Pathways to Empowerment

The Social Quality Approach as a Foundation for Person-Centered Interventions

in The International Journal of Social Quality
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  • 1 Netherlands Center for Social Care Research, Impuls Academic Collaborative Center, Radboud University Medical Center, The Netherlands judith.wolf@radboudumc.nl
  • 2 Impuls, the Netherlands Center for Social Care Research, Radboud University Medical Center, The Netherlands irene.jonker@radboudumc.nl

Abstract

A program for person-centered intervention—Pathways to Empowerment (PTE)—is indebted to the social quality approach (SQA), which has been developed as its scientific foundation. It provides comprehensive insight into all sorts of factors that have an impact on the quality of the daily lives of persons who have lost control in their lives. In this article, we describe what puzzles were encountered in this developmental process, specifically with regard to the constitutional factors of social quality, which are strongly linked to biographical development and personal agency and thus are the focal points of person-centered care. This part of the SQA seems less developed and researched. We describe how we have further developed the conceptualization of the constitutional factors and their dialectical relationships with the conditional factors into a practical structure for PTE. We make a case for the further development of the constitutional factors of the theory, specifically the concept of personal agency. A plea is made for reviewing the definition of social quality.

In memory of Geert

An individual is socially excluded if they do not participate in certain activities of society to a reasonable degree over time for reasons beyond their control, despite their desire to do so (Burchardt et al. 2002).1 Social exclusion, being one of the driving forces of health inequalities in the general population, can be considered as a blend of multidimensional and mutually reinforcing processes of deprivation in areas such as interpersonal relations, material resources, access to health services, and housing (Van Bergen et al. 2018; Van Straaten et al. 2016; WHO 2010). These processes result eventually in their isolation from the opportunities that mainstream society has to offer and their inability to fully participate in society, which may lead to homelessness (Van Bergen et al. 2018; Vleminckx and Berghman 2001; Wolf 2016). Impuls—the Netherlands Center for Social Care Research of the Radboud university medical center in Nijmegen, the Netherlands—has a long history of research and development in the field of integrated care for disadvantaged people with complex health, interpersonal, and material needs, who often have difficulty holding their own in society. Most of our care innovation activities have been carried out in close collaboration with our partners, which are care organizations, housing corporations, and municipalities involved in the field of homelessness, domestic violence, and housing. The general aim of the Impuls Collaborative Centre—being part of the Impuls Research Centre—is to improve and professionalize the daily work of professionals by developing well-grounded interventions and tools to support the recovery of disadvantaged people.

In 2007, our partners expressed an urgent need to enhance the quality of the work of professionals involved with homeless youth and adults, as well as with women who have experienced interpersonal violence. They felt that the work of these professionals lacked a scientific foundation and was to a large extent based on common sense and an eclectic collection of methods and techniques, resulting in large intraprofessional differences. These observations led the care organizations and Impuls to decide to develop a person-centered, recovery-supporting intervention in close collaboration with clients and professionals. We named this intervention “Pathways to Empowerment” (PTE). The general aim of PTE is to improve the quality of the daily lives of persons who experience loss of control in their lives by focusing on their strengths and stimulating their personal agency, participation in society, and self-direction in life. The main task of professionals is to help create the conditions in which growth and recovery are likely to occur. We used three sources of knowledge in the process of exploring, grounding, and articulating PTE: (1) the lived experiences of clients (experience-based); (2) the expertise of professionals supporting clients (practice-based); and (3) results and insights from research and theories (science-based). On the basis of a review of national and international literature in 2007 on a multitude of interventions for the most vulnerable people in society, on consultations of clients and professionals using Delphi method techniques (Altena et al. 2010; 2014; De Vet et al. 2013; Jonker et al. 2014), and on the basis of a review of literature in the fields of social psychology (including positive psychology) and sociology—in addition to a review of the literature on such concepts as self-regulation and self-determination—we chose the Strengths Model as the practical foundation of PTE. The Strengths Model emphasizes that the capacity for growth and recovery is an innate ability of human beings (Rapp and Goscha 2012).

From its start, the social quality approach (SQA) has been the theoretical framework to structure and ground PTE for its use in daily practice as well as for its implementation training courses. The SQA proved particularly useful in providing a comprehensive overview of factors influencing the quality of daily life of citizens, including the institutional and societal processes involved and the various types of recovery that are necessary for fostering agency, participation, and self-direction. From a better understanding of these factors, the SQA also helped to identify the necessary types of support and the roles of participants at stake as well as the requirements for the dialectical interactions among the actors. In order for professionals to be able to understand and apply the rather abstract concepts of the SQA, it was necessary to simplify and translate them so that they were more accessible. The challenge in this process was not to deviate too much from this theory. In the course of PTE, the development of the SQA of course was and still is critically evaluated and adjusted continuously.

A key issue consistently has been the understanding and interpretation of the constitutional factors of social quality, as these are the focal points of professionals’ actions for the enhancement of clients’ agency, participation, and self-direction. Another key issue was how professionals in their daily work with clients were able to support and sustain the symmetry and specific nature of the (dialectical) relationship between the client, their lifeworld, and collective identities like societal institutions, care organizations, and local government. This article focuses mainly on the issue of the constitutional factors of social quality.

In 2009, we set up a training infrastructure—the Impuls Academy—in order to be able to provide certified training courses to professionals, among others, and to give advice and support to organizations that decided to implement PTE. Since then, much experience has been gained regarding the clients’ processes of recovery and regarding ways to provide professional support that enhances the quality of their daily lives. A lot has also been learned from the training and coaching provided to the professionals and the implementation of PTE in care organizations.

The main aim of this article is to describe how we have used the theory of social quality as the foundation for the person-centered intervention that is PTE, and what choices were made, and difficulties encountered, in applying this theory in practice. Based on these experiences, this article will also reflect on the existing theoretical framework of the SQA. Much of this article draws on the experiences of the first author (JW) since 2007—in her role as a developer of PTE and the principal investigator of the research and development activities involved in the development and enhancement of PTE—and the experiences of the second author (IJ) in her role as head of the Impuls Academy since 2014, where she has been responsible for the implementation and maintenance of PTE in organizations and teams.

We start this article—because of the importance attached to the central position of persons who have difficulty to hold their own in society and, in relation to that, to have in-depth insight into the process of social exclusion—with picturing the target population of PTE. Next, we describe how we have used the SQA as the theoretical foundation for PTE. We then present the principles and pillars of PTE and elucidate how we adapted and integrated notions and logics of the SQA into a practical structure for PTE. We go on with elucidating the activities that have been undertaken since 2007 for the implementation and maintenance of PTE as well as its coverage in the Netherlands. We continue—based on the development and application of SQA for PTE—with presenting critical notes on the existing theoretical framework of the SQA and come up with suggestions for the further development of the theory. Finally, we discuss and conclude our observations and reasoning as regards PTE as well as the SQA.

Importance of Social Exclusion

PTE supports a wide range of people who, temporarily or more permanently, experience a loss of control in their lives. In situations where people are losing control, the pervasiveness or cumulation of risk factors may pose an unsustainable burden for the individuals involved, especially when protective factors do not provide a sufficient buffer (Van Hemert and Wolf 2011). This can trigger a chaotic profusion of risk factors. These may be (1) structural factors, deriving from developments in society such as financial crises, ageing, migration, or the COVID-19 pandemic; (2) interpersonal factors between individuals and groups, including erosion of traditional networks or communities, or hostility toward people based on otherness; (3) institutional factors, such as the workings of institutions, the quantity and complexity of rules and regulations, or the criteria for gaining access to basic rights; and (4) individual factors affecting self-regulation, including distressing life events such as divorce or loss of livelihood and adverse living conditions caused by domestic violence, poor-quality housing, payment arrears, or problematic debts (Edgar 2010; Jehoel-Gijsbers 2004; Wolf 2002). In the Netherlands, people at risk for social exclusion are those with lower education levels, low incomes, non-Western backgrounds, or poor health, as well as singles and one-parent families (Hoff and Vrooman 2011). People with background characteristics such as these have higher-than-average utilization rates for services in the social domain (Boelhouwer 2016; SCP 2015). The proportion of residents of the Netherlands aged 18 or older who were experiencing social exclusion in 2010 has been put at 5 percent (Vrooman and Hoff 2013). Typical for socially excluded persons is a lack of future perspective. They may feel lost and redundant and, as a homeless man aptly put it, wander in no-man's land:

Yes, you come to a point where you don't belong to anything. You don't belong to the group anymore, but you don't belong to the normal people either.

The people targeted by PTE can be categorized into subpopulations based on one or more characteristic attributes. These include (1) emotional and/or behavioral problems, including anxiety, depressed mood, and problems with impulse control, with effects such as excessive alcohol, drug, or food consumption); (2) physical problems, such as diseases and impairments; (3) interpersonal problems, including relationship conflicts, parenting difficulties, loneliness, or neighbor nuisance; and (4) material deprivations like debt, insufficient income, unemployment and homelessness. Mental, physical, or learning disabilities may underlie the problems and stressors, and limited mobility may be a factor. Situations may be overshadowed by chronic violence, such as child or elder abuse or partner maltreatment. Specific age-related events or adaptation issues, such as reaching adulthood, retirement, loss of partner, or children leaving home, may present people with formidable challenges. The misfortunes and setbacks and their associated stress may change how people's brains develop and function, and these changes can impede the capacity of personal agency (Babcock 2018).

I have the will, but I need to be supported to be able to show my determination and to help me to make my way out. There must be someone who believes in you.

PTE emphasizes, reasoning from the Strengths Model, that persons who for whatever reason experience loss of control in their lives are capable of recovering, of reclaiming and transforming their lives, and of regaining what they consider to be a meaningful life with hope and a better prospect for the future (Rapp and Goscha 2012)— a future with the capacity and energy to foster and sustain secure living conditions, meaningful activities, and contributions; positive connections with others; self-compassion and a positive identity; and full access to institutions, networks, and human and civil rights (Wolf 2016). Recovery does not mean that persons will no longer experience problems or symptoms or struggles with their issues. Nor does it mean that they will no longer need care or use specialized services and medication or will be completely independent in meeting all of their needs. Recovery is a process of trial and error by making small steps forward and backward. It is a process of celebrating successful experiences, but also of experiencing feelings of pain and frustration.

Social Quality Approach as Theoretical Foundation of PTE

Factors Influencing the Quality of Daily Lives

During the start of PTE in 2007, we adopted the definition of social quality as described by Laurent Van der Maesen and Alan Walker in 2005, namely, as “the extent to which people are able to participate in social, economic and cultural life and the development of their communities under conditions that enhance their well-being and individual potential, which enables them, in turn, to influence the conditions of their own existence.” We embraced the concept of social quality because it is explicitly linked to the notion of citizenship, being an important pillar of PTE. Moreover, it expresses the importance of reciprocal relationships (dialectics) between individuals and societal configurations. Furthermore, it clearly identifies what is needed for “decent lives” as well as a “decent society” (Abbott et al. 2016; Mahoney and Kearon 2018; Walker-Andrews 2005). It was very much in line with our view that, on the one hand, as citizens, individuals have basic social rights and the relative freedom to direct their own lives while also having the responsibility to secure their own living conditions and—given their capabilities—to contribute to society. Society, on the other, ought to provide, via its formal networks and institutions, the means, processes, and relations necessary for people to be active agents and to participate. At the same time, society ought to take responsibility for citizens who, for whatever reason, be it temporarily or long term, do not have sufficient capacity to fully participate and contribute (Wolf 2002; 2012).

The SQA offered us a deeper understanding of factors and processes associated with social exclusion, and was important for the underpinning of PTE because, in essence, social quality is concerned with risk factors for societal participation, which in turn are assumed to influence health and well-being (Holman and Walker 2017; Nijhuis 2017). This theory takes “the social” as its very starting point. It states that human beings are essentially social beings, meaning that people do realize themselves through interacting with a range of collectives, both from the formal world of systems and the informal lifeworld. This interdependency is formed in the context of two basic tensions, which can be represented on two axes: (1) vertically—society and the individual; and (2) horizontally—formal relationships (e.g., in systems, institutions, organizations) and informal relationships (e.g., in communities, families, groups). Within this framework, the SQA discerns dialectical interactions and interdependency within and between the realm of:

  • Subjective (constitutional) factors referring to the capabilities of persons that enable them to become competent social actors that can change or transform opportunities and contingencies and create new perspectives for relationships (agency); and
  • Objective (conditional) factors referring to opportunities and resources in society that enable actors to influence the (inter)relationships in order to create or adjust a new context for self-realization (structures and collective identities) (Van der Maesen and Walker 2012).

The SQA also discerns normative factors, through which the outcomes of the dialectics between the conditional and the constitutional factors at a certain time and place are judged and directed. The normative factors will enable a deeper understanding of the nature and quality of “the social,” and, as such, can be deployed as a guideline for practices and policies as well as for assessments of the outcomes of the linking of the constitutional and the conditional factors. When applied in practices involved with persons who have difficulty holding their own, as well as in policymaking concerning, for example, poverty, social exclusion, and homelessness, the SQA could well serve as a tool for reflection and insight, and thus as a lever for change: What things are needed to enable individuals to build strengths and realize their potentials? What can be considered a good, decent life? What can we do in situations of loss of control and or deprivation to keep things from getting worse? Are we doing the right things? The application of the SQA can expose risk factors for social exclusion that often also work as structural obstacles to recovery and support processes. One such obstacle is that the most vulnerable in society repeatedly find themselves incapable of organizing their naked existence without intensive involvement by professionals, due to the extremely complicated functioning of societal institutions and deeply rooted institutionalized exclusion mechanisms. Or they encounter stubborn neighborhood resistance to giving people who are “different” a place in their community. Conditional factors for societal participation often serve as protective factors as well. Social cohesion and socioeconomic security can, for example, do much to absorb the impact of experiences like personal misfortune or tragic life events. Such protective factors can strengthen the resilience and coping capacity of both individuals and their informal and formal networks, thereby supporting the individual recovery process (Wolf 2016).

Focus on Constitutional Factors: Four Types of Recovery

In care practices, which help clients to master the challenges in their lives, the emphasis logically lies on the constitutional factors of social quality. These subjective factors allow—within the confines of the conditional factors—persons to develop and enhance their capabilities by recognizing, gaining access to, and converting resources (e.g., knowledge, rights, cultural beliefs, relationships, and communities). These will enable them, as citizens, to strengthen their personal agency in order to participate in processes influencing the quality of their lives, and in order to also make contributions to society (see Hermann 2012). Moreover, these factors give important clues to professionals as to what is necessary to support the recovery process of clients. For the appropriate use in the practice of professionals, we adapted and renamed the constitutional factors of the SQA specifically to create possibilities for them to apply and integrate these notions in their own vocabulary, logic, and habitat. The four constitutional factors articulated in PTE within the context of the dual tension between the system-world and the lifeworld are: living conditions, interpersonal embeddedness, societal embeddedness, and self-regulation (Figure 1). Living conditions—personal (human) security—refer to the extent to which people have material and immaterial resources over time to be able to live a good life. Interpersonal embeddedness is the degree to which people experience meaningful, reciprocal positive relationships and develop a sense of connectedness with others based on shared values and identities. Societal embeddedness refers to the extent to which people are integrated (or are able to participate) in their community or society and are able to access and make use of their basic rights as citizens and have an interest in the world around them. Finally, self-regulation is the degree to which people are in control of themselves and their lives, and can alter their own internal states, processes, and responses—thoughts, feelings, and actions—in anticipation of future goals. Linked to each constitutional factor we identified a specific type of recovery—these being the focal points of care and essential for reinforcing agency, participation, and self-direction—namely, functional recovery, community recovery, citizen recovery, and personal recovery. We labeled the outcomes of these four types of recovery as a sense of usefulness, a sense of connectedness, a sense of citizenship, and a sense of self, respectively (Wolf 2016). In other words, the underlying structure of PTE is the application of the four constitutional factors of social quality in relation to the four types of recovery being the focal points of care and the desired outcomes of recovery processes.

Figure 1:
Figure 1:

Application of Constitutional Factors of Social Quality in Pathways to Empowerment

Citation: The International Journal of Social Quality 10, 1; 10.3167/IJSQ.2020.100103

Before describing the practical structure of PTE, grounded in the SQA, we will first clarify related concepts and notions that we have developed since 2007 as part of PTE.

Pathways to Empowerment Elaborated

Strength as a Principle

We consider the Strengths Model as the practical foundation of PTE. Clients’ accounts of their experiences in the helping process were a very strong motivator to decide for a strengths-based approach:

I expect nothing at all from them [from the care services]; I'm not doing that anymore. If you go there with that many expectations, then you're just letting yourself down in so many ways.

I do know what all can go wrong. And I've heard so many times that it's my problem. It's important for social workers to shed light on the positive, healthy side of their clients.

Moreover, research on strengths- and empowerment-based interventions—with a strong focus on people with severe mental health problems—has shown positive outcomes for clients in terms of health and hospitalizations (Björkman et al. 2002; Macias et al. 1994; Macias et al. 1997; Modrcin et al. 1988), skills for independent housing and daily activities (Macias et al. 1994; Modrcin et al. 1988), job training and income (Macias et al. 1997; Modrcin et al. 1988; Stanard 1999), social support and behavior (Macias et al. 1997; Modrcin et al. 1988), leisure (Modrcin et al. 1988), quality of life (Stanard 1999), and satisfaction with help (Björkman et al. 2002). Other groups—people with addiction problems, women with interpersonal violence experiences, and homeless youth—also seem to benefit from a strengths-based intervention (Rapp et al. 2008; Saewyc and Edinburgh 2010; Song and Shih 2010).

The fundamental assumption of the strengths perspective is that every person has strengths, talents, and goals and that their environments consist of resources, people, and opportunities. PTE adopted the six strengths principles as described by Charles Rapp and Richard Goscha (2012), presented in Box 1.

Strengths Principles

  1. 1.Clients with multiple, complex problems are capable of recovering, reclaiming, and transforming their lives;
  2. 2.The focus is on individual strengths rather than on deficits and problems, and on resources in the environments;
  3. 3.Clients are the directors of the helping process;
  4. 4.The client–worker relationship is primary and essential; recovery starts with trust;
  5. 5.The primary setting for working with individuals is the community; and
  6. 6.The community is viewed as an oasis of opportunities and resources.

The strengths model recognizes the influence of the environment on the health and well-being of clients and the importance of identifying, getting access to, and using the opportunities and naturally occurring resources in the community and wider society for their recovery. This model also identifies supportive and nurturing relationships as the most important active mechanism of the helping process and thus for the recovery of clients. Relationships can be discerned with informal caregivers, volunteers, and others involved in the community and with professionals and institutions and formal networks, while the relationship that clients have with themselves also very much matters.

Three Pillars

Based on the various sources of knowledge, we have developed three pillars of PTE—hope, self-regulation, and citizenship—that also have significant practical implications for how professionals support clients.

1. Hope

Social exclusion may reduce people's lives to sheer survival. In this process, people tend to lose their human capacity to critically reflect on their daily functioning and circumstances with a view to redefining their actions, and ultimately come to a standstill: their engine has stalled. But most still harbor some hope of a better future, of a life worth living. Hence, the first pillar of the strengths-based approach is hope—the hope for a life of meaning and purpose (Wolf 2016). Hope has been proven to be a protective and healing factor (Deci and Ryan 2000). Hope consists of two elements: (1) an appraisal of one's capability and determination to achieve a goal—this so-called hope agency refers to knowing your personal values and long-term goals (“I can”); and (2) the cognitive determination of the viability of routes to chosen goals—this pathway thinking relates to having confidence as a person that goals can be achieved (“I have a solid plan to achieve my goal”) (Snyder 1994). Goals are important because they give energy and direction to activities that give meaning to a person's life (Baumeister 1989). Self-determination theory (SDT) proved helpful in further helping us understand the motivational underpinnings of human action and goal attainment. SDT states that the more people experience their behavior as self-determined the more people are intrinsically motivated and the stronger their perseverance in achieving their own goals (Deci and Ryan 2000; 2009). In line with this theory, we consider a person's intrinsic motivation—personal values, desires, and goals in life, no matter how small—to be the fuel to restart the engine. It is the professionals’ task to support clients in exploring what strengths—skills, talents, aspirations, personal or environmental strengths—will generate sparks of hope in encouraging them to make their own choices and decisions and gather the courage to take small steps toward realizing personal goals. This is not an easy task, because in the process of social exclusion many people become alienated from themselves and tend to blame and shame themselves for everything that “went wrong” in their lives or did not work out in care processes:

So I thought, this is not the life that I want, this is not the life that I had in mind or had expected. Realizing this made me wiser. I had lost my focus and my goals. I wasn't in control anymore. That was wrong.

2. Self-Regulation

PTE does not focus on any particular problem or illness, but instead on the underlying disruptions in people's self-regulating capacity, irrespective of their origins and manifestations, that prevent them from achieving their goals. Self-regulation refers to the person as an active agent and decision-maker, a vital aspect of human adaptation to life, and can be considered as a prerequisite for self-direction (Baumeister 2005). It is, simply put, the self-organizing capacity of people—that is, the capacity to care for oneself and others and to live a “good life.” Self-regulation can be understood as the efforts and actions of individuals to master and adapt their emotions, thoughts, desires, motivations, and behaviors to realize their personal goals and invest in their health and well-being (De Ridder and De Wit 2006). The capacity to self-regulate can be considered the core of personal agency. In PTE, recovery therefore has been defined as the capacity of people to regulate themselves and their existence and to direct their own lives in light of the emotional, physical, interpersonal, and material challenges in their lives.

Self-regulation will be successful if the processes needed to manage yourself and the resources needed to achieve your goal are on hand. The inner processes are called executive functions. Examples of executive functions are the ability to think before acting, the ability to control your emotions, the ability to organize, and the ability to plan and prioritize. Self-regulation is inadequate if the management of those executive functions falters (Van der Stel 2013). This has been attributed to an inability to control impulses, a loss of self-control (Baumeister et al. 2007). In such cases, the management of emotions, cognitions, motivations, and behaviors is clearly not up to par. The more extreme the causes—exclusion, poverty, interpersonal violence, homelessness—and the earlier in childhood the exposure begins, the more severe and enduring stress people experience and the greater the impact is on the executive functions (Babcock 2018).

Self-regulation is the problem, but it is also the solution. When a person's self-regulation is disturbed—which in its extreme may lead to passivity, indifference, insomnia, and loss of appetite and self-care (not showering, too many or too few clothes given the weather, not noticing physical problems or pain) (DeWall and Baumeister 2006), that person has “to work” with this same capacity to adapt, regain control, and find a new balance. Self-regulation, therefore, is the key to recovery. It is not static, but dynamic. It can be further developed, but also—in case of impairment or deterioration—be compensated for, temporarily or in the long term, by making use of more or other personal and environmental strengths and resources. These support structures can be considered the “scaffolding” wrapped around the person (Vygotsky 1978; Wolf 2016). For all those involved with recovery processes, it is very important to be aware that self-regulation is not an individual characteristic, but, instead, is realized and developed in the interaction between individuals and the structures and collectives in the lifeworld and the system-world. PTE wants to support clients and professionals in their actions to strengthen this self-regulating capacity by improving the executive functions. These functions can be enhanced through goal-setting and goal-attainment (Jungmann et al. 2020). It is the task of the professional to maintain an ongoing appraisal of a client's current capacity to perform actions toward achieving such a goal and, should any hindrances to self-regulation be evident, what sort of compensations and resources—“scaffolding”—may be needed for the goal to be attained (Van der Laan 2007). The professional explores, together with the client, what factors might underlie the faltering self-regulation, and proceeds from the client's explanation as to what the problem is, in what context it arises and why—that is, the client's theory of change. The clearest insights into self-regulation are obtained by jointly performing actions toward the desired goals within the client's own living environment, whereby the professional—partly by serving as a role model—can help clients, within that joint learning process, to relearn how to put their own capabilities and resources to use and to strengthen them (Van der Laan 2007).

3. Citizenship

The notion of citizenship is a very important pillar of PTE. Socially excluded people are, and remain, citizens, despite their sometimes difficult to understand or troublesome behavior and their weak social status (Wolf 2002). A citizen is an individual who both “rules” and “is ruled” within their own social context (Van Gunsteren 1992). Citizens can make their own choices and direct their own lives, but they must also conform to rules and laws. To fulfill this dual function, a citizen must possess some measure of autonomy, good judgment, and loyalty (Nauta 2000). The perception that socially excluded people may be insufficiently competent to satisfy the ideal of autonomous citizenship cannot be a license to redefine their quality-of-life standards to the level of some kind of second-class citizens with reduced rights (Wolf 2002): “They should have equal membership or citizenship in the human collective” (Rapp and Goscha 2012: 27). Setting citizenship as a benchmark for change does not mean that every citizen must satisfy that ideal, but it does help to preserve an orientation toward it, a perspective on it (Wolf 2002). Disadvantaged and socially excluded people are subject to the same expectations as “other” citizens. In their capacity as citizens, they have:

  • Rights. They may take others to account, availing themselves of their civil rights, any acquired group rights, and their client rights.
  • Obligations. As participants in society and in social relations, they themselves are accountable for their actions and they may also be taken to account by others.
  • Autonomy. Given their right to individual self-direction, they may take part in society, participate in social relations, and direct their own lives.
  • Dependence. In their self-realization process and in their diverse roles, they are dependent on social interaction and support in networks; on laws, rules, and procedures designed mostly by others; on access to institutions; and on available community resources (Wolf 2016).

Translated into practical directions in PTE for professionals’ actions, citizenship means that socially excluded people, with all their idiosyncrasies, are to be fully accepted and treated with respect. At the same time, they may be held accountable for their actions, especially if those actions could harm themselves or others, for example their children, or jeopardize the atmosphere and safety in facilities such as homeless shelters. Professionals should not hesitate to confront them with their transgressive behavior and remind them of their obligations to themselves, others, and society at large. Respectful confrontations are ideal opportunities for adults to critically scrutinize their own actions, to consider what unforeseen consequences these might have for themselves or other people, and to adapt their behavior accordingly (Bouwkamp and Bouwkamp 2010; De Vries 2008). PTE provides professionals with techniques to confront clients while maintaining a trustful working relationship. A commitment to the notion of citizenship further implies that socially excluded people are entitled to use community resources and that professionals, in their role as guides and mediators, are there to help them secure access to and use of such resources.

Personal Involvement

Before we continue with describing the practical structure of PTE, we want to elucidate the role of clients and others involved, including the professionals, in the recovery process as envisioned in PTE. The challenge for disadvantaged persons is to overcome and master the adversities, setbacks, and losses in their lives and to develop meaningful lives that are in line with their personal values and goals and that give them hope and perspective. The process of recovery is a very personal one. Personal is not the same as individual. Recovery is above all also a societal process (Korevaar and Droës 2011; Slade 2009; Van der Stel 2013; Wilken and den Hollander 2012). Only in the interaction with the environment can one develop agency. To be able to make progress in this journey, the support and encouragement of others and other resources—being family, friends, peer support workers, volunteers, or people in the community or professionals—are therefore of the utmost importance. However, no one can take over the responsibility of clients for their recovery. Professionals also “do not possess the power to control or to predict how one's recovery will unfold” (Rapp and Goscha 2012: 52). Their role is in a way quite modest and consists of helping to develop or alter the circumstances and resources for clients to enable their recovery. Probably the most important task of the professional is, using motivational techniques and activities, to create an environment with the highest possible chance of touching and tapping into the intrinsic motivation of clients, fostering their will power to explore their strengths and values and become more active, and supporting the motion toward realizing personal goals through competence-building and boosting learning processes with others involved. The practical structure of PTE was developed not to be used as a mold, but as an aid for professionals for reflection on strongly intertwined factors and elements that influence the experiences of their clients and the quality of their daily lives. In this vein, it is important to realize that people's processes of recovery are unique, that types of recovery may present themselves and evolve in different combinations and at different paces, and that recovery tasks and recovery perspectives will vary.

Practical Structure Based on the SQA

The practical structure of PTE has been built on the SQA. The SQA therefore has been elaborated for practical purposes into the PTE structure. The structure reveals four sets of factors and elements (Table 1):

  • Constitutional factors (far left) that are linked to the four types of recovery and therefore are the focal points of the involvement of professionals with clients and others: living conditions linked to functional recovery, interpersonal embeddedness linked to community recovery, societal embeddedness related to citizen recovery, and self-regulation related to personal recovery;
  • Recovery tasks are the actions to be carried out by the clients themselves. Through these actions, persons try to realize the factors that constitute the quality of their daily lives in dynamic and ongoing interaction with the conditional factors by using their capacity for agency, thus creating for themselves new perspectives and new ways of being meaningful and connected with society. The actions are related to the four types of recovery. Because recovery requires the active involvement and effort of clients, we have defined the tasks in terms of actions toward goal pursuits: taking part, fitting in, emancipating, and self-regulating yourself. It is essential to understand and, if necessary, change clients’ action space through modifying the conditional factors that are required for their recovery.
  • Recovery perspectives are the desired outcomes of the PTE intervention for clients that are related to the four types of recovery: a sense of usefulness, a sense of connectedness, a sense of citizenship, and a sense of self, which are important as requirements for participation and self-direction in life, the latter being the overall aim of PTE. These outcomes are the result of the dialectical interactions between the agency capacity of individuals and the constitutional and conditional factors of social quality.
  • Conditional factors (far right) provide the context of opportunities and resources or protective factors that can be used in PTE. These also constitute the risks and obstacles in society for clients’ agency, participation, and self-direction that need to be identified and confronted.
Table 1:  

Social Quality Structure of Pathways to Empowerment in Practice

Focal points of care pathway based on constitutional factors of social qualityRecovery tasksRecovery perspectivesConditional factors of social quality as context
Living conditions

Functional recovery



The focus of the care pathway is on improving human (personal) security.
Taking part

... involves your prerequisites and capabilities for leading a good life: your housing, employment, income, education, leisure time, and feeling a sense of security.
Sense of usefulnessSocioeconomic security
Interpersonal embeddedness

Community recovery



The focus of the care pathway is on fostering reciprocity and social recognition.
Fitting in

... involves the ties you develop and maintain with other people and just being there for each other. Things like having a partner, children, relatives, friends, contacts, neighbors, etc.
Sense of connectednessSocial cohesion
Societal embeddedness

Citizenship recovery



The focus of a care pathway is on promoting social responsibility and the empowerment of clients as citizens, as users of care and various institutions, etc.
Emancipating

... involves attaining your basic rights and the resources and institutions you can make use of. And also your own interest in the world around you.
Sense of citizenshipSocial inclusion
Self-regulation

Personal recovery



The focus of the care pathway is on strengthening personal capabilities and executive functions.
Being yourself

... involves feeling good and feeling healthy. Accepting yourself. Feeling you're in control of yourself and directing your life. Being resilient and adaptive to challenges. And also: having a zest for life.
Sense of selfSocial empowerment

Source: (Wolf 2016: 62)

Implementation and Coverage

Initially, PTE was implemented in the care organizations that participated in the Impuls Collaborative Centre, focusing on homeless adults and youths, and women with interpersonal violence experiences. There were also training courses provided by the Impuls Research Centre. Since 2009, the latter has had a certified training organization consisting of twenty trainers, which has provided certified training courses to professionals working with various target groups in different settings and diverse areas of intervention, such as mental health and addiction care, social care, care for refugees, and forensic care.

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To a substantial degree, the functioning of professionals is governed by their surrounding environment, just as is the case for the clients. If the working environment of the professionals remains unchanged, chances are high that they will promptly regress into their old work patterns. To successfully implement PTE and to ensure PTE will have an impact on the lives of clients, an organization must therefore make sure that its very work structures and processes are based on the principles in which PTE is grounded (Aarons and Sawitzky 2006; Drake et al. 2003; Rapp and Goscha 2012). An organization that fully opts for PTE is case-centered, works with clearly defined focuses, ensures reciprocal processes of management and change, has a learning and reflective organizational culture, and regards clients as experts and professionals as craftsmen (Wolf 2016).

Set of PTE Training Courses

For the implementation and maintenance of PTE within organizations and teams, the Impuls Academy provides several training courses. The basic training course for practitioners (for a minimum of eight and a maximum of fourteen participants) comprises four one-day sessions and teaches the fundamental principles and pillars of PTE. The underlying theories of PTE are treated, and exercises are performed using the accompanying support tools of PTE (including strengths assessments, personal action plans, evaluation of self-regulation capacities, and group supervision in teams).* Opportunities are also given to practice PTE skills and to present and discuss case examples. From the very first day of the course, the professionals begin applying PTE in their practice settings to enable them to share experiences in applying PTE and to reflect on this with other course participants. After completing the basic PTE course, professionals are capable of working with clients using the PTE intervention. The team support training course for team leaders or senior supervisors is a three-day course (ten to fourteen participants) designed for staff members who are responsible for embedding PTE into their teams. It familiarizes participants with the strengths-based intervention and teaches them how they can use their position on the team to support, encourage, structure, and facilitate the introduction and maintenance of PTE within the team. One major focus of this training course is on leading so-called “group supervision sessions” for professionals aimed at encouraging reflection, case-based learning, and strengthening working according to PTE. In addition to the basic PTE courses, there is a PTE training course for coaches (seven days) for twelve to sixteen participants. These internal coaches work within organizations, and their main job is to help embed and reinforce PTE in routine practice. This training teaches the principles and pillars of PTE in more depth, gives insight into the responsibilities and tasks of PTE coaches and the PTE tools that are available for them in supporting and monitoring the daily work of professionals, and supports them in hands-on ways to perform their job as coaches well. The tasks include the review of tools, such as the strengths assessment and the personal recovery plan, and providing individual coaching to PTE professionals. Training for ancillary staff is a one-day course for eight to twenty participants that familiarizes staff members such as voluntary reception workers, caretakers, human resources officers, and front-office workers with PTE, and it teaches them to adopt a strengths-based attitude in their own jobs. The course explains the strengths principles of the PTE and some of its central notions, including what is expected of a supportive, hope-inducing working relationship, the meaning of citizenship, and the importance of supporting clients’ capacity for self-regulation. The training for management is a one-day course for executives, board members, and managers of organizations implementing the PTE approach. This course focuses on the principles and pillars of PTE; characteristics of sustainable, strengths-based organization that will support PTE in practice; the requirements regarding the working structures and processes, including leadership; and the impact that PTE may have on clients and professionals.

Coverage of PTE

In the last ten years, PTE has been implemented in seventy-five organizations across The Netherlands, supporting various groups of vulnerable citizens, such as homeless people, incarcerated persons, people addicted to substances, and immigrants. In the last few years, PTE has also been implemented in community and municipality settings for youth care, social care, and in employment-finding organizations. The Impuls Academy has certified 5,600 professionals in these settings after successful completion of the four-day PTE basic training course. In addition, 114 internal coaches were certified after their seven-day training session.

Training Courses PTE 2010–2020N
Basic training course for practitioners591
Team support training course for team leaders or senior supervisors29
Training course for internal coaches25
Training for ancillary staff61
Training for management18
*

The tools can be obtained from the second author.

Reflections on the Social Quality Approach

Based on the application of the SQA for PTE and the practical experiences with PTE, we present critical notes on the existing theoretical framework of the SQA. Based on these, we will come up with some suggestions for the further development of the theory.

Traditional Focus on Conditional Factors

To the best of our knowledge, up to now the SQA has been applied as a framework for (comparative) research aiming at understanding the nature and experience of the social quality of groups, communities, and countries in order to gain insight into the quality of the daily living circumstances of citizens. Often these also assessed the impact of policy measures resulting in local or national reports shedding light on degrees or lack of social quality and, if applicable, inequalities among citizens (Abbott and Wallace 2012; De Neubourg and Steffens 2005; Mahoney and Kearon 2018). In these studies, social quality is often defined as “the extent to which people are able to participate in societal based relationships under conditions which enhance their well-being and potential” (Van der Maesen and Walker 2012: 68). The research on social quality until now has mainly focused on the four conditional factors as the objective aspects of daily circumstances. The focus, then, was to investigate changes in societal developments and their impact on the quality of daily lives of citizens (IASQ 2019). However, this kind of research does not give a full understanding of the social quality of people's daily lives at a certain time and place. The full comprehension of the latter also requires research into the constitutional factors, the results of which then must be linked to current conditional factors and assessed by the application of the normative factors. This observation previously was made by Van der Maesen and Walker (2012). When carried out from the perspectives of a decent life and a decent society—through the eyes of disadvantaged and socially excluded citizens and professionals who support them—research and development activities do not merely provide insight into the need to change the conditional factors. Recently, in a recent working paper from the International Association on Social Quality, an updated framework on social quality has been presented that may well serve as a basis for these activities (IASQ 2019). However, there seems to be little to no attention in these approaches for the constitutional factors and the normative factors. From the PTE perspective—as stated above—it is precisely these constitutional factors that need to be made the focus of attention.

The Essence of the Constitutional Factors

As described earlier in this article, the daily living circumstances and experiences of disadvantaged, excluded people are deeply rooted in strongly intertwined patterns of personal, interpersonal, institutional, and societal problems. These often result in disturbed or impaired capacity for self-regulation and self-realization, evoking strong feelings of powerlessness, even despair. In order to reverse these exclusion processes, it is necessary to adapt and implement policies aimed at strengthening the conditional factors of social quality in communities and societies. But of course, that is not sufficient. Inevitably, the constitutional factors of social quality equally must be addressed in their dialectically interdependent relationship with the conditional factors. Moreover, the constitutional factors are strongly linked to biographical development, personal agency, and the development of competencies and resilience, and are the focal points of person-centered care. However, this component of the SQA seems to be less developed and researched. In-depth descriptions of the constitutional factors of social quality within specific societal-cultural contexts are lacking, and studies in this area are scarce (De Vet et al. 2019; Roy et al. 2020).

In developing PTE, applying the constitutional factors as a foundation, we had trouble understanding the precise meaning of this set of (subjective) factors. This was not only due to the varying definitions of these factors and the changing use of terminology in publications, it was also due to the observation that these factors seemed to have been defined both from an “objective,” societal perspective as well as a “subjective,” biographical perspective. For example, in the book on social quality published in 2012 by Van der Maesen and Walker, the former appears to be the case when personal (human) security is defined as “the existence of rights and acceptable rules,” social recognition as “the experience of respect by others,” social responsiveness as “the openness of groups, communities and systems,” and personal (human) capacity as “the possibilities to relate to others” (2012: 56). The text on the constitutional factors continues, stating: “People as social beings need capacities (language, cognition, knowledge and so on) to engage with others; because of their social nature they need recognition by others; in order to function they need the security of an acceptable and understandable contract of rules and rights; and they need to be able to gain access to and communicate with the groups, networks and institutions that make up society” (2012: 57). Defined and described this way, constitutional factors seem to be mainly understood as enabling interpersonal and societal factors for individuals to become competent actors rather than personal factors enabling agency, as explained in the same book: “the development of the individual into a person with the competence to act in different human relationships” (2012: 56). Also, the naming of these factors suggests that constitutional factors are interpreted as societal factors. Although various texts in this book on social quality are related to personal agency, we could not find a clear definition of this crucial concept. The description most related to agency was that of personal (human) capacity presented as one of the constitutional factors. It was referred to as “the social and cognitive competencies that help to determine the scope for individual activation” (2012: 58).

Constitutional factors defined in terms of “enabling factors” may well obscure the social quality architecture as a whole (Van der Maesen and Walker 2012: 66), because it seems to generate considerable overlap with the conditional factor of social empowerment, which is defined as “the extent to which the capabilities of individual people and their ability to act are enhanced by social relations” (2012: 62). The SQA rightly takes the “social” as its very starting point, but in its elaborations it seems to have disregarded “human agency” as a concept and its dialectical interaction with “structure.” This observation led us to further explore the notion of agency and the constitutional factors of social quality within the societal context by taking account of the narratives of clients and professionals and by examining related concepts such as hope, self-regulation, self-control, self-determination, and willpower for use in person-centered care, as was shown in Figure 1 and Table 1.

The Essence of the Reciprocity of Relationships

When we started developing PTE in 2007, we used the definition of social quality as described in 2005 (Van der Maesen and Walker 2005). Definitions of social quality since then have changed over time. In our view, in this process a notion of utmost importance for citizens in general, and disadvantaged citizens in particular, has gone astray. This regards the phrase indicated in bold, in the definition of social quality: “the extent to which people are able to participate in societal based relationships under conditions which enhance their well-being and potential, which enables them, in turn, to influence the conditions of their own existence” (Van der Maesen and Walker 2005: 12). By deleting this notion, one very strong feature of the SQA—that is, the reciprocity between citizens and society—seems to have been moved to the background. For the target population of PTE, this is of utmost importance. To be able and to be enabled “to influence the conditions of your existence” marks the very difference between those who are included (“normal” people) and those who are excluded and feel redundant. To be able to exert influence and contribute as a citizen, as a parent, and as an employee gives meaning to people's lives. For citizens who have not been able to take up societal roles in their lives or over the years have lost the possibility and or capability to perform these roles, activities such as serving coffee and being a host in a homeless shelter is of vital importance for their sense of personal agency. This should not be underestimated. Disadvantaged and excluded persons emphasize time and again their dire need for opportunities to be meaningful to others and to contribute to society. From our experiences in PTE, we would like to make a strong case for reintegrating “which enables them, in turn, to influence the conditions of their own existence” again into the definition of social quality.

Conclusion

Range of Applicability of PTE

In this article, we have elucidated how we have grounded the person-centered intervention of PTE in the SQA. We have further developed the conceptualization of its constitutional factors and its dialectical relationships with the conditional factors into the practical structure of PTE. These concepts are used as an aid for supporting the recovery processes of persons experiencing loss of control in their lives, aiming at fostering personal agency, participation, and self-direction. Although PTE initially concentrated on disadvantaged people marginally subsisting at a great distance from mainstream society, by 2020 the target group had become a great deal more varied, now also including people who have temporarily lost their balance in life or who have specific support needs. This broadening of the target population appeared to make no difference in our approaches to the constitutional factors of social quality or in how we applied these in PTE. In other words, the practical structure of PTE also appears to match very well with clients who generally cope well but are in need for time-limited support because they are confronted with specific age-related events or adaptation issues. This was confirmed when in the spring of 2019 we examined the applicability of PTE in a particular social care setting, namely a municipal “broad access” to care facility [Brede Toegang]. This so-called “matching process,” that we perform with every new target population of PTE, in this case was carried out in close collaboration with residents of the municipality and professionals working in this setting. It revealed that no changes in the practical structure of PTE were needed.

Functionality of the SQA

Evaluations of the so-called “model integrity” of PTE—consisting of one-day audits assessing PTE as applied in practice by professionals using different methods and consulting various stakeholders (clients, professionals, coaches, team coordinators)—have shown that most clients are very satisfied with being supported with PTE:

I had a negative self-image. At some point you start believing what they're all saying about you. That's different now. … I've discovered I can stand up for myself and that I'm very socially minded. I now know I can make my own decisions and accomplish things. I ask my own questions about what kind of future I want and how I can achieve that.

I've been through all sorts of methods, but this is the first time it's not therapeutic. This is simple, effective and sound; it's now more human. It's not an assignment, because it belongs to me.

Professionals and team coordinators do appreciate that PTE with the SQA has a solid and scientific foundation. The same holds true for the changes that have been introduced as a result of reflections on its implementation. They do not just notice that PTE has a positive impact on the lives of clients, but also on the relationships in the teams and organizations (more strengths-based interaction and leadership) and in particular settings (e.g., reduction of aggressive behavior in shelters):

I see I can get on with it now. The treatment team meeting helped me catch my breath. Clients like it. They're positive, want to check it out, have made some small steps, can see what's been done so far. Feel they've got more grasp.

Client-centered at all times, search for strengths, capabilities and talents, don't make it harder than it is. Great that it's systematically grounded. Client is a citizen.

Of course, there are also concerns, and there is still a lot of work to be done. Professionals very much value and understand the essence of the SQA and concepts such as citizenship, and they endorse the contextual approach to PTE. However, they acknowledge that it requires recurrent training and coaching in order to sustain a different way of working with clients. Recent assessments of the model integrity of PTE show that professionals, in supporting clients, in particular struggle to make use of the opportunities and naturally occurring resources in the community. This is not only related to the professionals’ specific beliefs or competencies, but also to the maneuvering space their organizations allow them. PTE surely does not operate in a vacuum. It—as professionals and team coordinators confirm—is under continuous pressure of institutional and societal forces and developments, such as cutbacks, financial pressures to provide time-limited support, reorganizations, registration pressure due to accountability requirements, etc. In all respects, these pressures are mostly at odds with the principles and pillars of PTE. As team coordinators explain:

If the agency is put under pressure, whether that's financial pressure or political, then … it's going to lapse back into previous behavior and start saying to clients, “It's a good idea if you do what we say, then you'll all turn out okay.” At that point, your PTE is in jeopardy.

And besides that, of course, there's also outside interests, like all the things you've got to account for, making sure everything's in order. There's eligibility determinations and service needs determinations. Sometimes that's out of kilter with peace of mind, with personal development, with the focus on PTE.

The evident success of PTE—implemented so far in 75 care organizations in the Netherlands, an interest from abroad, and officially certified by the Dutch Certification Committee for Social Care Interventions—may reveal the functionality of the application of the SQA in processes of person-centered care. Despite the challenges we encountered in applying the SQA in order to structure and ground PTE, this approach has proven to be extremely useful. It helps professionals to understand the circumstances and needs of clients within a wider context. This includes the interpersonal, institutional, and societal factors and processes that have an impact on their lives and process of recovery. It also helps to focus not exclusively on the individual and their personal recovery.

Revisiting Constitutional Factors

We also uncovered the necessity to readdress the conceptualization of the constitutional factors and their dialectical interactions with conditional factors and vice versa—all of this against the background of the normative factors. More work is needed on the key concept of personal agency because this would allow a better understanding of biographical development, self-regulation, and self-realization by which individuals can take care of themselves and others, and by which they do have the confidence and competencies to contribute to society, which is crucial for processes of recovery. This is all the more necessary because personal agency and its associated conditional realm of empowerment—“the enhancement of personal capabilities”—is considered to be the core of the SQA (Hermann 2012: 202). Encouraging leads can be found in the original definition of empowerment in the theory of social quality with references to equity, capabilities and capacities, and choice (Beck et al. 2001).

Here also emphasis is put on the interaction of action and structure. The same holds true for Sridhar Venkatapuram's description of agency, namely, as encompassing “the full breadth of acts that individuals undertake in determining, revising and pursuing their conception of the good life” (2011: 132). Interesting too is the work of Roy Baumeister and colleagues on will power and self-control, making a link to self-regulation and considering the agent to be an important aspect of “the self”: “By means of its executive function, the self exerts control over its environment (including the social environment of other people), makes decisions and choices, and also regulates itself” (2007: 8). Self-regulation here is loosely related to decision-making and choosing. The capacity to self-regulate can be considered the core of personal agency. Agency is also associated with a person's ideas “about being one's own person and acting in accordance with one's own reasons and values” (Entwistle and Cribb 2013: 24). SDT is no less relevant in this respect. We recommend to also take into account theoretical concepts and research related to stress, scarcity, poverty, and social exclusion in order to gain more insight into how these factors hinder and thwart people's self-realization and also negatively affect their health (Wolf et al. pending).

When further developing the concept of “personal agency” and its related constitutional factors in the realm of the SQA, these concepts and approaches may be useful. People themselves are the main drivers of their processes of recovery and the changes in their lives. The key to recovery is personal recovery, but of all four types of recovery this appears to be the most difficult to influence with professional interventions (Wolf 2016). In the same vein, we have strongly advocated reviewing the definition of social quality by integrating again the phrase that pertains to the reciprocity in interpersonal relationships—that is, “to influence the conditions of their own existence.” The connections with these societal conditions are the vital means through which people essentially survive, acknowledging that the “need to belong” can be considered one of the most powerful and pervasive of human motivations (Baumeister and Leary 1995).

Acknowledgments

In the fall of 2019, a project group with Judith Wolf, Laurent van der Maesen, and Harry Nijhuis met several times and discussed the practical structure of PTE, its SQA foundation, and the puzzles associated with it. The discussions have been a true inspiration for this article. We thank Laurent and Harry for their very helpful comments and suggestions for this article. This article could not have been written without the lifelong inspiration and visionary gaze of Geert van der Laan, Emeritus Professor of Social Work at the University of Humanistic Studies in the Netherlands.

Note

1

This article is dedicated to the late Emeritus Professor of Social Work at the University of Humanistic Studies, Geert van der Laan.

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  • Macias, C., R. Kinney, O. W. Farley, R. Jackson, and B. Vos. 1994. “The Role of Case Management within a Community Support System—Partnership with Psychosocial Rehabilitation.” Community Mental Health Journal 30 (4): 323339. doi:10.1007/Bf02207486.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Mahoney, I., and T. Kearon. 2018. “Social Quality and Brexit in Stoke-on-Trent, England.” International Journal of Social Quality 8 (1): 120. doi:10.3167/IJSQ.2018.080102.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Modrcin, M., C. A. Rapp, and J. Poertner. 1988. “The Evaluation of Case Management Services with the Chronically Mentally Ill.” Evaluation and Program Planning 11 (4): 307314. doi:10.1016/0149-7189(88)90043-2.

    • Crossref
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    • Export Citation
  • Nauta, L. 2000. Onbehagen in de filosofie [Unease in philosophy]. Amsterdam: Van Gennep.

  • Nijhuis, H. 2017. “Toward Comprehensive Conceptualizations of Contemporary Public Health.” International Journal of Social Quality 7 (2): 6084. doi:10.3167/IJSQ.2017.070204.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rapp, C. A., and R. J. Goscha. 2012. The Strengths Model: A Recovery-Oriented Approach to Mental Health Services. 3rd ed. New York: Taylor & Francis.

    • Search Google Scholar
    • Export Citation
  • Rapp, R. C., A. L. Otto, D. T. Lane, C. Redko, S. McGatha, and R. G. Carlson. 2008. “Improving Linkage with Substance Abuse Treatment Using Brief Case Management and Motivational Interviewing.” Drug and Alcohol Dependence 94 (1–3): 172182. doi:10.1016/j.drugalcdep.2007.11.012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Roy, B., J. R. L. M. Wolf, M. D. Carlson, R. Akkermans, B. Bart, P. Batalden … , and G. Hesselink. 2020. “An International Comparison of Factors Affecting Quality of Life among Patients with Congestive Heart Failure: A Cross-Sectional Study.” PLoS ONE 15 (4): e0231346. doi:10.1371/journal.pone.0231346.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Saewyc, E. M., and L. D. Edinburgh. 2010. “Restoring Healthy Developmental Trajectories for Sexually Exploited Young Runaway Girls: Fostering Protective Factors and Reducing Risk Behaviors.” Journal of Adolescent Health 46 (2): 180188. doi:10.1016/j.jadohealth.2009.06.010.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Sociaal en Cultureel Planbureau (SCP). 2015. De sociale staat van Nederland 2015 [The social state of The Netherlands]. The Hague: Sociaal en Cultureel Planbureau.

    • Search Google Scholar
    • Export Citation
  • Song, L. Y., and C. Y. Shih, C. Y. 2010. “Recovery from Partner Abuse: The Application of the Strengths Perspective.” International Journal of Social Welfare 19 (1): 2332. doi:10.1111/j.1468-2397.2008.00632.x.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Slade, M. 2009. Personal Recovery and Mental Illness. Cambridge: Cambridge University Press.

  • Snyder, C. R. 1994. The Psychology of Hope. New York: The Free Press.

  • Stanard, R. P. 1999. “The Effect of Training in a Strengths Model of Case Management on Client Outcomes in a Community Mental Health Center.” Community Mental Health Journal 35 (2): 169179. doi:10.1023/A:1018724831815.

    • Crossref
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    • Export Citation
  • Van Bergen, A. P. L., J. R. L. M. Wolf, M. Badou, K. de Wilde-Schutten, W. Ijzelenberg, H. Schreurs, … and A. M. van Hemert. 2018. “The Association between Social Exclusion or Inclusion and Health in EU and OECD Countries: A Systematic Review.” European Journal of Public Health 29 (3): 575582. doi:10.1093/eurpub/cky143.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van der Laan, G. 2007. “Professionaliteit en ambachtelijkheid” [Professionalism and craftsmanship]. Journal of Social Intervention: Theory and Practice 16 (2): 2534. http://doi.org/10.18352/jsi.111.

    • Search Google Scholar
    • Export Citation
  • Van der Maesen, L. J. G., and A. C. Walker. 2005. “Indicators of Social Quality, Outcomes of the European Scientific Network.” European Journal of Social Quality 5 (1–2): 824. doi:10.3167/146179105780337431.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van der Maesen, L. J. G., and A. C. Walker, eds. 2012. Social Quality: From Theory to Indicators. London: Palgrave Macmillan.

  • Van der Stel, J. 2013. Zelfregulatie, ontwikkeling en herstel [Self-regulation, development, and recovery]. Amsterdam: SWP.

  • Van Hemert, A. M., and J. R. L. M. Wolf. 2011. Wat is OGGZ? [What is OCGZ?]. The Hague: Dienst Onderwijs Cultuur en Welzijn.

  • Van Gunsteren, H. R. 1992. Eigentijds burgerschap [Contemporary citizenship]. The Hague: Wetenschappelijke Raad voor het Regeringsbeleid.

    • Search Google Scholar
    • Export Citation
  • Van Straaten, B., G. Rodenburg, J. Van der Laan, S. N. Boersma, J. R. Wolf, and D. Van de Mheen, D. 2016. “Substance Use among Dutch Homeless People, a Follow-Up Study: Prevalence, Pattern and Housing Status.” European Journal of Public Health 26 (1), 111116. doi:10.1093/eurpub/ckv142.

    • Crossref
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    • Export Citation
  • Venkatapuram, S. 2011. Health Justice: An Argument from the Capabilities Approach. Cambridge: Polity Press.

  • Vleminckx, K., and J. Berghman. 2001. “Social Exclusion and the Welfare State: An Overview of Conceptual Issues and Policy Implications.” In Social Exclusion and European Policy, ed. D. G. Mayes, J. Berghman, and R. Salais, 2746. Cheltenham, UK: Edward Elgar.

    • Search Google Scholar
    • Export Citation
  • Vrooman, J. C., and S. J. M. Hoff. 2013. “The Disadvantaged along the Dutch: A Survey Approach to the Multidimensional Measurement of Social Exclusion.” Social Indicators Research 113 (3): 12611287. doi:10.1007/s11205-012-0138-1.

    • Crossref
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    • Export Citation
  • Vygotsky, L. S. 1978. Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press.

  • Walker-Andrews, A. S. 2005. “Perceiving Social Affordances: The Development of Emotional Understanding.” In The Development of Social Cognition and Communication, ed. B. D. Homer and C. S. Tamis-LeMonda, 93116. Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

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    • Export Citation
  • Wilken, J. P., and D. den Hollander. 2012. Handboek integrale rehabilitatiebenadering [Manual of the integrated rehabilitation approach]. Amsterdam: SWP.

    • Search Google Scholar
    • Export Citation
  • Wolf, J. R. L. M. 2002. Een kwestie van uitburgering [Exit from Society]. Amsterdam: SWP.

  • Wolf, J. R. L. M. 2012. Handleiding voor een krachtgericht begeleidingstraject [Manual for a strengths-based care trajectory]. Nijmegen: Radboudumc.

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    • Export Citation
  • Wolf, J. R. L. M. 2016. Krachtwerk: Methodisch werken aan participatie en zelfregie [Pathways to Empowerment: Methodically working on participation and self-direction]. Bussum, The Netherlands: Coutinho.

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  • Wolf, J.R.L.M., and M. FILIPOVIČ HRAST. Social exclusion, homelessness and health through the lens of social quality. Chapter in Routledge Handbook of Homelessness (pending).

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Contributor Notes

Judith R. L. M. Wolf is Professor of Social Care, Head of the Netherlands Center for Social Care Research, and Director of the Impuls Academic Collaborative Center at Radboud university medical center in Nijmegen, The Netherlands. She has more than thirty-eight years of experience in conducting both academic and applied research on socially vulnerable people (including homeless people and abused women) as well as on the social and healthcare services needed by these groups. She was/is the principal investigator in large-scale multisite research projects such as a homeless cohort study in the four largest cities in The Netherlands and two randomized controlled trials on the effects of critical time intervention (CTI) and with Impuls involved in European projects, such as the “HOME_EU” project “Homelessness as Unfairness,” which seeks to provide a comprehensive understanding of homelessness in Europe. She is member of several committees and advisory platforms, such as the Academic Board of Platform31, a knowledge and networking organization for local and regional policy, practice, and research, The Hague; The Advisory and Assessment Committee on Social Interventions at Movisie—Netherlands Centre for Social Development, Utrecht; and The Advisory Board of the CTI Global Network at the Silberman School of Social Work, Hunter College, City University of New York. Email: judith.wolf@radboudumc.nl

Irene E. Jonker is a Senior Researcher at Impuls, the Netherlands Center for Social Care Research at Radboud university medical center in Nijmegen, The Netherlands. She has more than eighteen years of experience in conducting research on socially vulnerable people, including shelter-based abused women. Since 2014, Irene has been Head of the Impuls Academy and responsible for the implementation and maintenance of strengths-based interventions, such as PTE and Critical Time Intervention (CTI) in organizations and teams in The Netherlands. Email: irene.jonker@radboudumc.nl

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    Application of Constitutional Factors of Social Quality in Pathways to Empowerment

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  • Macias, C., R. Kinney, O. W. Farley, R. Jackson, and B. Vos. 1994. “The Role of Case Management within a Community Support System—Partnership with Psychosocial Rehabilitation.” Community Mental Health Journal 30 (4): 323339. doi:10.1007/Bf02207486.

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  • Mahoney, I., and T. Kearon. 2018. “Social Quality and Brexit in Stoke-on-Trent, England.” International Journal of Social Quality 8 (1): 120. doi:10.3167/IJSQ.2018.080102.

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    • Export Citation
  • Modrcin, M., C. A. Rapp, and J. Poertner. 1988. “The Evaluation of Case Management Services with the Chronically Mentally Ill.” Evaluation and Program Planning 11 (4): 307314. doi:10.1016/0149-7189(88)90043-2.

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    • Export Citation
  • Nauta, L. 2000. Onbehagen in de filosofie [Unease in philosophy]. Amsterdam: Van Gennep.

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    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rapp, C. A., and R. J. Goscha. 2012. The Strengths Model: A Recovery-Oriented Approach to Mental Health Services. 3rd ed. New York: Taylor & Francis.

    • Search Google Scholar
    • Export Citation
  • Rapp, R. C., A. L. Otto, D. T. Lane, C. Redko, S. McGatha, and R. G. Carlson. 2008. “Improving Linkage with Substance Abuse Treatment Using Brief Case Management and Motivational Interviewing.” Drug and Alcohol Dependence 94 (1–3): 172182. doi:10.1016/j.drugalcdep.2007.11.012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Roy, B., J. R. L. M. Wolf, M. D. Carlson, R. Akkermans, B. Bart, P. Batalden … , and G. Hesselink. 2020. “An International Comparison of Factors Affecting Quality of Life among Patients with Congestive Heart Failure: A Cross-Sectional Study.” PLoS ONE 15 (4): e0231346. doi:10.1371/journal.pone.0231346.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Saewyc, E. M., and L. D. Edinburgh. 2010. “Restoring Healthy Developmental Trajectories for Sexually Exploited Young Runaway Girls: Fostering Protective Factors and Reducing Risk Behaviors.” Journal of Adolescent Health 46 (2): 180188. doi:10.1016/j.jadohealth.2009.06.010.

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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
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    • Crossref
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    • Export Citation
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  • Snyder, C. R. 1994. The Psychology of Hope. New York: The Free Press.

  • Stanard, R. P. 1999. “The Effect of Training in a Strengths Model of Case Management on Client Outcomes in a Community Mental Health Center.” Community Mental Health Journal 35 (2): 169179. doi:10.1023/A:1018724831815.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van Bergen, A. P. L., J. R. L. M. Wolf, M. Badou, K. de Wilde-Schutten, W. Ijzelenberg, H. Schreurs, … and A. M. van Hemert. 2018. “The Association between Social Exclusion or Inclusion and Health in EU and OECD Countries: A Systematic Review.” European Journal of Public Health 29 (3): 575582. doi:10.1093/eurpub/cky143.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van der Laan, G. 2007. “Professionaliteit en ambachtelijkheid” [Professionalism and craftsmanship]. Journal of Social Intervention: Theory and Practice 16 (2): 2534. http://doi.org/10.18352/jsi.111.

    • Search Google Scholar
    • Export Citation
  • Van der Maesen, L. J. G., and A. C. Walker. 2005. “Indicators of Social Quality, Outcomes of the European Scientific Network.” European Journal of Social Quality 5 (1–2): 824. doi:10.3167/146179105780337431.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Van der Maesen, L. J. G., and A. C. Walker, eds. 2012. Social Quality: From Theory to Indicators. London: Palgrave Macmillan.

  • Van der Stel, J. 2013. Zelfregulatie, ontwikkeling en herstel [Self-regulation, development, and recovery]. Amsterdam: SWP.

  • Van Hemert, A. M., and J. R. L. M. Wolf. 2011. Wat is OGGZ? [What is OCGZ?]. The Hague: Dienst Onderwijs Cultuur en Welzijn.

  • Van Gunsteren, H. R. 1992. Eigentijds burgerschap [Contemporary citizenship]. The Hague: Wetenschappelijke Raad voor het Regeringsbeleid.

    • Search Google Scholar
    • Export Citation
  • Van Straaten, B., G. Rodenburg, J. Van der Laan, S. N. Boersma, J. R. Wolf, and D. Van de Mheen, D. 2016. “Substance Use among Dutch Homeless People, a Follow-Up Study: Prevalence, Pattern and Housing Status.” European Journal of Public Health 26 (1), 111116. doi:10.1093/eurpub/ckv142.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Venkatapuram, S. 2011. Health Justice: An Argument from the Capabilities Approach. Cambridge: Polity Press.

  • Vleminckx, K., and J. Berghman. 2001. “Social Exclusion and the Welfare State: An Overview of Conceptual Issues and Policy Implications.” In Social Exclusion and European Policy, ed. D. G. Mayes, J. Berghman, and R. Salais, 2746. Cheltenham, UK: Edward Elgar.

    • Search Google Scholar
    • Export Citation
  • Vrooman, J. C., and S. J. M. Hoff. 2013. “The Disadvantaged along the Dutch: A Survey Approach to the Multidimensional Measurement of Social Exclusion.” Social Indicators Research 113 (3): 12611287. doi:10.1007/s11205-012-0138-1.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Vygotsky, L. S. 1978. Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press.

  • Walker-Andrews, A. S. 2005. “Perceiving Social Affordances: The Development of Emotional Understanding.” In The Development of Social Cognition and Communication, ed. B. D. Homer and C. S. Tamis-LeMonda, 93116. Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

    • Search Google Scholar
    • Export Citation
  • Wilken, J. P., and D. den Hollander. 2012. Handboek integrale rehabilitatiebenadering [Manual of the integrated rehabilitation approach]. Amsterdam: SWP.

    • Search Google Scholar
    • Export Citation
  • Wolf, J. R. L. M. 2002. Een kwestie van uitburgering [Exit from Society]. Amsterdam: SWP.

  • Wolf, J. R. L. M. 2012. Handleiding voor een krachtgericht begeleidingstraject [Manual for a strengths-based care trajectory]. Nijmegen: Radboudumc.

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