New in Psychiatry
Arun Kumar
Psychiatrist, Lakeshore Hospital, Cochin.
drarunkumark@yahoo.com
| ABSTRACT
Nidotherapy is a treatment approach founded in the UK by Peter Tyrer. It employs systematic assessment and modification of a patient’s environment to minimize the impact of a mental disorder on the patient himself and the society he lives in. The patient’s wishes, opinions and lifestyle are understood, and all environmental factors are adjusted to make them fit him the best. Though a recent Cochrane review concluded that further research is needed into the possible benefits of nidotherapy, some evidence has emerged to support its efficacy. Keywords: Nidotherapy, persistent mental disorders, environmental manipulation |
In our practice, we psychiatrists commonly see many patients whose illness do not improve even after we try all possible mainstream treatments. Nidotherapy is a new approach, founded in the UK by Peter Tyrer, which could be a last resort solution to address the living conditions of such patients suffering from severe mental disorders for whom the conventional psychiatric services are not able to do anymore help.
‘Nidotherapy’ describes the systematic manipulation of the physical and social environments to help achieve a better fit for a person with a persistent or permanent mental disorder.1 The term is derived from the latin word ‘Nidus’ which means the nest. In analogy, the treatment aims to provide an environment like the birds’ nest — which can accommodate anything placed in it, irrespective of the type or shape of the object. Nidotherapy creates a set of mini-environments, each fashioned to suit the person it is accommodating.
Nidotherapy derives its principle from Charles Darwin’s concept of survival of the fittest (or the adapted). The struggle for dominance of the environment, in competition with others, is constant throughout life and across generations. Success comes to those who are best fitted for the environment. There is definitely an imbalance when people with chronic mental illness are put in the same race for dominance along with healthy people. Nidotherapy is introduced, to rephrase Darwin’s words again, to change the environment to create ‘better adaptation in however slight a degree to the mental state conditions’.
Nidotherapy is a collaborative approach designed to minimize the impact of any form of mental disorder on the individual or the society through systematic assessment and modification of the environment. It attempts to be a formalized and planned method of achieving all forms of environmental change — from moving the house to feeling at ease in the settings where you spend most of your time. It therefore covers physical, social and highly personal forms of environmental change.2 It differs from all other psychosocial interventions in that it does not explicitly target symptom reduction or any other changes in the individual’s affect, behavior or cognition. Any such change, if it occurs, is secondary and coincidental.
It is essentially a complicated matching process whereby patients’ deep desires, vague wishes, fundamental opinions and lifestyle are understood sufficiently to ensure that environmental factors in all their forms are adjusted sensitively and specifically to make the best fit for him. Many other treatments too take great account of the environment — but they are all fundamentally concerned with making adjustments to the person, either exclusively or sometimes in connection with the environment. Such treatments include person-centered planning, cognitive behavioral therapy, modelling and shaping, schema-focused therapy, family therapy, systems theory, social case work and the care program approach. In all these, however, environmental modifications are made with the intention of inducing changes in the patient himself.
Accepting people the way they are, foregoing insistence on treatment, and heeding the individuals’ wishes seem to be the dictum in which nidotherapists start their work. Patients are chosen based on their treatment history — whether they have been adequately tried on known pharmacological and non-pharmacological interventions. Incomplete remission with existing treatment plans make them suitable candidates for nidotherapy. 8-12 sessions are initially held, and then the number is increased if the patient’s social functioning - the yardstick used to measure the efficacy of nidotherapy – does not improve.
The nidotherapist or his clinical team visit the patients at their home and establish a therapeutic alliance. Unlike in other treatments, the bond here is stronger and more intense. The patient is given an option to discontinue medications that have not been effective. The therapist sees the environment from the patient’s point of view (collateral collocation). Both the patient and the nidotherapist take joint responsibility for developing the program, but the patient has to be the final owner. They jointly plan, in agreement with all concerned parties, achievable environmental targets aimed at changing the surroundings or interpersonal relations. The team also involves a trusted arbiter, usually a close relative or friend of the patient, in order to resolve conflicting views between the therapist and the patient with regards to the environmental changes. If the targets are right, social functioning will improve. If it doesn’t, the goals are reset.
Nidotherapy is still in the growing stage as far as evidence base for effectiveness is concerned. Not many head-on trials with other treatment modalities have been done so far. However, a randomized controlled trial revealed that nidotherapy is more cost-effective than usual therapies in the management of comorbid serious mental illness and personality disorder. Patients in an assertive outreach team who had severe mental illness, comorbid personality disturbance, and continued management problems were randomized to receive nidotherapy enhanced assertive treatment (up to 12 sessions) or continued assertive outreach care. Researchers measured the use of psychiatric beds over one year (primary outcome), and change from baseline in other health service resources, psychiatric symptoms, social functioning, and engagement with services (secondary outcomes) at 6 and 12 months. The nidotherapy group had a reduction in symptoms and engagement with services, and a marginal superiority in social function. After one year, they had a 110% reduction in hospital bed use as compared to the control assertive care. The mean cost saving for each patient allocated to nidotherapy was 14,705 Pounds per year, mainly as a consequence of reduced use of psychiatric beds.3,4
Spencer et al. examined the views of patients with comorbid mental illness and antisocial personality features about the acceptability and value of nidotherapy (given over a six-month period as an adjunct to conventional care), and found that nidotherapy was both feasible and acceptable. Those patients felt that nidotherapists are valuable allies in a world they otherwise perceived as hostile. Nidotherapy was also found to improve adherence to other therapies.5
A Cochrane review concluded that further research is needed into the possible benefits of nidotherapy and until then it should be considered as an experimental therapy.6
In conclusion, nidotherapy may hold a promising future in the management
of chronic psychiatric illnesses in situations where the clinicians find
they have exhausted all other treatment options.