Does gender matter in Supported Employment? A qualitative study of participants’ experiences

1.1Supported 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.

1.2Qualitative 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.

1.3Objective

The objective of this study was to explore participants’ experiences of participating in an SE intervention and the influence of gender on their experiences.

1.4The 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 workshops¹ 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.

2.1Setting 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:

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).

2.2Data 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.

2.3Data analysis

The transcribed material was first analyzed with qualitative content analysis according to Graneheim and Lundman (2004) by the following steps:

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.

Fig. 1

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.

2.4Ethical considerations

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.

3.1Characteristics 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.

3.2Overview of experiences of participating in SE

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.

Fig. 2

Themes and corresponding categories.

3.3Gender 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.

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.

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.

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.

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.

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.

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.

3.4Reflections 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.

4.1Main 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.

4.2Methodological 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.

4.3The 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.

4.4The 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).