Categorization Work in the Swedish Welfare State : Doctors and social insurance officers on persons with mental ill-health

Abstract: This dissertation contributes to the debate on street-level bureaucracy, which highlights how the decisions made by workers in public bureaucracies effectively become public policy. This debate has paid relatively little attention to the study of how professionals carry out their work by means of institutional categorization, a knowledge gap that this study helps to close. Moreover, this study contributes to the understanding of how persons with mental ill-health are matched with institutional categories.The aim of this dissertation is to shed light on the institutional categorization process involving persons with mental ill-health in two interrelated areas of welfare settings: primary healthcare and sickness insurance. To pursue this aim, 27 in-depth interviews with 30 participants (18 doctors and 12 social insurance officers) were performed. The interviews, which were based on vignettes – short hypothetical scenarios – made it possible to get insight into how doctors and social insurance officers would reason in a situation similar to that depicted in the vignette.This study emphasizes how discretion is exercised when individuals are matched with the institutional categories that doctors in primary health settings and social insurance officers have at their disposal. Ideally, this process is a rational process through which clients’ objective traits are assessed against the criteria that define the various institutional categories. However, the process is not straightforward; thus, different kinds of social mechanisms are linked to the processes of institutional categorization, such as signaling, screening, the logic of appropriateness, moral work, and discrimination. On a more practical level, this study emphasizes the difficulties imbued in the process of institutional categorization. There are multiple reasons for these difficulties. Human complexity is one of them: the interviewed professionals often work with situations that require responses to human dimensions, which are oftentimes too complicated to reduce to standard formats. Another reason for these difficulties has to do with the ambiguity and/or complexity of institutional category schemes. Moreover, the process of institutional categorization takes place in a context of conflicting demands and professional logics, both within a single organization and across the organizations that work together with respect to the same patient/client.Future research concerned with institutional categorization should address how persons with mental ill-health are matched with the institutional categories in other areas of welfare, such as social services and employment services. A deeper knowledge about how the various organizations of the welfare state match individuals with institutional categories, could bring us closer to an understanding of the problems of multi-organizational collaboration.

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