Relationship between quality of life and social integration among patients with schizophrenia attending a Nigerian tertiary hospital.

BACKGROUND: Despite decades of de-institutionalization and the best efforts of community mental health services, individuals with schizophrenia living outside the hospital may be described as in the community but not of the community, and remain in a very real sense socially excluded. AIM AND OBJECTIVES: To determine the relationship between social integration and quality of life among patients with schizophrenia attending the outpatient clinic of the Neuropsychiatric Hospital Abeokuta in Nigeria. METHODS: One hundred and fifty-one patients were recruited. Sociodemographic questionnaire, MINI-PLUS, WHOQOL-BREF, Social Integration Scale and PANSS were administered. Multivariable regression analyses were performed to identify the determinants of quality of life and the relationship with social integration. RESULTS: The mean (± SD) age of the respondents was 40.00 (± 10.23), 56.3% were males, 37.1% were single. Independent predictors of lower quality of life were: (1) more severe psychopathology for the domains of general health (p = 0.003), social relationship (p = 0.019) and environment (p = 0.008); (2) longer duration of illness for the social relationship (p = 0.028) and environment (p = 0.015) domains; and (3) negative symptoms (p = 0.034) for the physical domain. CONCLUSION: There is a need to pay closer attention to social outcome measures such as quality of life and level of social integration among patients with schizophrenia who come in contact with psychiatry services, and not just on symptom remission only.

Development of atypical parental behavior during an inpatient family preservation intervention program.

Since failed reunification is a detrimental outcome for children, particularly infants and toddlers, the aim of this study was to gain insight into support to families in multiple-problem situations to help them achieve sustainable good-enough parenting. Therefore, we examined outcomes of an assessment-based inpatient family preservation program. We prepared a thorough target-population description (n = 70) using file analysis. Next, we examined atypical parental behavior during the intervention using the Atypical Maternal Behavior Instrument for Assessment and Classification with a repeated measures design (n = 30). The family files revealed a great number of issues at the family, parent, and child levels, such as practical matters, problems in parent functioning and between parents, and difficulties in the broader environment. We found a significant decline in three dimensions of atypical parental behavior over time. This program has great potential in supporting vulnerable families in their pursuit of family preservation.

Debido a que un fracasado intento de reunificación es un resultado perjudicial para los niños, particularmente los infantes y niños muy pequeñitos, la meta de este estudio fue adquirir percepciones en cuanto al apoyo a familias en situaciones de problemas múltiples para ayudarles a lograr una crianza sostenible suficientemente buena. Examinamos, por tanto, resultados de un programa de paciente interno para la preservación de la familia (FP) basado en evaluación. Preparamos una detallada descripción de la población de enfoque (n = 70) usando análisis de registros. Examinamos conductas atípicas de los padres durante la intervención usando el Instrumento de Conducta Materna Atípica para Evaluación y Clasificación (AMBIANCE) con un diseño de medidas repetidas (n = 30). Los registros familiares revelaron un gran número de asuntos al nivel de la familia, los padres y los niños, tales como asuntos prácticos, problemas en el funcionamiento de los padres y entre padres, y dificultades en el más amplio entorno. Encontramos una baja significativa en tres dimensiones de conducta atípica de los padres a lo largo del tiempo. El programa FP tiene un enorme potencial para apoyar a familias vulnerables en su esfuerzo por preservar la familia.

Puisque la réunification échouée est un résultat détrimentaire pour les enfants, en particulier les nourrissons et les jeunes enfants, le but de cette étude était d'explorer le soutien aux familles dans des situations avec de nombreux problèmes afin de les aider à atteindre un parentage durable et suffisant. Nous avons donc examiné les résultats d'un programme de maintien familial (abrégé ici MF en français) fondé sur l'évaluation et en hospitalisation. Nous avons préparé une description approfondie de la population cible (n = 70) en utilisant une analyse par dossier. Nous avons examiné le comportement parental atypique durant l'intervention en utilisant AMBIANCE, l'instrument de comportement maternel atypique pour l'évaluation et la classification avec une conception à mesures répétées (n = 30). Les dossiers familiaux ont révélé un grand nombre de problèmes au niveau de la famille, du parent et de l'enfant, tels que des problèmes pratiques, des problèmes dans le fonctionnement du parent ou entre les parents, et des difficultés dans le milieu plus large. Nous avons trouvé une baisse importante sur trois dimensions du comportement atypique parental au fil du temps. Le programme MF offre de grandes possibilités dans le soutien aux familles vulnérables dans leur quête de maintien familial.

Supported accommodation for people with schizophrenia.

Background: As a result of deinstitutionalization of psychiatric treatment and care, many people with severe mental illness have been offered supported accommodation. However, research on this costly intervention in Norway has been scarce. Aims: The aim of this study was to prospectively investigate the clinical and demographic factors associated with allocation to supported accommodation for people with schizophrenia. Methods: The study was a prospective cohort study of 334 people with schizophrenia acutely admitted to Haukeland University Hospital between 2005 and 2010. Information concerning allocation to supported accommodation in their residential municipalities was collected retrospectively. Univariate and multivariate statistical methods were used to assess the association of clinical and demographical variables with allocation to supported accommodation. Results: Supported accommodation was allocated to 29.6% of the participants during the study period. Age, gender, implementation of compulsory mental health care, substance abuse, symptom burden and suicidality were not associated with allocation to supported accommodation. Functional impairment, especially difficulties with activities of daily living, experiencing exacerbation in the course of chronic disease, being medicated and of Norwegian origin, favoured supported accommodation. Conclusions: Our results supported the hypothesis that people with severe mental illness presenting the greatest need for supported accommodation, based on functional difficulties and exacerbation of chronic disease were allocated supported accommodation. Symptom burden was not associated with allocation. Clinical implications: Further research is needed to examine the impact of supported accommodation on the outcomes for people with schizophrenia.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes.

BACKGROUND: Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services. METHODS: Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'. RESULTS: Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research. CONCLUSIONS: A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Preliminary outcome study on assertive community treatment in Japan.

AIMS: The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project. METHODS: The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge. RESULTS: Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased. CONCLUSION: Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.

Referrals into services for offenders with intellectual disabilities: variables predicting community or secure provision.

BACKGROUND: There is a need for research to promote an understanding among service developers on why people with intellectual disabilities (ID) are referred to offender services in order for them to receive appropriate assessment and treatment. Previous studies investigating referrals into forensic ID services have concentrated on referral sources and administrative variables such as legal status. AIMS: To construct a predictive model for choice of service referral based on a comprehensive range of information about the clientele. METHOD: We conducted a case record study of 336 people referred to community services and 141 to secure provision. We gathered information on referral source, demographics, diagnosis, index behaviour, prior problem behaviours and history of abuse. RESULTS: Comparisons revealed 19 candidate variables which were then entered into multivariate logistic regression. The resulting model retained six variables: community living at time of referral, physical aggression, being charged, referral from tertiary health care, diverse problem behaviour and IQ < 50, which correctly predicted the referral pathway for 85.7% of cases. CONCLUSIONS: An index act of physical aggression and a history of diversity of problem behaviours as predictors against the likelihood of community service referral suggest that professionals have similar concerns about people with ID as they do about their more average offending peers; however, the more severe levels of ID mitigated in favour of community referral, regardless. Offenders with ID tend to be referred within levels of service rather than between them, for example, form tertiary services into generic community services.

Deinstitutionalization and network of mental health services: a new scene in health care.

OBJECTIVE: to analyze the process of deinstitutionalization resulting from a psychiatric hospital shut down, and know the fate of users after dehospitalization. METHOD: a descriptive, qualitative study based on the critical-analytical perspective, which had as its setting the Hospital Colônia de Rio Bonito. Institutional documents and narratives of five managers who participated in the deinstitutionalization process were analyzed. RESULTS: Hospital Colônia deinstitutionalization lasted longer than expected. For this to happen, a tripartite intervention was necessary, and especially the mobilization of networks and implementation of Psychosocial Care Networks by the cities. Regarding destination of users, most were referred to therapeutic or transinstitutionalized residences. Final considerations: Hospital Colônia deinstitutionalization led to the establishment of connections between services and people. This was a powerful device for the implementation of Psychosocial Care Networks at municipal level.

The development of a specialist hostel for the community management of personality disordered offenders.

BACKGROUND: Since the late 1990s, in England and in Wales, there has been increasing interest in the particular challenges of managing offenders with personality disorder (PD). In 1999, a specialist hostel, managed by the probation service but with a high level of forensic mental health service input, was opened to high-risk PD offenders. AIMS: To describe the first 93 high-risk residents with PD who were completing sentences under life licence, parole or probation, and their outcome. METHODS: We investigated the nature of the offences residents had previously committed, their psychological profile in terms of personality patterns on the Millon Clinical Multiaxial Inventory (MCMI-III) and the Psychopathy Checklist-Revised (PCL-R), as well as staff commentary on their progress, to establish whether these factors related to outcome in terms of completion of stay in the hostel or premature discharge. Curfew failures and rearrest rates were also measured. RESULTS: Of the 80 men who completed their residency within the two years of the study, the majority (50) left the hostel for positive reasons under mutual agreement. One-fifth were rearrested while resident, which is a lower rate than would be expected for such a group of offenders. PCL-R scores were predictive of outcome, but so was previous offending history. Self-defeating traits on the MCMI-III and negative comments written by hostel staff were also associated with failure. CONCLUSIONS: The hostel development demonstrated that probation and health services can work together to manage violent offenders with high levels of psychological dysfunction, and the evaluation provided some indications of how such arrangements might be enhanced.

Hawai'i's "Going Home Plus" project: a new option to support community living.

The Going Home Plus project facilitates the transition of individuals from hospitals, nursing facilities, and intermediate care facilities for the mentally retarded (ICF-MRs) into community settings. The project is a collaborative effort between the State of Hawai'i Department of Human Services (DHS), the University of Hawai'i Center on Disability Studies and their community partners to help elderly and younger persons with disabilities who have been living in an institution for at least six months and express a choice for community living. The project, which provides services such as transition coordination and telemedicine, strives to become a valuable resource for institutionalized patients, their families, and medical professionals.

A place for the heart: A journey in the post-asylum landscape. Metaphors and materiality.

The downsizing of psychiatric hospitals has created a new institutional landscape in the local community to support people with severe mental problems in their daily living. This study explores meeting places in Norway from the users' perspectives. The users used four metaphors to describe these meeting places: "like a home", "like a family", "like a landing ground" and "like a trampoline". The users have decorated the interiors of the meeting places with hearts made from various materials, and these could be considered as symbols of the places. The metaphors used: the hearts and the rooms and interiors, reflect old ideas about calmness and dignity rather than new ideas based on New Public Management.

Deinstitutionalization of long stay patients in a psychiatric hospital in Rio de Janeiro. / Desinstitucionalização de pacientes de longa permanência de um hospital psiquiátrico no Rio de Janeiro.

Critical Time Intervention (CTI) is a time-limited mental health intervention offered to people with mental disorders during critical/transition periods. This study assesses the impact of CTI-BR on social performance and quality of life within a population in the process of deinstitutionalization, after long-term hospitalization in a psychiatric institution. The study population was split into two groups, one of which received CTI plus the regular care. Results showed no advantage of the intervention compared to the regular programs provided by the institution. When study participants are analyzed as a group, we found positive improvement regarding their social functioning and self-perception of their mental-health. Results show that it is possible for elderly patients discharged from long-term psychiatric care to live in residential facilities in the community, supervised by clinical teams.

A percepção da equipe de trabalhadoras do SRT acerca do domicílio e da produção do cuidado no contexto da pandemia de Covid-19 / The perception of the RTS team of workers about the home and the production of care in the context of the Covid-19 pandemic

Resumo Introdução: Os Serviços Residenciais Terapêuticos (SRT) são pontos da Rede de Atenção Psicossocial alinhados com a lógica da desinstitucionalização. O objetivo deste estudo foi analisar a percepção de 'casa' pela equipe de cuidadoras de SRT e suas implicações para a produção do cuidado durante a pandemia de Covid-19. Métodos: Estudo qualitativo de abordagem cartográfica que teve como cenário de estudo 4 SRT do município do Rio de Janeiro. Para a coleta dos dados, foram realizadas entrevistas com 9 trabalhadoras e observação participante de reuniões. Resultados e discussão: Os analisadores Lugar de Casa e Efeitos da Pandemia emergiram do processamento. O primeiro mostra a percepção das trabalhadoras acerca do ambiente da casa, enquanto o segundo traz a influência da pandemia na produção do cuidado nas SRT. O ambiente das residências é múltiplo, diverso e, por vezes, contraditório, permeado por diferentes modos de vida e influenciado por aspectos culturais, percepções e experiências vividas.

Abstract Introduction: The Residential Therapeutic Services (RTS) are places of the Psychosocial Care Network aligned with the logic of deinstitutionalization. This study aimed to analyze the perception of 'home' by the SRT team of caregivers and its implications for the production of care in the Covid-19 pandemic situation. Methods: Qualitative study of cartographic approach, which had 4 SRT in the city of Rio de Janeiro as scenario. Data collection involved interviews with 9 workers and participant observation of the SRTs' meetings. Results and Discussion: The analyzers Home and Pandemic Effects emerged from analysis. The first analyzer shows the workers' perception of the home environment, while the second analyzes the production of care and the influence of the Covid-19 pandemic on the SRT. The residence environment is multiple, diverse, sometimes contradictory, composed of different lifestyles and influenced by cultural aspects, perceptions and life experiences.

Challenge of psychiatric rehabilitation for patients with long-term hospitalizations using the Nirje's normalization principles as a valuation standard: two case studies.

This research investigates the current care of hospitalized, chronically mentally ill persons to determine to what extent current hospitalization supports Nirje's principles of normalization. We propose that care-providers try to incorporate rehabilitation programs that help the patients acquire the pattern and rhythm of living necessary for them to live in the community in their daily hospital life rather than to fit the patients into hospital rules or schedule. Therefore, care-providers must look back on their own views of the humanity, disabled people, and support and may have to change them if necessary. It is important that care-providers do not give up having psychiatric patients not give up restoration of normal social living. To develop such individual attempts into rewarding activities, it is necessary to set goals in the hospital and to let an interdisciplinary team work to achieve them. Moreover, the situation is expected to change if efficient care management is implemented to support psychiatric patients in the community. High-quality care to realize independent living of patients in the community including collection and distribution of information, management of symptoms, assistance for self-care, and psychological education is provided at hospitals that maintain the idea of, and strong belief in, providing high-quality care for returning patients to the community. The findings of this study will provide insights into how to design better hospitalization and/or community care for the mentally ill.

Exploring the Use of Special Housing Units by Men Released From New York Correctional Facilities: A Small Mixed-Methods Study.

This small, mixed-methods study sought to understand the use of special housing units among formerly incarcerated men. In the present study, 110 participants were placed in solitary confinement, ranging from ≤30 days to 20 years, with a mean of 2 years (SD = 2.55). These men ranged in age from 35 to 67 years, with a mean age of 46 years. Years of incarceration ranged from less than 30 days to 34 years; the mean number of years incarcerated was 4 (SD = 6.39). Of the 110 participants, qualitative interviews were conducted with 30 men to explore their experiences during time spent in solitary. The qualitative themes that emerged from the study were getting special housing units might be used for punishment, getting used to solitary, and getting solitary might mean peace of mind. Personalized reentry plans for men placed in special housing units facilities are urgently needed.

Has deinstitutionalization affected inpatient suicide? Psychiatric inpatient suicide rates between 1990 and 2013 in Israel.

OBJECTIVE: To examine variations in rates of inpatient suicide and clinical risk factors for this phenomenon. METHOD: The National Israeli Psychiatric Hospitalization Case Registry was used to study inpatient suicide. Clinical risk factors for inpatient suicide were examined in a nested case control design. RESULTS: Between 1990 and 2013 there were 326 inpatient suicides, at an average of one inpatient suicide per 1614 admissions. A significant decline in rates of suicide per admission over time (p<0.001) was associated with a reduced number of beds (p<0.001) and a decline in nationwide suicide rates (p=0.001). Clinical risk factors for inpatient suicide were: affective disorders (OR=5.95), schizoaffective disorder (OR=5.27), schizophrenia (OR=3.82), previous suicide attempts (OR=2.59), involuntary hospitalization (OR=1.67), and more previous hospitalizations (OR=1.16,). A multivariate model with sensitivity of 27.3% and specificity of 95.3% for inpatient suicide, showed a positive predictive value of 0.4%. CONCLUSIONS: The absolute number and rates of inpatient suicide per admission have decreased over time, probably due to the decreased number of beds lowering total time at risk. Patients with affective and psychotic disorders and with previous suicide attempts have the greatest risk of inpatient suicide. However, clinical characteristics do not enable identification of patients who are at risk for suicide.

The Sasagawa project: a model for deinstitutionalisation in Japan.

Japanese psychiatric services are still typically hospital-based. The Sasagawa Project is the first systematized deinstitutionalization project in Japan that aims to make the transition from hospital to residential living while ensuring both the quality and continuity of care for the patients. Seventy-eight (51 males) patients (mean age 54.6) with chronic schizophrenia, who were considered appropriate for discharge received continuous cognitive behavioural therapies based on the Optimal Treatment Project manualised protocol, both before and after the hospital closure. During the first 12 months after the deinstitutionalisation was initiated on April 1st, 2002, ten people had incidents that interrupted their stay in the residential Sasagawa Village. A common criticism of many treatment outcome trials is that evaluation is focused on changes in clinical severity. In the Sasagawa project the transition appeared to have been smooth and relatively few incidents occurred could be related to the transition to a less intensive residential care. This project might be a useful model for effecting and monitoring transition from hospital to community care in Japan and other countries where such changes have been proposed.

Ouvidores de vozes de um serviço de saúde mental: características das vozes e estratégias de enfrentamento / Los que oyen voces en un servicio de salud mental: características de las voces y estrategias de enfrentamiento / Voice hearers of a mental health service: voice characteristics and coping strategies

Resumo Objetivou-se compreender a experiência de ouvir vozes a partir das características e conteúdos das vozes, e das estratégias utilizadas por dezesseis ouvidores usuários de um Centro de Atenção Psicossocial do Sul do Brasil. Trata-se de uma pesquisa qualitativa de caráter exploratório. Se deu através de entrevistas semiestruturadas e análise de conteúdo. Evidenciou-se que as características e conteúdos das vozes podem ser determinantes das reações emocionais dos ouvidores frente à experiência, sendo mais difícil lidar com ela quando os conteúdos são negativos. Através das estratégias utilizadas pelos ouvidores, percebeu-se uma resistência ao modelo biomédico, mesmo dentro de um serviço de saúde mental. Conclui-se que há uma necessidade de se pensar outras possibilidades de recuperação para as pessoas que ouvem vozes, que deem conta da complexidade da experiência e que sejam condizentes com o modelo de atenção psicossocial.

Resumen El estudio objetivó comprender la experiencia de oír voces a partir de las características y contenidos de las voces y las estrategias utilizadas por dieciséis oyentes que utilizan un Centro de Atención Psicosocial en el sur de Brasil. Esta es una investigación exploratoria cualitativa. Se llevó a cabo mediante entrevistas semiestructuradas y análisis de contenido. Se destacó que características y contenidos de las voces pueden ser determinantes de reacciones emocionales de los oidores delante la experiencia, siendo más difícil ocuparse de ella cuando los contenidos son negativos. A través de estrategias utilizadas por los oidores, se notó una resistencia al modelo biomédico, aunque dentro de un servicio de salud mental. Se concluye que hay una necesidad de pensar otras posibilidades de recuperación para las personas que oyen voces, que aporten la complejidad de la experiencia y que sean compatibles con el modelo de atención psicosocial.

Abstract The study aimed to understand the experience of hearing voices from the analysis of the characteristics and contents of the voices, and of the strategies used by sixteen voice hearers who use a Psychosocial Care Center in Southern Brazil. This is a qualitative exploratory research, conducted through semi-structured interviews and content analysis. It was evidenced that the characteristics and contents of the voices can be determinant of the hearer's emotional reactions to the experience, being more difficult to deal with when those are negative. By analyzing the strategies used by the hearers, resistance to the biomedical model was perceived even within a mental health service. It was concluded that there is a need to think about other possibilities of recovery for people who hear voices, possibilities that take into account the complexity of the experience and that are consistent with the psychosocial care model.

From deinstitutionalization to recovery-oriented assertive community treatment in Hong Kong: What we have achieved.

This paper explored the effectiveness of Assertive Community Treatment (ACT) for severely ill mental patients during a period of rapid deinstitutionalization in Hong Kong. We employed a flanking historical control design. The treatment group comprised 70 participants with 3 or more admissions to psychiatric hospitals within the preceding 12 months, and received ACT. Two historical control groups (C1 and C2), each 70 participants, with similar inclusion criteria flanking the recruitment period of treatment group, were identified and received Treatment as Usual (TAU). Outcome data were measured at baseline, 6, 12 and 18 months of intervention. Readmission rates, bed-days, emergency room visits and days of missing medical appointments improved with time during the deinstitutionalization process, irrespective of treatment modality. In addition, ACT had superior effect in most of these outcome parameters, compared to the control groups. We reported that the current model of ACT, with a relatively small case load per case manager, round the clock services, multidisciplinary team approach, with psychiatrists integrated in the services and case managers responsible for health and social care, is an effective intervention for helping people with mental illness who pursue their chosen independent living in the community.

Opportunities for health promotion: including the chronically ill and disabled.

One of the aims of health promotion and illness prevention is to reduce the prevalence of chronic disease that is so apparent in the developed countries, yet the very individuals who already have chronic diseases and disabling conditions constitute a sizeable population which could contribute to health promotion programs. There are two chief elements which argue for an extension of health promotion toward the chronically ill and disabled: (1) the lifestyle management which is characteristic of health promotion is similar in many respects to the comprehensive self-care regimens followed by chronically ill persons, and (2) the philosophy of independent living for disabled persons shares social foundations with the concept of health promotion and could add the strength of social advocacy to health promotion. This paper examines social and medical variables linking the two health trends of health promotion and independent living for disabled persons. Observations of a U.S. independent living program, The Timbers, are reported to illustrate an active combination of the two philosophies. Finally, sociological implications are presented, with a focus on the potential of health promotion programs.