labor market. There is a greater risk for problems of this nature if the assaults occur very frequently and for a long period oftime. The agreement" s parties agree in their assessments that mobbing, according to this definition. violates the German constitution with respect to the citizens' integrity and human dignity . Mobbing at the workplace may lead to mental and physical injuries in the subjected employee. When that happens, production losses and increased costs arise for the University Hospital. This agreement aims at creating a structure which protects the University Hospital from these losses at an early stage. Within the framework of an open and cooperative managerial philosophy within the University Hospital, the establishment of a Consult Service is chosen as a relevant measure for a qualitative personnel policy. The Consult Service wi ll thus contribute to an improvement in the company climate and increase the personnel's work satisfaction. In the same manner, work performance and motivation will be increased.

§1 Validity The agreement includes: (a) in content: the establishment of a Consult Service to work with personnel conflicts at the workplace. (b) in person: all employees and students. (c) the place: The University Hospital Hamburg-Eppendorf.

§ 2. The Consult Service's Work 2. 1 Goals The Consult Service is aimed at: o Discovering conflicts and taking measures at an early stage. • Protecting the University Hospital and its employees and students from attacks and assaults which mean that injuries may arise in accordance with the definition in the introduction. • Avoiding illnesses and subsequent costs as a consequence of conflicts at the workplace. o Providing help and support during occupational rehabilitation. 2.2. Assignments These may include:

252

•

Providing information and advice to employees who turn to the Consult Service to overcome a precarious s[tuation. • Mediation between employees involved in a conflict and the subjected employee. • Providing information about mechanisms involved in workplace conflicts and preparing and implementing measures to solve conflicts at the workplace. • Procuring possibilities for occupational rehabilitation. • Development and preservation of a network with internal and external institutions and experts. • Social and mental help and support for the subjected employee. • Education. • The Consult service provides information about existing rights with respect to participation and co-determination within the framework of the laws of personnel representations. • When necessary, mediation for employees seeking advice from special authorities. • The Consult Service will report to the Directorate and personnel representatives on a six month basis and in anonymous form and account for the cases in analytical form including an assessment of the Service's results. The Consult Service should provide advice to every employee who seeks help and carry out its assignments impartially and in such manner that the assignment corresponds to the individual needs of those who seek advice. 2.2. 1 Authority The Consult Service should not receive their instructions through official channels. The individuals employed within the Consult Service work independently of the employer and the personnel representation. Information which the Consult Service needs access to for their services will be put at their disposal within the University Hospital without delay. The Consult Service's personnel are not be permitted to be hindered when exercising their duties or be subjected to disadvantages in their occupational development within the University Hospital. The Consu lt Service has the authority to obtain advice from experts. The costs in this context must be approved in advance by the hospital management. Even additional education which is necessary for the Consult Service's work must be approved by the management.

253

2.3. The Consult Service's Structure 2.3.1. The personnel structure The director of the Consult Service is appointed in consultation with the hospital management and the personnel representation . The Consult Service's protective function has authority over the hospital's administrative director. When required, there should be possibilities of acquiring additional personnel. The need for this should be specified in the half year reports. The director of the Consult Service is relieved from his other assignments at the hospital. Additional personnel. even those who are temporary, should receive similar leaves when necessary. 2.3.2 Qualifications The d irector of the Consult Service should have comprehensive qualifications with respect to professional knowledge as well as social and personal competence. This should also be specified when personnel is sought. 2.3.3. Office space The Consult Service should be offered necessary office space including appropriate office equipment. 2. 3. 4 Guidance Structure The Consult Service should mediate advice to the subjected employee and other employees involved in order to solve the conflict. A prerequisite for this is that the employee seeking advice desires this mediation . The support that is necessary in this context should be offered by all areas that may come into question within the University Hospital. The Consult Service should have the possibility of contacting external specialists, e.g. for conflict intervention. This contact should occur in consultation with the agreement's parties. Specialists within the University Hospital should be given priority in connection with these consultations. §3 Informative Obligation All employees and students at the University Hospital should be informed of this agreement.

§4 Qualification Qualifying measures on the theme of mobbing should be offered such as e.g. seminars on mobbing, conflict management and conflict culture. This should occur within the framework of the hospital's further education and applies above all to employees with managerial functions, but also to

254

personnel representatives. The ability to solve conflicts constructively should be discussed when jobs are advertised and personnel are sought on the open market. This factor should also be taken into consideration when assessing and selecting managerial qualities.

§'5 Obligation/or Intervention All employees with managerial assignments are obligated to discuss personnel conflicts with the Consult Service. These employees and all other co-workers are obl igated to actively support the Consult Service.

§6 Sanctions Any employee who repetitively harasses employees at the University Hospital in accordance with the definition in the introduction, and who thereby causes the University Hospital and its employees injuries, must expect labor legislative consequences.

§7 Confidentiality The Consult Service should work under professional secrecy for employees who seek advice. Whatever the Consult Service is informed of during advisory or mediating work will thereby fall under professional secrecy. This even applies when personnel within the Consult Service terminate their employment. However, the employee seeking advice may voluntarily exempt the Consult Service from professional secrecy vis-avis institutions within the University Hospital. This exemption may be total or partial with respect to certain information. §8 Cooperation The Consult Service. the University Hospital and the personnel representation along with the equal opportunity representative at the hospital should co-operate trustfully according to the law for the good of the hospital and its employees. §9 A Final Word

The agreement goes into effect on October I, 1997. The agreement may be terminated at any time by either of the agreement's parties with a period of notice of three months from the end of the year. This may even only apply to individual paragraphs in the agreement.

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