PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 101 Social Work & Social Sciences Review 16(1) pp.xx-xx. DOI: 10.1921/1103160301 Participation and coping: A mutual dependence? Rita Elisabeth Eriksen1 Abstract:Whatimplicationsmightanunderstandingofamutualdependencebetweentheconceptsof participationandcopinghaveforprofessionalengagementwithserviceusers?Thisarticlepresentswhy participation is central to peoples’ lives and how service user coping with and personal participating in everyday life might be understood. Service users have access to personal and environmental resources and want to manage their everyday life as much as possible. To be able to cope they have to participate. An analytical framework was developed as a result of a study based on qualitative interviews with service users in Norway. A framework was constructed to explore how the service users participated and coped with their everyday life – both on an individual level and through interactions with their environment. This framework emerged from preliminary analysis and was then used in further analysis of the data. The study showed that professionals would be advised to build on the participation and coping that service users had established in their daily life as citizens as well as people using social services. Some service users expressed that the more social contexts they participated in, the better they experienced their coping. Keywords: participation; coping; service users; constructed analytical framework 1. Associate Professor , Diakonhjemmet University College Address for correspondence: Institute of Social Work and Family Therapy, Diakonhjemmet University College, Postbox184 Vinderen, N- 0319 Oslo, Norway. r.eriksen@diakonhjemmet.no RITA ELISABETH ERIKSEN 102 Introduction What is the essential meaning of participation and coping? Participation refers to experiencing real influence on and involvement in one’s environment and coping with the challenges arising from participating either individually or collectively. Positive experiences of coping are necessary to strengthen self-esteem (belief in one’s own knowledge and skills) and the ability to continue to cope and participate. The challenges connected to coping depend on actual persons, situations, incidents and resources. Meaningful experiences of coping inspire human beings to participate in their everyday life and they feel more included in the society (Saleebey, 2006). Belief in the possibility of positive change is strengthened the more one participates in or copes with various situations (Folkman et al, 2004). This in turn reinforces self-esteem which may increase people’s coping and participation in various aspects of their everyday life – both as citizens and as service users. To understand these types of experiences, I constructed an analytical framework (See ‘Preliminary data analysis’ below) based on a study of service users from Norway in 2004. The research question of the study was: how do service users experience coping and participation in their everyday lives individually or through interactions with their environment? (Eriksen, 2007; 2012). The aim of this current article is to examine: 1. the interdependence between participation and coping processes for service users in everyday life, and 2. whether an analytical framework, based on concepts arising from the preliminary analysisofdataofthisstudy,canbedevelopedfurthertounderstandtheprocesses of participation and coping for service users who engage with professionals in social work practice and through research. Why is service user participation central in social work practice? In Norway a service user is understood to be a person who receives welfare services (Rønning et al, 1998). The ideal of service user participation has a clear political priority in Norway. According to the government’s national strategy for qualityimprovementinthehealth-andsocialservicesserviceuserparticipationisalegalright which might be practiced in different ways: by participating and thereby influencing future policy and by having influence on different levels of organizational systems, groups and individuals. This implies that decisions regarding treatment, care and social services are based on service users having reliable knowledge about how the quality of welfare services develops (The Directorate, 2005a). Inspiteofgoodintentionsfromprofessionals,theidealofserviceuserparticipation is often difficult to carry out in practice (Bailey 2012). For example interviews with PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 103 people using social services in Oslo in 2003 indicated that many were dissatisfied with the help they received, for example assistance in resolving challenges in their everyday life. The satisfaction of these service users was lowest on a dimension that asked about their experience of service user participation (Eriksen, Bråttveit & Døhlie, 2003). Service user participation may support further development of welfare services and social work practice. Service users have many years of experience and knowledge stemmingfromtheirparticipationasserviceusersandascitizens.Priortoapplyingfor welfareservices,serviceusershaveoftenspentasignificantamountoftimeattempting to solve their problems on their own. Services that build on the resources service users access themselves (such as personal abilities, informal networks of family and friends as well as more formal networks of professional services) will increase the possibility that statutory assistance will be experienced as a good service (Uggerhøj, 1995). What is service user participation? Social services in Norway are organized in a bureaucratic fashion and regulated by laws and guidelines (Jenssen, 2009). Service users experience these services as liberating or oppressive. On the one hand, professionals are charged with the task of administering the means of the state in a justifiable manner. This involves casework including statutory requirements in respect of documentation and applications for help from service users. On the other hand, professionals may be willing to give up some of their power and authority in order to achieve motivating and positive coping outcomes in their collaboration with service users. In theory, service users are supposed to experience a positive gain from the assistance they receive from service providers, so that in turn they can participate in andcopebetterwiththeireverydaylife.Atonelevelserviceuserparticipationinvolves the taking of power from professionals since it is not possible for professionals to give their power to anyone (Freire, 1972). Consequently service users may experience their options as limited, especially if they are dependent on benefits. They might submit an appeal concerning benefits related decisions, however, this is not easy because service users are often afraid of losing their benefits and often have no other alternative means of income. Despite good intentions of professionals, service users might experience that too much power is being used or that power is exercised in ways that make service users feel inferior (Underlid, 2005). Professionals have a particular responsibility to encourage service user participation in the ways they engage and collaborate with them. On the other hand, they are not supposed to under-communicate their statutory duties and are employed to distribute means on behalf of the public in accordance with laws and professional assessments. Service user participation is based on dialogues with services, in which both the competence and experiences RITA ELISABETH ERIKSEN 104 of service users and professionals are included. In certain situations the authorities are criticized for disclaiming their public responsibility and for conveying too much private responsibility to get service users to participate. Occasionally, such heavy burdens are carried by service users to the extent that they feel unable to participate. From service user participation in social services to ’personal participation in the everyday life’ At the starting point of the study from Norway (Eriksen 2007), I focused on service users’ participation in encounters with the social services. In this context I limited participation to the individual level where service users engage actively and have real influence on the decisions that are made during their formal relations with professionals. My research perspective changed to a study of personal participation and coping in everyday life once the service users told their stories. Personal participation is human beings’ experiences of activities and of real influence on decisions concerning their everyday life – alone or together with people from their informal social networks. The life situations of the service users involved much more participation and coping than did their interactions with professionals. By taking this everyday-perspective the possibilities of the social users participation was strengthened. Service users spoke of life situations which involved varying degrees of strain and this positively or negatively influenced their possibilities of participation in other aspects of their everyday life. They seemed to experience a mutual connection between such personal participation and their coping: for example the more they participated in different arenas, the better they coped with their experienced challenges. From participation to ’coping and participation’ Research has documented that service users have very complex problems and are described as poorly resourced, especially financially (Harsløf et al, 2008). The possibilities for participation and to be self-reliant are therefore varied. Service users who enjoy little prosperity in a society with a generally high standard of living as in Norway, may experience this as a burden. In such life situations it is important to strengthenone’sself-esteemthroughpersonalparticipationandpositivereinforcement from one’s environment (Høilund et al, 2005). Poverty is experienced as worse for those who have a short period of poverty compared to those who have a longer period, because people with short periods are used to a higher standard of living (Hamilton et al, 2006). My assumption was that service users who participate in and cope with the most challenging life situations over an extended period of time, must have a lot of resources to draw support from. With a resource-orientated or strengths perspective PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 105 (Saleebey, 2006) professionals emphasize the service user’s resources, capabilities, support systems, and motivations to meet challenges and overcome adversity (Barker, 2004,420). Due to the service users’ stories I understood that their experiences of participation meant having real influence on decisions concerning their everyday life as well as being able to cope with the challenges they encountered. I obtained theoretical inspiration from Antonovsky (1987) to understand coping in more depth – especially his concept of sense of coherence (SOC). A strong or a weak SOC will influence whether a person experiences coping or not. SOC has three elements and consists of the individual’s: 1. understanding of the situation, 2. belief in possible solutions, 3. experience of meaning. In their model of transaction Lazarus et al (1984) describe how individuals make cognitive assessments of experienced stressors. They emphasize factors from both the individual and the environment. In the light of these theories I developed an understanding of the concept stressor based on internal or external challenges, such as bad feelings or threats, and used stress to refer to dynamic, subjective experiences that the stressors had created. The literature of coping presents a broad use of the coping-concept (Ibid.). In my study coping is interpreted as movements in the directions desired by the service users. Movements are construed as conscious thinking or actions. Personal participation and service user participation are thus movements that support the coping processes either by activity and/or real influence in the service users’ desired directions. Based on service users’ experiences in the study in 2004 an analytical framework was constructed in the preliminary analysis (Eriksen, 2007; 2012). This frameworkrepresentshowcopingandparticipationareunderstood.(See“Preliminary data analysis’ below) Social support provides resources to aid service users’ coping and participation in their environment. Social supports are people who contribute a confirmation of meaning, respect, real influence, and direct assistance to service users' lives or belonging to a group. Method The study took place in Eastern Norway in 2004 and was based upon 21 qualitative interviews of service users (ranging in age 18-60 years). They were 9 women and 12 men. Criteria for inclusion were unemployment and dependency on benefits. All serviceuserswhoapproachedsocialservicesduringtheperiodofrecruitmentbetween February and May were invited to participate. The interviews were conducted in the RITA ELISABETH ERIKSEN 106 social services’ agency. Service users were involved as meaning-creating participants who contributed in constructing their experienced everyday lives (Kvale, 2008). The interview guide was semi-structured and consisted of ten themes concerning the service users’ experiences of coping and participation in their life situations. For example, an interview question connected to the theme ‘coping’ was: ‘Will you please talk about what makes your life worth living?’ A question connected to ‘participation’ was: ‘What kind of activities do you enjoy?’ The contents of the in-depth interviews were strongly influenced by the service users’ stories. The duration of interviews was 1-1,5 hours (for more information relating to the method see Eriksen 2007; 2012.) Preliminary data analysis Intheanalysesakeyaimwastounderstandwhichelementsofcopingandparticipation took place: the person(s), the environment, the incident or the situation? For example how did the service users experience unemployment and how did this contribute to their coping and/or participation or did it cause them more stress? Analysis of service users’ narratives consisted of three levels of abstraction (Malterud, 2011). In this article I limit myself to commenting on the first level, which was developed into an analytical framework. This framework was a result of preliminary analysis of data and was used in further analysis of the second and third levels of abstraction. The analysis was inspired from the interaction model (Shulman, 2008) and considered service users’ experiences in terms of: 1. an individual perspective, 2. an environmental perspective, 3. an interaction perspective (between the individual and the environment). These three perspectives were supplemented with results from the preliminary analysis based on the service users’ stories of their experienced participation and coping. The software programme NVivo (QSR, 2002) was used to identify and categorize themes from the data. For example a theme was: ‘Personal participation in applying for job’. The first coding dealt with finding themes with analysis-questions like: ‘what was the text about?’ The next phase was to search for the meaningunits, which meant finding details in the data concerning experienced coping and participation (Ibid.). Data analysis required the integration of data reduction, relevant theory and preliminary conclusions. These cumulative processes had iterative effects on each other and were crucial to the evolving analysis and the analytical framework as it was constructed of five personally experienced coping and participation abilities: can, think, wish, act and learn. This was no unitary theoretical understanding, but the data strongly influenced the theoretical concepts that were interpreted as relevant. PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 107 These abilities represented movements, that referred to a service user’s thinking and/or acting. Can refers to participation and coping knowledge. Think refers to the amountoftrustthatexiststosupportparticipation,copingandself-esteem.Wishrefers to the will and motivation for coping and participation. Act refers to participation and coping behaviours. Learn refers to experienced participation and coping through the learning process. The framework should be understood as dynamic, in the sense that experiences of participation and coping take place in service users as individuals and/or in their interactions with people in their environment. The participation and coping abilities can, think and wish were constructed with inspiration from Lazarus et al’s understanding of cognitive assessments and Antonovsky’s concept sense of coherence (SOC). In order to achieve desired goals, it may be necessary for service users to carry out some actions (do). Coping-orientated individuals participate and believe in success and do not worry about possible defeats (Covington et al, 1976). They assess their own mistakes as something to learn from, in ways that will allow them to participate or cope better next time (learn). This led me to conclude that participation and coping abilities are learned as experiencedbased knowledge. Summing up, the analytical framework is based on service users’ experiences of participation and coping interactions at two levels in their everyday life: 1. Interactions within the service user: 2. Interactions between the service user’s five participation and coping abilities (can, think, wish, act and learn). 3. Interactions between the service user and her/his environment: Theenvironmentincludespeopleintheserviceuser’sinformalandformalnetworks and is experienced as consisting of resources (such as social support) and challenges (such as lack of available jobs). The study established that the order of the participation and coping movements was by chance and that the movements could possibly consist of one or several coping abilities. The analytical framework must be understood as circular by social work professionals or researches who might want to utilize it. This means that coping and participation processes can take place in smaller or wider circles, and that service users can move forward or backward in their experiences. The analysis was focused on the ways the service users experienced reality. In order toachieveoptimalcopingorparticipation,theyneedcompetence,resourcesandskills in all the five abilities of the framework, though this may lessen the consequences of their experienced challenges. Social support from the environment might strengthen the service users’ experiences of participation and/or coping. Having access to and ability to mobilize individual or environmental resources is central to strengthening participation in coping with everyday challenges (Thoits, 1995; Espvall, 2008). The study (Eriksen, 2007) showed that the service users were a heterogeneous RITA ELISABETH ERIKSEN 108 group both concerning the challenges they experienced and the resources available to them for support. Service users expressed the processes of coping and participation as thinking and actions. They were either mentioned as shorter or longer processes taking place before, during or after the time of interviewing. Their narratives revealed differentexperiencesthatIusedtounderstandanddeterminecommoncharacteristics in their coping and participation movements. The descriptions given by the service users were related to two main challenges: 1) unemployment and 2) living with a shortage of money over time. Regarding unemployment their everyday lives were characterized by actively participation and coping, that is looking for work or finding meaningful leisure activities. Some of them felt that they were employable and tried to find jobs. Their participation and coping with possible employers had little influence on whether they got a job or not. Others felt that they were not employable and were not looking for jobs. Regardless of whether they experienced themselves as employable or not, service users had to defend their unemployment to themselves and people in their environment. Furthermore, the descriptions service users gave of their everyday lives were characterized by experiences based on the opportunities and limitations that followed from the second main challenge: living with a shortage of money over time. Their economic situations thus limited what activities they could take part in. The service users experienced that whether and how they participated had little influence on how much benefits they received. However, they reported that they had significant influence on how they spent their income. The informant Tor I will now illustrate the analytical framework with the five participation and coping abilities and the ongoing interactions between the service user and his/her environment. An unemployed service user Tor tells his story. He lived alone in his flat, tried hard to get a job, but did not succeed. He had to apply for benefits: I didn’t know what rights I had. The social services didn’t inform me about this. I had to pull myself together. I tried to normalize myself and make a meaningful life. Many people are unemployed. I thought of the future. After a while I got the information I needed. I have been employed since I was 16 years old and now I am 54. I want to work. The community has to ask the government for more money to make more jobs. For me it is the same whether I rake leaves or paint some houses. It is ‘normal’ for Tor to be employed. Over several years he built up his working competence (can) (personal participation). Despite his hard efforts he was unable to find any employment (low social support). His generalization that many others are PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 109 also unemployed might function as a protective factor to help him to cope with the experienced consequences of his unemployment (can, think). He approached the social services to get some assistance (think, wish, act) (service user participation) and engaged in the process of socialization to learn what rights he had as a service user (learn). Tor did not give up because he wanted a meaningful future (think, wish) (personal participation). Tor’s participation and coping abilities guided him to social services, where he was given relevant information and the benefits he needed and was entitled to (can, wish, act) (service user participation) (social support). He desperately wanted a job and hoped for new possibilities in the future (think, wish, learn). Tor was willing to take whatever work he could get (can, wish). My benefits are supposed to cover all my expenses – housing, food, clothing and so on. The rates are low! I do not get anything from others. I love dancing and have to have a beer bash in a restaurant twice a month. You have to get out to meet people. I used to do that for many years and then it suddenly stopped. I used to go hiking or sit in the park talking with people passing by. It has to be done once in a while. You cannot just walk between your four walls at home alone. You cannot invite people for only a cup of coffee every time. Tor created a sense of coherence in his everyday life by managing how he budgeted his finances (can, act, learn) (personal participation). He established limits for what he could afford: with food having the highest priority (can, act, learn) (personal participation) and using free activities such as hiking to cope. This coping activity possibly functions as a protective factor to promote better health (can, think, wish, act, learn) (social support). One challenge that Tor may experience is having greater social needs than his finances allow (low service user participation). Single people might have to mingle more with people outside their homes than people that live in households with several people. Torseldominvitedpeopleintohishome,becausethiscostsmoney.Torexperienced difficulties in accepting invitations from others because he felt he could not afford to do ‘the same’ (low personal participation). However, he invited some people into his home for coffee where costs were minimal (can, act, learn). Tor was ashamed of not having employment, though he believed that the government and his community were responsible for creating new jobs. At this point, his primary participation and coping focus is searching for employment (can, wish) (personal participation). If he does not get a job, his understanding of his lifesituation is likely change. Unemployment has led to reduced social contact, which has further weakened his informal social support network even though he found new social arenas like the park and hiking (can, act, learn) (personal participation) as opportunities for social contact. RITA ELISABETH ERIKSEN 110 Discussion Constructing a theoretical framework in analysis can enhance knowledge developed from qualitative analysis. As a result of moving between theories of participation and coping and data, the analytic framework was developed as a tool to understand the service users’ coping and participation and how these interacted. This framework is an operationalization of coping and participation as a first level of abstraction after intensive analysis of data and theories. The framework was a result of the preliminary analysis and was a useful tool for further analysis in the two levels of abstraction that followed. With a starting point in the service user’s life situation the framework helped me to interpret their experiences rather than force the framework upon the data (Malterud, 2011). The limitations of the study is that it is rather small involving only 21 informants. However the framework provided greater opportunities to obtain a shared insight into how service users experienced participation and coping, understood, acted and learned, as individual participants and interacted with their environment. In this respect their experiences revealed a mutual dependence between their coping and participation. Knowledge about such phenomena could be used to understand the experiences of other service users living in similar life situations (Fook, 2002). The use of a framework may have influenced my interpretations. My experiences as a researcher may also have impacted on the patterns that I felt were revealed during the analysis, for example on the elements that I understood to belong together, and on the words used to describe experiences (Malterud, 2011). In order to limit my bias as a researcher I returned to the original transcriptions and tapes of the interviews systematically. This I found helpful in analyzing the data as a general whole, then the different parts in detail, as well as the interactions between the themes in the data. I analyzed the interviews on an individual as well as on an environmental level, and compared them within the group of service users. Thoroughly explaining each step in the process increases the chances that other researchers can closely replicate my results (Eriksen 2007; 2012). Although an exact replication of analysis is questionable in qualitative research, the documentation of methods and the analytical framework used in this study, could better assist future researchers in reproducing and verifying experiences of service users and continue the process of knowledge production (Schwandt et al, 1988). Social workers as well as researcher can use theoretical frameworks as analytical tools to assist them in their role. Therefore, it is important to find methodological approaches that could develop knowledge and be useful in practice. Arelevantquestiontoposeiswhether professionalsincluding social workerscould get a better insight into the everyday participation and coping of their service users by using such a framework as the one in this study. One issue is that only a minority of social work professionals use results from research (The Directorate, 2005b). However if research is experienced as relevant to tasks that professionals carry out, the PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 111 use of the results from research could increase and services may improve due to the application of new knowledge. The framework could provide professionals a tool to achieve better insight into how service users reflect on, act and learn from their own coping and participation. For example the framework may be used in assessments, analysis, and planning, for evaluating service users’ coping and participation. The use of the framework may also strengthen approaches that are more oriented towards identifying service users resources – individually and in their environment. When the resources of a service user are focused upon systematically, they become more visible to professionals and in turn empower service users as citizens. When experiencing difficult life situations, service users may become more vulnerable and only participate in their everyday life on a small scale. During such periods professionals may risk being too resource oriented and not pay enough attention to pain, despair and sorrow that the actual challenges of managing adversity might pose for service users. Service users may experience this inattention as rejection or a disclaiming of professional responsibility. For some service users the very fact that they actively collaborate with their professionals can lead to enhanced control over their everyday lives. Maluccio calls this ’the triggering effects’ (Maluccio, 1979), which is metaphorically seen similar to ripples that spread in the water when a stone has been thrown into it. A systematic focus on the experienced participation and coping resources of the service users could reveal (latent) knowledge and contribute to better social services. This, in turn, could strengthen the practice of the professionals. As participating individuals, service users experience what kind of help feels best for them in their life situations. However, professionals may have varying approaches given their understandingandexperience.Withtheframeworkofthisstudyasatoolforanalyzing dialogues, professionals and service users may find a more common knowledge base for understanding the challenges associated with participation and coping. Conclusion It is, perhaps, fruitful to divide the concept of participation into service user participation (formal networks) and personal participation in everyday life (informal networks). Service users face some unique challenges in addition to those as citizens. Generally speaking, service users develop a special competence, as service users as well as citizens, and use a variety of skills by taking part in different activities and coping with a broad range of challenges. By harnessing this expert knowledge, service users could increase their influence on the way services are delivered and everyday life experienced. A shortage of resources might be experienced as troublesome and prevent participation and coping. On the other hand, to experience participation and coping RITA ELISABETH ERIKSEN 112 and have access to resources could be experienced as protective and promote future coping and participation. Use of the framework of this study in conversations with service users can strengthen their consciousness about their resources. Researchers and social work professionals can use the framework of this study and explore it through the three basic perspectives (individual, environmental and interactional perspectives). The service users in this study had a lot of participation and coping resources, but were not accustomed to thinking of themselves as resourceful. The self-esteem of service users may be strengthened by becoming more aware of their resources and by increasing their belief in their ability to solve their challenges. Service users could be motivated to participate more and cope better as citizens in their everyday lives as well as in collaborative relationships with professionals. References Antonovsky, A. (1987) Unraveling the Mystery of Health. San Francisco: Jossey Bass Bailey, D. (2012) Interdisciplinary Working in Mental Health. Palgrave Macmillan. Barker,R. (2004) The Social Work Dictionary. Washington: NASW Covington,M. and Beery,R. (1976) Self-Worth and School Learning. New York: Holt, Rinehart & Winston Eriksen, R.E. (2007) The Everyday Life of Service Users: Coping in a (user)perspective. Thesis. Trondheim: NTNU Eriksen, R.E. (2012) The Coping Model: what is it and what might be its implications for social work practice? The European Journal of Social Work, 1, 1-17 Eriksen, R E., Brottveit, Å. and Døhlie, E. (2003) Users’ Evaluations of the Social Services.Oslo: Dept. of Social Services and Diakonhjemmet University College Espvall, M.(2008) From obligations to negotiations: Reciprocity and reflexivity in informal financial support. The European journal of social work, 11, 4,355-367 Folkman, S. and Moskowitz, J. (2004) Coping: pitfalls and promises. Annual Review of Psychology, 55, 745-774 Fook, J. (2002) Social work: Critical theory and practice. London: Sage Freire, P. (1972) Pedagogy of the Oppressed. New York: Continuum Hamilton, K. and Catterall, M. (2006) Transition into poverty. The Marketing Review 6, 2, 123-136. Harsløf, I. and Seim, S. (2008) The Dynamics Of Poverty. Oslo: Universitetsforlaget. Høilund, P. and Juul, S. (2005) Acknowledgement and Power of Judgement in Social Work. Copenhagen: Hans Reitzels Jenssen, A.G. (2009) User Participation in Social Services. Thesis. Trondheim: NTNU Kvale, S. (2008) Doing Interviews. London: Sage Lazarus, R. and Folkman, S.(1984) Stress, Appraisal and Coping. New York: Springer Maluccio, A. (1979) Learning from Clients. New York: The Free Press PARTICIPATION AND COPING: A MUTUAL DEPENDENCE? 113 Malterud, K. (2011) Qualitative Methods in Medical Research. Oslo: Universitetsforlaget Qualitative Service Research International(QSR), (2002 July) NVivo, (3.ed.)(Computer Software), Melbourne Rønning, R. and Solheim, L. (1998) Help Based on its Own Premises? Oslo: Kommuneforlaget Saleebey, D. (2006) The Strengths Perspective in Social Work Practice. Boston: Pearson Schwandt, T. and Halpern, E. (1988) Linking Auditing and Metaevaluation:Enhancing quality in applied research. Newbury Park: Sage Shulman, L. (2008) TheSkillsofHelpingIndividuals,Families,GroupsandCommunities.Belmont: Brooks/Cole The Directorate of Health and Social Affairs (2005a) National Strategy for Quality-Improvement 2005-2015. IS-1162. Oslo The Directorate of Health and Social Affairs (2005b) Use of, Attitudes to and Need for Knowledge in the Social Services. IS-0153. Oslo Thoits, P. (1995) Stress, coping and social support processes. Journal of Health and Social Behavior, Extra Issue, 53-79 Uggerhøj,L. (1995) Help or Dependence. Aalborg: Aalborg Universitetsforlag Underlid, K. (2005) The Psychology of Poverty. Oslo: Samlaget