J Health Behav Med Hist 2025-11.
From On-Off Switch to Dimmer. A Call for Nuance in Work Incapacity and Sickness Absence.
Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands
Abstract
Sickness absence is still largely treated as a binary phenomenon: a person is either fully fit for work or entirely unfit. This “on-off switch” model dominates medical assessments, organizational policies, and social security systems. Yet it fails to capture the complexity and variability of real-life functioning. In this opinion paper, I argue for a shift toward a dimmer model — one that recognizes the spectrum of work ability, supports partial participation, and allows for preventive withdrawal when necessary. While full incapacity is sometimes appropriate and essential, many situations are more ambiguous. By clinging to binary decisions, we risk unnecessary long-term absence, premature return to work, and the over-medicalization of human experiences. It is time to adopt a more adaptive, behavioural, and humane framework for managing the interface between health and work.
Introduction: A Binary System in a Grey Reality
In everyday practice, decisions around sickness absence often follow a predictable pattern: once symptoms begin to interfere with work, the result is full withdrawal. Not necessarily because the individual is entirely incapacitated, but because the system implicitly encourages this course of action. You are either at work or you are not. You are either sick or well. The on-off switch remains the dominant metaphor.
This binary framing reflects a technocratic and medicalized understanding of human functioning. It provides administrative simplicity and aligns with legal and insurance structures. However, in today’s reality — where more people are navigating chronic symptoms, psychological strain, and complex personal stressors, combined with growing labour market shortages — this rigid model proves increasingly inadequate.
When Full Work Incapacity Is Necessary
Let there be no misunderstanding: total work incapacity is real, and in some cases, it is the only appropriate response. Certain individuals experience symptoms so severe — whether physical, psychological, or both — that even minimal engagement in work is impossible.
Others are temporarily unavailable due to essential medical treatments, such as chemotherapy, intensive psychotherapy, or post-operative recovery. In these situations, absence from work is not only reasonable — it is a necessary part of the healing process.
In addition, preventive withdrawal from work can be the wisest course of action. Returning too early — particularly in cases of burnout or post-viral fatigue — may delay recovery or increase the risk of relapse. In such instances, rest is an active intervention, not a sign of weakness or avoidance. These scenarios justify a full “off” position. But they are the exception, not the norm. Most real-life cases fall somewhere in between: moderate symptoms, fluctuating capacity, the ability to perform some tasks but not others. One person might need complete detachment; another — an entrepreneur, for example — may continue working from a hospital bed, adjusting their role to match their capacity. This diversity underscores the need for a more flexible approach.
The Problem with the On-Off Model
The on-off model is appealing in its simplicity. It offers clear boundaries and relieves all parties — employers, employees, and professionals — from the discomfort of uncertainty. But this comfort comes at a cost.
- Over-medicalization: Emotional, social, or situational difficulties are reframed as illness.
- Loss of agency: Workers become passive recipients rather than active participants in recovery.
- Disuse and deconditioning: Prolonged absence often reduces functional capacity and resilience.
- Systemic rigidity: The system discourages early dialogue, graded returns, or creative adjustments.
Perhaps most concerning: being “sick” is often the only culturally and administratively accepted reason to pause or scale back work. There is little space to say, “I’m overwhelmed and need to adjust,” without invoking medical language.
Introducing the Dimmer Model
We need a new metaphor that reflects how people actually function — not as machines that are simply “on” or “off,” but as dynamic systems that fluctuate in energy, focus, and ability. That metaphor is the dimmer.
In the dimmer model:
- Work participation is scalable — not just on or off, but more or less.
- Function is fluid, varying with context, time, and task.
- Recovery is active, and may involve adjusted or partial work.
- Conversations focus on possibilities, not solely on limitations.
This model supports graded return, task redistribution, and adaptive environments — not just after complete absence, but ideally before it occurs. It aligns with behavioural health principles: adaptive coping involves self-regulation, not total disengagement. In this view, calling in sick is not a diagnosis but a behavioural signal that something in the work-health balance needs attention.
Why We Prefer the Binary — and Why That Must Change
The binary persists not because it is accurate, but because it is convenient. It avoids complexity and provides a sense of clarity. For professionals, it enables defensible decisions. For workers, it legitimizes the need for rest. For employers, it simplifies roles and expectations.
But comfort is not the same as truth. In reality:
- Many workers can do something, even if not everything.
- Many need relief or adaptation, not full withdrawal.
- Many would benefit from staying partially involved, rather than disappearing completely.
The dimmer model invites us to acknowledge the grey zone: the moments when someone might contribute a few hours, take on lighter duties, or remain socially connected to the workplace while gradually recovering.
Practical and Policy Implications
Shifting from the on-off switch to a dimmer model requires systemic change across several domains:
Clinical Practice
- Move from “Can you work?” to “What can you do — today?”
- Encourage early, partial participation, not delayed full return.
- Recognize and support recovery within work, not only through absence.
Organizational Culture
- Normalize temporary adjustments and flexible task expectations.
- Foster trust-based dialogue about vulnerability, health, and ability.
- Train leaders in early signal recognition and recovery-oriented support.
Policy and Certification
- Allow for graded sickness certifications and self-declared partial capacity.
- Reduce the reliance on medical diagnoses as the sole pathway to time off.
- Incentivize preventive adaptations rather than reactive absence.
Importantly, this shift requires flexibility from both sides. Not only employees, but also employers must be willing to rethink work design, including which tasks — or parts of tasks — can be performed when someone is partially limited by illness or medical treatment.
A lack of flexibility — both before and after a sick report — is often a key driver of excessive, prolonged, or unnecessary full absence. Too often, the system defaults to full disengagement simply because no viable middle ground is offered or accepted.
Conclusion: A Better Switch for a Complex Reality
Human beings are not light bulbs that just flick on or off. We dim, we flicker, we shine brighter or softer depending on our energy, health, environment, and support. Our systems should reflect that reality.
The dimmer model doesn’t deny the need for full absence when necessary — it simply widens the spectrum. It creates space for nuance, for tailored solutions, and for honest dialogue.
In doing so, it challenges a culture that over-medicalizes distress and suppresses complexity. It allows people to say, without shame or diagnosis:
“I’m not broken — I just need to adjust.”
That simple shift — from on-off to dimmer — may be one of the most humanising and impactful changes we can make in occupational health.