Abstract
BACKGROUND:
In Sweden, gender differences have been found in standard vocational rehabilitation as well as in evidenced-based methods such as Supported Employment (SE). However, these quantitative findings have not been followed up by qualitative research to clarify the issue.
OBJECTIVE:
To explore participants’ experiences of participating in an SE intervention and the influence of gender on their experiences.
METHOD:
Semistructured interviews with 10 women and 7 men participating in SE in Sweden were conducted. Qualitative content analysis followed by a gender analysis were performed using the material.
RESULTS:
The participating men and women had different background characteristics. Overall, the participants shared the same experiences of SE. They valued a trustful relationship with the employment specialist and the diversified and individualized support from the employment specialist. Unlike the men, the women had experienced difficulties receiving SE from authorities, and when receiving SE, they expressed the value of a slow start, being challenged, and whole-life support.
CONCLUSION:
The findings might moderate the rapid job principle in SE and indicate the need to acknowledge that the path to employment might look different, depending on the participants’ gendered experiences and living conditions, for SE to be more successful for both men and women.
Introduction
The right to employment is emphasized in the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2007). Despite this, persons with disabilities are less likely to be employed than persons without disabilities in all regions of the world. Moreover, women with disabilities are less likely to be employed than men with disabilities (United Nations, 2019). This is the case in Sweden as well, even if there are small gender differences in labor market participation in the Swedish population as a whole (Statistics Sweden, 2020). In addition, gender differences favoring men have been found in vocational rehabilitation services in different countries, e.g. in the United States (O’Neill et al., 2017), in Japan (Hayashi et al., 2016), and in Norway (Øyeflaten et al., 2014). According to Lindsay et al. (2018), who also found gender differences favoring men in a systematic review examining the role of gender in securing and maintaining employment for young persons with disabilities, a possible explanation to this situation is differences in vocational and training opportunities for young men and women with disabilities. In Sweden, gender differences have also been found in the outcomes of the standard vocational rehabilitation (VR) efforts given to persons with disabilities according to an official government report (SOU 2022 : 4) as well as in the evidence-based VR method Supported Employment (SE) (Swedish Social Insurance Agency, 2017). These quantitative findings from VR in Sweden have not, to the best of our knowledge, been followed up by qualitative research to develop a more in-depth understanding of why these gender differences occur. According to UN Women (2018), raising awareness and knowledge of issues concerning gender equality for women with disabilities is an important responsibility to fulfil the goal of gender equal rights and opportunities, including VR, to a well-functioning working life.
Supported Employment
SE was developed in the United States during the 1970 s and 1980 s as an alternative way of supporting persons with disabilities in gaining employment instead of the prevailing sheltered workshops with a train-then-place perspective (Rusch & Huges, 1989). As outlined by Wehman (1986), SE builds on three basic principles to individually support persons with severe disabilities to reach sustainable employment: support locating an appropriate job in an integrated setting, intensive job-site training, and permanent on-going support. The support is provided by a qualified staff person later referred to as an employment specialist. There is also the manual-based version of SE called Individual Placement and Support (IPS) targeted toward persons with severe mental illness, and IPS emphasizes client choice, rapid job finding, competitive jobs, integrated work settings and follow-up support services while de-emphasizing the exclusion of clients, extensive initial assessment, and prevocational training. Another important part of IPS is that employment specialists should be integrated into mental health services (Becker & Drake, 1994). Both SE and IPS are person-centered approaches, and the employment specialist should respect the individual's self-determination. Each SE process should be adapted to the individual, although it should also adhere to the other basic principles (Drake et al., 2012; European Union of Supported Employment, 2010).
In several systematic reviews, SE and especially IPS have been shown to be more efficient than other methods of VR concerning employment rate after participating in the interventions (e.g., Nøkleby et al., 2017; Suijkerbuijk et al., 2017). Some reviews have requested further subgroup analysis of the outcomes (Marshall et al., 2014; Nøkleby et al., 2017), and a recent scoping review investigating how different intersecting statuses, such as gender and disability, affected employment outcomes in SE/IPS (Witte et al., 2023a) discovered that many studies did not report intersecting statuses’ effects on employment rate outcomes and that sample sizes were often too small to perform reliable subgroup analyses. Hence, it is still unclear how a social structure such as gender influences the outcomes of SE/IPS.
Qualitative research about SE/IPS
Although the majority of the research regarding SE/IPS has been of the quantitative type, there has also been qualitative research on the experiences of the participants in the interventions. Qualitative studies have found that factors at the structural, organizational, and individual levels influence participants’ experiences. An ethnographic review with synthesis of qualitative data up until 2018 (Moen et al., 2020) (of which 6 studies were performed in Sweden) found that participants in IPS highly valued the individualized support and personal relationship with the employment specialist. They also viewed participating in IPS as a personal development process. The participants experienced that their mental health influenced their ability to work and that they needed to find appropriate coping strategies, which the employment specialist was able to aid with. They also experienced that a supportive network, both professional, private, and their employer, increased their ability to achieve their work goals. Of the 14 studies in the ethnographic review that researched the participants’ perspectives, none included a gender perspective. In addition, the ethnographic review (Moen et al., 2020) only studied IPS, and to our knowledge, there is no equivalent review studying qualitative research of participants’ experiences of SE except from IPS. In Sweden, some qualitative single studies have been done studying experiences of participating in an SE intervention. A qualitative study examined what circumstances the SE participants described as influencing the rehabilitation process (Hillborg et al., 2010). They found that influences on the VR process and the outcomes could arise at the individual, contextual and structural levels. The support given needed to be perceived as relevant, and activities needed to be in line with the individual goals of the participants. The study also found that the VR process can be a long one and that employment success is not easily assessed beforehand. A qualitative study examining social inclusion as an employee participating in SE (Gustafsson et al., 2018) found that the feeling of being a valued worker and of belonging socially in the workplace were important factors for social inclusion and that the job matching done in the SE process was crucial for achieving this. These two studies did not include a gender perspective. Another qualitative study comparing experiences from participants in traditional VR with participants in a variant of SE called Individual Enabling and Support (Porter et al., 2018) highlighted the importance of a person-centered approach adapting to and addressing individual needs in the support given. Facilitating factors in the support were professionals who were able to provide hope, power, and a holistic approach to the support. A small part of the study also focused on how the participants perceived their gender in relation to the support. The findings showed that a few of the women felt that their diagnoses were downplayed due to their gender and that they may have been listened to more seriously if they were men and that the men felt that they had higher work demands due to their gender. Gender differences were found in both of the VR methods. These three studies on SE conducted in Sweden are all in line with the findings from the ethnographic review studying the experiences of participants in IPS (Moen et al., 2020), but the gender perspective is sparce. Because gender differences have been found in evidence-based VR methods such as SE in Sweden in employment outcomes (Swedish Social Insurance Agency, 2017), there is a need for in-depth knowledge and awareness about these issues for a more gender-equal VR, including participants’ experiences from a gender perspective.
Objective
The objective of this study was to explore participants’ experiences of participating in an SE intervention and the influence of gender on their experiences.
The concept of gender in this study
The context of this study was organizations working with VR according to SE. Therefore, a gender theory such as Joan Acker’s theory of gendered organizations (Acker, 1990) is a suitable analytical tool. The theory concedes that gender is produced and reproduced in four different but linked processes. First, the process of the gender-segregating organization of work (or VR), appropriate behavior, environment, and power, including working and family life. Second, the process of creating and recreating the symbols and images that are related to and express gender segregation. Third, the process of forming relationships between men, between women and men, and between women maintains gender-related segregation. Fourth, the process of forming the individual identity related to gender is shaped by the former three processes.
From a VR perspective, a previous study (Witte et al., 2023b) may serve as an example of how Acker‘s theory (1990) could be interpreted. First, the process of gender segregation may impact men’s and women’s different paths through the welfare system and the time when they receive VR services; for example, men with autism may be offered sheltered workshops 1 after finishing secondary education, while women with autism, who have not yet been diagnosed, may struggle with establishing themselves in the labor market, often ending up in sick leave and then receiving their diagnoses. Second, images of how a person, for example, with an autism diagnosis, should behave are commonly attached to boyish/male behavior, thereby leading to girls/women receiving a diagnosis later and accordingly not receiving VR until they end up in sick leave. Third, the relations in VR where the employment specialist works with men, who are offered sheltered workshops or VR interventions directly after secondary education, and women, who have been on prolonged sick leave, might lead to employment specialists working more cautiously with women, as they expect them to be more vulnerable, and working faster toward work with men, who they see as more ready for a job. These three processes form the individual gender identity in relation to VR, where women might perceive themselves as vulnerable and thus need a more careful process, while men might perceive themselves as more ready to work and thus are more demanding of a rapid job process.
Methods
A basic qualitative research method (Merriam & Tisdell, 2016) with individual semistructured interviews with participants in SE interventions was used for this study to explore the experiences of the SE participants.
Setting and participants
In Sweden, there are different types of organizations engaged in SE, who, for the most part, follow the basic principles outlined by the European Union of Supported Employment (2010) and Drake et al. (2012), and the participants were recruited from the following four types of SE organizations: Type 1 (sheltered workshops) – Organizations working with SE in the context of sheltered workshops in a special legislation for persons with intellectual disabilities, autism spectrum disorders (ASD) and, to a limited extent, traumatic brain injuries. These organizations are publicly financed by the municipalities in Sweden. The gender distribution among the participants in these organizations that took part in the study ranged from equal to 40% women and 60% men. Type 2 (nongovernmental organizations (NGOs)) – NGOs procured by the government, the publicly financed municipalities, and health care services and in this status offering SE. These NGO SE organizations work with persons with different kinds of disabilities, but mainly psychiatric (Rudnick, 2014), neuropsychiatric (in the Swedish context neuropsychiatric disabilities are defined as ASD, attention deficit and hyperactivity disorder (ADHD), Tourette syndrome, and language disorders, hence somewhat differently than in the international arena (Hyman, 2008; Swedish National Board of Health and Welfare, 2019)), and intellectual disabilities. The gender distribution among the participants in these organizations that took part in the study ranged from 30% women and 70% men to 40% women and 60% men. Type 3 (coordination agencies) – Organizations working with SE in the context of the coordination agencies financed by the publicly financed municipalities, health care services, the Swedish Public Employment Agency, and the Swedish Social Insurance Agency. Coordination agencies work with persons with different kinds of disabilities. The gender distribution among the participants at the coordination agency taking part in this study was equal. Type 4 (employment agency) – SE at the Swedish Public Employment Agency. This SE program works with persons with different kinds of disabilities. The gender distribution in this SE program was approximately 40% women and 60% men.
A strategic sample of both men and women from these four types of SE organizations was recruited. Approximately 40 employment specialists from all four types of SE organizations were asked to recruit approximately 1 of their SE participants each. Inclusion criteria were as follows: being at least 18 years old, having a psychiatric, neuropsychiatric, or intellectual disability, having participated in an SE intervention for at least 6 months, and having had a work placement in at least one workplace during the time with the SE organization. Seventeen SE participants consented to take part in the study. This sample size was considered appropriate to attain data saturation considering the relative homogeneity of the participants (Guest et al., 2006).
Data collection
Semistructured interviews with the SE participants who agreed to take part in the study took place from May to October 2022. The interviews were held either in a private room at the SE organization, in the interviewee’s home, via video call or via telephone call depending on the interviewee’s preferences. Differences in the interview mode could have possibly affected the results, although differences between face-to-face interviews and video calls seem to be very small (Krouwel et al., 2019), differences between face-to-face interviews and telephone interviews have shown mixed results (Irvine et al., 2012; Janssen et al., 2010), and differences between telephone versus video interviews (with the camera on) have shown very small differences in data quality (Lindsay, 2022). The interview guide contained background questions and questions about experiences of coming to an SE intervention and receiving SE. See Table 1 for detailed interview questions. The participants were informed that the analysis would contain an evaluation of the answers of men and women. The first author, who is a female social worker with several years of experience working professionally with persons with different disabilities, conducted all the interviews. The interviews were audio recorded, transcribed verbatim and anonymized.
Interview guide
Interview guide
The transcribed material was first analyzed with qualitative content analysis according to Graneheim and Lundman (2004) by the following steps: A read-through of the transcribed material was performed to obtain an overall picture of the content. The transcribed material was divided into meaning units, i.e., the text was divided into units that addressed the same issue. These units were usually sentences, parts of paragraphs or short paragraphs. The meaning units were transferred to condensed meaning units, i.e., close-to-the-text abbreviations of the content of the meaning units without the meaning of the content being lost. The condensed meaning units were named with codes, which were shorter labels that reflect the content of the meaning units. The codes were then sorted into categories. The categories were groups of codes that had something in common. Graneheim and Lundman write that sorting into categories is the core feature of qualitative content analysis and that “no data related to the purpose should be excluded due to lack of a suitable category. Moreover, no data should fall between two categories or fit into more than one category” (2004, p. 107). The categories were then grouped into themes. According to Graneheim and Lundman, a theme is an expression of the underlying meaning in the material (2004). Steps 4 to 6 in the analysis build on abstraction and interpretation (Graneheim & Lundman, 2004). In this analysis, the authors have kept to a low degree of interpretation, even though the level of abstraction is higher, therefore the analysis is more of a manifest qualitative content analysis close to the interview transcripts (Lindgren et al., 2020).
For the first 3 steps, 4 of the transcribed interviews (2 men and 2 women) were examined individually by all 3 study authors and then the results were compared. Because a high degree of consensus was reached in dividing the material into meaning units, the first author continued doing steps 1 to 3 alone for the remainder of the transcripts. Steps 4 to 6 were performed by the first author, and then the second and third author reviewed the data analysis for inconsistencies. See Fig. 1 for an example of steps 2 to 6 in the data analysis process.
Example of steps 2 to 6 in the data analysis process.
After the qualitative content analysis was finished, the material was analyzed according to gender to identify whether there were differences in what the participating men and women had talked about. Comparison of groups in qualitative health research has increased in use the latest years to explore differences in experiences and needs among groups (Lindsay, 2019). Nevertheless, the methods on how to perform these kinds of data analyses are not yet set. So far, the most common type of data analysis method seems to be that the complete material is first coded and then similarities and differences between the groups are examined (Lindsay, 2019). In this study, the comparison was done at the category level of the qualitative content analysis. In categories where at least 3 women/men talked about the same content but none of the opposite gender did, or if the opposite gender was talking about the content of the category in very different ways, the category was gender-marked.
When the analysis was finished, a reference group consisting of a representative of an SE organization in Sweden, a representative of a disability organization representing persons with intellectual disabilities and a representative of an autism organization commented on the results as a means of member checking (Birt et al., 2016). The individual members of the reference group received the analyzed results of the study ahead of a digital meeting, led by the first author, where they could comment on the results. The digital meeting was audio recorded.
The study design of this study was approved by the Swedish Ethical Review Authority (dnr: 2019-06088 and dnr: 2021-05528-02). Information about the study was provided both orally, face-to-face or in the form of a short video with accessible information, and in writing to the potential SE participants before written informed consent was provided by the SE participants who wanted to participate in the study.
Results
The results from the analysis will be presented in the following way: first, there will be a presentation of the characteristics of the participants, after which an overview of the categories constructing the main themes will be presented, and then there will be a presentation of the gender differences found in the categories. Finally, reflections from the reference group will be presented.
Characteristics of the participants
Seventeen SE participants, 10 women and 7 men, agreed to take part in the study. As seen in Table 2, there were some considerable differences between the men and the women in the study. The women were older than the men, and only women participated in the coordination agencies, while it was mostly men who participated in NGO SE organizations. The women reported experience of psychiatric disabilities to a much higher extent than the men, and the women, apart from the two with intellectual disabilities, had received their diagnoses as adults, while the men had received their diagnoses before the age of 18 (apart from one man who had received an additional psychiatric diagnosis as an adult). More of the women than the men had at least upper secondary education and working experience. For a majority of the women, the SE intervention was their first VR activity. The women also had a partner, lived together with other adults (partner or parents) and had children under the age of 18 to a higher extent than the men.
Characteristics of the SE participants
Characteristics of the SE participants
aAs described by the participants. Many of the participants were diagnosed with multiple types of disabilities; therefore, the sums of the columns do not add up to the number of participants. Two of the male participants did not specify their disability, but as these two men are in sheltered workshops, they were diagnosed with neuropsychiatric and/or intellectual disability. bOne of the male participants received a neuropsychiatric diagnosis before the age of 18 and a psychiatric diagnosis after the age of 18. cTwo of the women and one of the men had educations from special education at upper secondary level, but as the grades from this education are worth less than ordinary grades from upper education, they are here counted as “less than upper secondary”.
All 17 participants described in very general terms that the support they had received from the SE organizations had been good. The analysis focused on more detailed descriptions of the participants’ experiences of SE to gain better insight into how they experience this “good support”. The 49 categories derived from the codes in the material were formed into 5 themes reflecting different aspects of the SE process. These themes are Entering the labor market, Trustful relationship with the employment specialist, Diversified and individual support from the employment specialist, Supportive workplaces, and Personal development. See Fig. 2 for an overview of themes and categories.
Themes and corresponding categories.
The first theme consists of categories that express the participants’ understanding of how to (re)enter the labor market and what constitutes barriers and enablers to enter the labor market.
The participants primarily wanted to (re)enter the labor market for two different reasons: they found it meaningful to work, and they wanted to have real income and not be dependent on the welfare system.
Almost all the participants noted the importance of having appropriate support from different authorities to be able to enter the labor market, especially health care and labor-market related authorities.
The participants also discussed several barriers to work, and among them, their impairments per se, with tiredness for example, were described as the most common barrier and therefore were seen as a disabling factor, as the impairment clashed with expectations in the labor market, for example, productivity and interactions. However, they also noted more external barriers, such as low education level and employers’ hesitance to employ persons with mental health problems. In regard to enablers of work, the participants mentioned personal factors such as being a social person or being good at following instructions but also having self-awareness about their strengths and weaknesses.
Although some participants mentioned only the SE organization as an important facilitator for entering the labor market, many also mentioned other significant others, such as family members, especially mothers, friends, and teachers, as important support persons.
Theme 2 – Trustful relationship with the employment specialist
This theme consists of the categories that address the different aspects of the relationship between the participant and the employment specialist. In some categories in this theme different kinds of emotional support are mentioned, when it is related to the trustful relationship between participant and employment specialist. Other kinds of support will be further discussed in Theme 3.
Most of the participants mentioned that they got along well with their employment specialist, and some participants pinpointed that the matching of participant and employment specialist was central and the importance of being able to switch employment specialist if the relationship was not functioning well. The participants talked about how the employment specialists offer emotional support in different ways, such as checking that the participant was alright and giving encouragement. The participants talked about the importance of being recognized as an individual person and being respected and listened to.
You’re accepted. You’re respected and you’re not being pushed around. Simply put, you’re treated as a human being.
Participant 13, woman
When individual recognition was forgotten, it affected how the participants experienced the SE intervention. One participant described how she was taken to a study visit at a school to obtain information about how to complete grades in secondary school even though she had already completed such grades; for her, the study visit was just a waste of time.
The participants talked about how the employment specialists noticed things about them that they did not notice themselves and that they were supporting the participants’ empowerment.
And she wants so much, for me. It also feels reassuring that someone else believes in me more than I do myself.
Participant 6, woman
Some participants pointed out that it was important to be open with their needs toward the employment specialist, even if it might be difficult at the beginning of a relationship. Some participants said that they were ready to start a job when they came to the intervention, and some other participants were not motivated at all. Despite this, the employment specialists worked with persons with no motivation until they found their own motivation.
Some of the participants seemed to have a very open relationship with their employment specialist, where both parties could show many kinds of feelings but also that they could have a more personal relationship where they shared book recommendations, were invited to the employment specialists’ home, or still maintained contact even though the formal SE intervention was finished. In light of the relationship between participant and employment specialist, the participants talked about the employment specialists’ competence and engagement in their work and that they had a very difficult profession that had to adapt to many different persons. This adaptation process sometimes failed, and one of the participants explained how her employment specialist exceeded her comfort zone when being too personal, which made the participant feel a bit unsafe and led to a change of employment specialist.
Theme 3 – Diversified and individual support from the employment specialist
This theme consists of the categories where the participants talked about the kind of support they received from their employment specialists.
As SE is a work-oriented intervention, the participants talked to a large extent about the work-related, or sometimes study-related, support they had received. This support relates to finding workplaces, making initial contact with the workplaces, being with the participant at the workplace, having follow-ups with managers/supervisors together with the participants at the workplace and working toward employment. In one case, work-related support was received “behind the scenes” because the participant could handle the workplace by herself. When the goals were study-related, the participants received support in finding and organizing the studies.
One of the important forms of support that the participants and the employment specialists work together with is to find a suitable workplace for the individual. The matching of the workplace needs to fit both the interests and the specific needs of the participant and the workplace. A good match between the participant and workplace makes the coming work effort for both the participant and the employment specialist less straining.
The participants talked about how SE organizations were inclined to fill their individual needs. This approach could sometimes be problematic when the participants had difficulties attending to their own needs.
Maybe it was at some point, this thing with me having a hard time accepting that things are for me, that it felt like “Yes, but now I must satisfy the employment specialist. Now I must perform.” So, there was probably one such occasion when I was quite upset about this.
Participant 7, man
The participants talked about how the support they received followed their changing needs, but when the support did not follow the need, the satisfaction of the participants declined. The participants also talked about how the employment specialists supported them in finding balance in life and keeping their limits, that the employment specialists functioned as their sounding boards and that the employment specialists were good at giving clear feedback.
Theme 4 – Supportive workplaces
This theme consists of the categories where the participants talked about their workplaces, as interns or employed, and what the workplaces meant to them.
Many of the participants spoke of the importance of having something to do, and this was also something that led many of them to participate in SE in the first place.
It’s not healthy. Take it from me, who has been isolated for so many years, you don’t get out of depression by just staying at home and being on long-term sick leave. I don’t see that as a solution to the whole thing if you don’t have an active ... some activities or some therapy or something that brings you back. But it’s very important not to let go of people who are...because it’s extremely difficult to find the motivation and come back.
Participant 9, woman
That the people at the workplace are able to accommodate to the persons’ individual needs was important for the satisfaction of the participants. Feeling belonging to a group of people and feeling support from supervisors/managers and colleagues in the workplace seemed to be crucial for the wellbeing of the participants. The participants talked about the importance of having suitable duties at work. However, what constituted suitable duties was an individual issue, and different participants emphasized different things.
Many of the participants had been in SE for a long time, and they had tried many workplaces, both as interns and employees. This did not seem to bother them in most cases, seeing it instead more as experiences that they gained from, even if the long-term goal was sustainable employment. The different workplace experiences also rendered work references for the participants. Enjoyment, or at least not feeling unhappy, at the workplace was also important for the participants.
The participants were vulnerable at work and could lose their internships or employment due to many factors, such as COVID restrictions, lack of work duties, and movement of the specific company, leading to increased commuting time. However, the participants’ impairments were also expressed as a factual problem in relation to work.
Then, I got a placement at a store over there, but I guess I had a borderline period then. It was a little hard, you know. I couldn’t manage that much. So, I quit.
Participant 11, man
Some participants also noted that the employment specialist supported the employer as well and tried to make everyone satisfied.
Theme 5 – Personal development
This theme consists of the categories where the participants talked about how SE has influenced and affected them as persons.
The participants talked a lot about how SE has led to that they now have plans and dreams for the future again and that they know better now what they want and need from a workplace for their well-being and to be able to work.
We can start by saying that when I came to this SE organization, I didn’t know who I was, what I wanted, what I was going to do. After all, they’ve helped build the person I am today.
Participant 1, man
The participants also talked about how they had learned so many new things and learned to handle new situations and that these experiences had led to better confidence and more independence.
A few of the participants commented that their health had improved after entering the SE intervention, and some of the participants also commented that they had made new friends during the SE intervention due to group activities at the SE organization.
Overall, many of the participants discussed personal growth and that they had achieved progress due to participating in the SE intervention.
Gender differences in the interview data
In general, men and women in the study talked about and emphasized the same aspects of the support they received in SE. However, there were some noticeable gender differences at the category level in the themes Entering the labor market, Trustful relationship with the employment specialist and Diversified and individual support from the employment specialist.
In the theme Entering the labor market, several of the women, but none of the men, had noted that receiving information about SE services from the authorities they were dependent on was random in nature.
There is never anyone, I have gone and talked before, in a bigger city, with therapists and so on, and no one has mentioned any kind of support for job training or anything like that.
Participant 8, woman
In the theme Trustful relationship with the employment specialist, the women appreciated that the employment specialists challenged them and placed (reasonable) demands on them in order for them to progress. The men did not mention this at all.
I say that I wouldn’t have been able to do this if she hadn’t pushed me and challenged me a bit and sort of said “Well, now we’re going to do it this way.” and I “Yeah, well, ok.”
Participant 10, woman
In the theme Diversified and individual support from the employment specialist, only the women in the study emphasized the possibility with a slow start in SE, sometimes without even being at a workplace, to then progress into more demanding activities.
It all started with me coming here one day a week for two hours to sit drawing, which I also did at home, so I basically just moved my drawing from home to here, two hours one day a week, because that’s what I could physically cope with. And after those two hours I was exhausted for two days. Because then I had been at home on sick leave for a couple of years.
Participant 3, woman
The women in the study seemed more inclined than the men to receive and accept whole-life support, such as receiving reminders of appointments and help with keeping structure, and not just work- or study-related support.
Interviewer: I’m thinking about whether these parts you’ve worked on, are they mostly focused on the workplace, or also for life in general?
Participant: Both, actually. We have tried to include both.
Participant 17, woman
Some of the men also mentioned that the SE organization could give other kinds of support than work- or study-related support, but they had mostly rejected that kind of support.
But I was a lot like this that I wanted to handle everything myself, but they always repeated “If there is something, anything, just tell us!” It was a lot like that when you were talking to them, like “But do you need help applying for this or that?” And as I said, I’m a bit stubborn so I could be like “No, I want to do it myself.” But they were always there. They were there if I needed anything.
Participant 11, man
One distinguished part of the whole-life support that the employment specialists provide is helping to handle different authorities the participants need to deal with. It was mostly women who received this kind of support, and the men seemed more reluctant. She can sort of help me if it’s the Employment Agency and the Social Insurance Agency, because I think the Social Insurance Agency would like to have contact with my employment specialist, so then she’s the one who can talk to them about how I’m doing and how things are going with my training and how I feel.
Right.
It has been a wonderful relief. Great, really great!
Participant 8, woman
I will have to apply for a new period of disability pension, and it’s messy. It’s messy, right. Do the employment specialists help with that too? Or who will help you with that? They’ve talked about it. I don’t want to say yes or no. Actually, I don’t know. They’ve talked to me about this and wondered if they can provide any support or anything. I don’t know how much influence they have. I just don’t know.
Participant 4, man
However, there was also a tendency among the participants, both men and women, to separate work- and study-related support from other kinds of support and thereby limit the SE intervention. Another thing related to this phenomenon is that some participants, both men and women, did not want their family to be involved in the support.
Reflections from the reference group
The reference group confirmed the results from the interviews but thought it was interesting that gender had a larger impact than they had expected.
Many of the women in the study wanted whole-life support, while the men just wanted work- or study-related support. The reference group, drawing from their experiences, thought that women who had been out in working life and trying to navigate the welfare systems might be more receptive of that kind of support, while young men might feel alienated in the world of middle-aged women who make up the profession of employment specialists, even if men too might benefit from whole-life support. A broader palette of employment specialists of different backgrounds might help this situation. This notion is also supported by some of the interview findings.
The difficulties in finding and receiving SE interventions (or any work-related intervention), especially for the women, were not a new aspect to the reference group. They spoke of the fact that the welfare system is very complex, and even when persons are inside the welfare systems, the authorities have trouble fulfilling their responsibilities. When receiving SE, many of the authorities’ obligations that are unfulfilled land in the knee of the employment specialist to deal with before the participant can focus on work.
The reference group talked about the duality of the women both wanting the opportunity to a slow start and that they wanted the employment specialists to make demands on them. They reflected the idea from the interviews that making demands is also a way of showing respect and treating persons in the interventions as real human beings. They had experiences that demands that are too low can be devastating for people’s success in different fields of life, including working life, and that the processes may take longer with demands that are too low. The competence of the employment specialist was highlighted here, as was their ability to both listen and give individual support as well as not lose the work focus, which is crucial in SE, where a quick path to employment is usually stressed. The employment specialists work with themselves as a tool, and even in more systematic interventions such as SE, the biggest factor of success seems to be the working alliance between participant and professional. Finding the right balance in these kinds of relationships can be problematic but is part of the profession.
Discussion
Main findings
The objective of this study was to explore participants’ experiences of participating in an SE intervention and the influence of gender on their experiences. The main findings of the study were that, in general, men and women experienced participating in SE in the same ways. They all emphasized the same barriers and enablers for entering the labor market, and they all valued a trustful relationship with the employment specialist and diversified and individualized support from the employment specialist. They all noted the value of a supportive workplace, and they experienced personal growth from participating in SE. However, there were also noticeable gender differences. The characteristics of the men and women in this study were not the same. The women, in general, were older, had higher educational levels and work experience, and had also received their diagnosis later in life than the men. They also had different living conditions than the men. These differences in characteristics may have influenced the gender differences found in the experiences of participating in SE. The women experienced access to SE interventions as a random procedure; they valued the whole-life support in SE and appreciated both being challenged and the opportunity for a slow start in SE.
Methodological considerations
The recruitment of participants was done by the employment specialists. This procedure could have influenced the results in a positive way which may be indicated by that all participants thought that they had received good support from the SE organizations. Therefore, the views of SE participants who have a more negative view of the SE interventions are possibly lacking in this study.
From the beginning, the study aimed to interview 20 men and women who had at least 6 months of experience participating in SE to be well ahead of the recommendations of 12 participants in a relatively homogenous sample to reach data saturation (Guest et al., 2006). This proved to be difficult because it was challenging to recruit enough men within the timeframe of the study. In addition, the SE participants were not very homogenous, as the men and the women had different characteristics. Despite this, data saturation was reached at the category level except in one instance: the category Enablers for work: Maybe none? was only mentioned by one man. The rest of the categories were mentioned by at least two of the participants.
The interesting circumstance that men and women receiving SE in this study had different characteristics may be because men and women receiving SE are different in characteristics. The diagnosis of girls and women with both ASD and ADHD is lagging, and girls are diagnosed later than boys (Klefsjö et al., 2021; Young et al., 2018). Women are often only referred for a diagnosis of ADHD when psychiatric symptoms have shown (Klefsjö et al., 2021). Women, at least in Sweden, take more long-term sick leave than men, and the reason for sick leave is often psychiatric illnesses such as depression and anxiety (Forte, 2020). There also seem to be tendencies that men and women take different paths through the welfare system (Witte et al., 2023b) where men with disabilities get straight into the welfare system and women with disabilities, often undiagnosed, receive no support, try managing themselves but end up in sick leave.
The findings in relation to the theory of gendered organizations
In relation to Joan Ackers’ theory of gendered organizations (1990), the process of gender segregation is present in the current study, where men and women had different characteristics in terms of experiences of work, studies, and family situations and different paths into SE interventions.
The process of creating and recreating symbols and images is reflected in the notion that women want the employment specialist to make demands of them, perhaps because they have experiences of being viewed as weak, especially since they also have disabilities to deal with. Women and persons with disabilities are often perceived as weak and vulnerable (Garland-Thomson, 2002). Due to this logic, men with disabilities would also be seen as weak, but gender might trump disability in this case, as seen in the study by Porter et al. (2018), where the men perceived higher working demands than the women and the women felt that their diagnoses were downplayed due to their gender. Coming to the third process, if the women participating in SE are being seen as weaker than they are by the employment specialists, that might slow down the process. Many of the women wanted a whole-life support and being able to start slowly and then progress, and the employment specialists have a delicate task in the SE process, balancing between speeding up the process adhering to the SE principle of rapid job search and attending to individual needs adhering to the SE principle of individualized support. In person-centered approaches to health care and therapy (which resemble SE/IPS in individual support), gender sensitivity, where knowledge about gender processes as well as reflections of gender socialization to avoid reproducing discriminating processes, has to some extent been highlighted in recent years (Lindsay & Kolne, 2020; Macke & Hasler, 2019), but there has been a lack of gender-sensitive approaches in research on SE/IPS.
The findings in light of previous research
The overall findings are all in line with previous qualitative research on experiences participating in SE where individual, person-centered, and holistic support are stressed and SE is seen as an individual development process (Hillborg et al., 2010; Moen et al., 2020; Porter et al., 2018). The findings of the importance of job matching are also in line with previous research (Gustafsson et al., 2018; Moen et al., 2020). The additional findings that women and men in SE, to some extent, have different experiences and requests, have not been previously studied, and further research is needed to explore the issue. The finding that women, to a higher extent than men, want a slow start and then progression in the SE interventions is interesting in light of the previous reported randomized trial of SE in Sweden (Swedish Social Insurance Agency, 2017), where gender differences favoring men were found in employment rate at the 15-month follow-up, but these gender differences were no longer as prominent at the 18-month follow-up (Fogelgren et al., 2023).
Conclusions
Although the overall experiences of SE were shown to be similar for men and women, some differences were also found. Many of the women, unlike the men, wanted whole-life support, with both the opportunity for a slow start and reasonable demands from employment specialists. These findings might moderate the view in SE that a quick path to employment is crucial for being considered a successful SE process (i.e., the-rapid-job principle) to a view that the path to employment might look different depending on the participants’ experiences and living conditions for the intervention to be more successful for both men and women.
For practitioners, it will be important to recognize that SE processes might be gender coded and that men and women, to a part, want and need different kinds of support in the SE process, where women to a higher extent than men want whole-life support, the possibility of a slow start and also to be reasonably challenged in the SE process. Hence, the individualized person centeredness in SE must not be forgotten.
Footnotes
Acknowledgments
The authors would like to thank Dr. Matilda Fredriksson and Ph.D. student Sofie Adaszak for valuable comments on the manuscript and Dr. Marinette Grimbeek for valuable feedback on the translations of the interview transcripts from Swedish to English.
Conflict of interest
The authors have no competing interests to declare.
Ethics statement
The study design of this study was approved by the Swedish Ethical Review Authority (dnr: 2019-06088 and dnr: 2021-05528-02).
Funding
This work was supported by FORTE, The Swedish Research Council for Health, Working Life and Welfare (grant STYB-2019/0005).
Informed consent
Informed consent was obtained from all interview participants.
In a Swedish context, sheltered workshops are characterized by a broader approach where e.g. SE interventions might be included.