Nidotherapy: why it is new and exciting, and why you should take

notice

Peter Tyrer, Imperial College, London Peter Tyrer, Imperial College, London

My first successful patient (May 1968)

• Man aged 35, worked at agricultural research institute. Depressed for 2 years. Seen in out-patient clinic. Had not received any previous treatment. Fully assessed and as he had classical depressive symptoms was put on amitriptyline 50mg rising to 100 mg daily.

• No response after four weeks, increased to 150 mg daily, showed dramatic improvement after a further four weeks of treatment.

• I concluded he had responded to my treatment but..........................................................

My patient made the change, but in nidotherapy we aid it

I will now introduce you to Daniel, a patient under the care of an assertive outreach team who has been in hospital for 14 months after repeated failures to live in supervised accommodation in the community. We meet him in 2007 ….

What is somewhat unusual about this case in the setting of current NHS psychiatry?• The consultant seems to know the patient

remarkably well

• He spends a lot of time shopping with him

• He treats him as a rather irritating equal

• He answers straight questions with straight answers

Origin of nidotherapy

• Named after the Latin, nidus, or nest, as the nest is a very good example of a environment that will adjust itself to any shape that is placed within it.

• In nidotherapy we deliberately analyse every part of the environment with the patient to find out where there is a misfit that might be adding to the psychiatric problem

Definition

• Nidotherapy is:-• ‘the collaborative systematic assessment and

modification of the environment to minimise the impact of any form of mental disorder on the individual or on society’ (Tyrer, Sensky and Mitchard, 2003; Psychotherapy and Psychosomatics, , 72, 350-356)

10 principles of nidotherapy•

1. All people have the capacity to improve their lives when placed in the right environment (Daniel stays in London)

2. Everyone should have the chance to test themselves in environments of their own choosing (even if they have no negotiating skills)

3. When people become distressed without apparent reason the cause can often be found in the immediate environment (but we do everything possible to blame something else)

4. A person's environment includes not only place but also other people and self (but we often forget this)

5. Seeing the world through another's eyes gives a better perspective than your eyes alone (a remarkably difficult task that is the stuff of empathy)

6. What someone else thinks is the best environment for a person isn't necessarily so (paternalism fails)

7. All people, no matter how handicapped, have strengths that can be fostered (eve if we have to look very hard to find them)

8. A person’s environment should never be regarded as impossible to change (unless we are burnt out)•

9. Every environmental change involves some risk but this is not a reason to avoid it (the status quo is not an answer to anything when people remain unwell)

10. Mutual collaboration is required to change environments for the better (try and get the patient on board otherwise the decisions you make may come back and haunt you)

• e it may come bac and bite you)s k

Reverse Darwinism

• Darwinism – everyone fights to get their place in natural environments and the most adapted win, the rest fall by the wayside and perish

• Nidotherapy - we create a highly specific, often artificial, environment in which those unadapted for natural environments can thrive and prosper

In which conditions is nidotherapy likely to be helpful?

• In the evidence based framework of interventions we are fairly low down with nidotherapy

• Only schizophrenia But other treatments are not doing very much better

Our provisional ordering of diagnostic suitability for nidotherapy

Intellectual disabilityAutistic spectrum disorderPersonality disorderDementiaDepression (chronic) Cocaine dependenceAlcohol dependenceSchizophreniaAttention deficit hyperactivity disorderObsessive compulsive disorderPhobiasPost-traumatic stress disorderAnorexia nervosaPanic disorderBipolar disorder

Why this order of preference?

• For conditions at the top of the list there are many for which patients do not seek treatment at all, and may sometimes abhor it altogether

• Tyrer P, Mitchard, S., Methuen, C. & Ranger, M. (2003). Treatment-rejecting and treatment-seeking personality disorders: Type R and Type S. Journal of Personality Disorders, 17, 265-270

The components of nidotherapy• Selection of patients

• Form of treatment (individual, group, staff)

• Components of treatment Environmental analysisCreating a nidopathwaySetting timetablesMonitoring and modifying the nidopathway

• Selection of therapists (usually a secondary issue)

Current case

• Parents (both medical) ask us to see their daughter (28) whom they think has a personality disorder as (i) she does not seem to settle at anything, (b) she is always arguing with them and other members, (c ) she has no friends, (d) her life is drifting away with no prospects ahead

• ‘Can you act now with nidotherapy, Professor Tyrer, before it is too late?’

Environmental analysis

• Physical environment initially seemed OK – flat bought with help of parents – but later she felt she had not put her stamp on it properly

• Relations with parents very poor – felt constantly belittled and criticised, and felt to be inadequate as she was in the design trade, not medicine

• Personal and social environment – very limited social circle and generally unhappy at present work. Browses Internet for jobs for hours but does nothing about applying

Nidopathway

• Banning of contact with parents for one month (now extended to two)

• Painted flat• Occupational wishes explored – had been

stunted by parents – now engaged again• Makes contacts with friends from the past,

one of whom she is going to New York with shortly

Outcome (after 10 weeks)

• New job – much more satisfying as is more involved with design than merchandising

• Feels completely relieved that parents are off her back

• Self-confidence remarkably improved• Widening social circle• AND Depression score on HADS scale down

from 12 to 2 – without this symptom ever being addressed

And even when conditions are usually treatable nidotherapy can still have a place

Isobel – using nidotherapy when CBT has limited response

Aged 50, widowed with 3 grown up children

Severe health anxiety and OCD – limited response to CBT, chronically depressed by it all, with no response to antidepressants, so stopped them herself

Half Asian and considers herself unattractive, especially to older, white half sister who is well off and very successful

Loner at school, felt a disappointment to her parents because she never fitted in.

Decided to marry first serious boyfriend who was Swiss, because she thought no one else would ever want her. Married in Switzerland, emotionally and sexually abusive relationship, she was loathed by his family and ceased contact with them

Husband developed a very aggressive form of multiple sclerosis, she had to nurse him

She is religious, but feels rejected by God because she agreed her husband shouldn’t be resuscitated even though these were his wishes too

Environmental analysis

Physical – lives in a house found for her by her mother on her return from Switzerland, hates it, OCD very hard to control when there

Socially isolated – finds others’ company tedious, nothing worthwhile going on in her town

Occupation/recreation – not working, no qualifications, lives on pension from Switzerland, couldn’t hold down job with her OCD anyway, occasional volunteering at coffee shop at church, youngest by a mile, nothing in common with anyone else. Interested in quilting

Religion – evangelical church, attending bible study group, where she feels at odds with everyone else, never feels she read enough, spoke to Vicar’s wife re problems with anxiety, told to attend a special group, and that her fears were a punishment for not following the word of God

Financial – no money to spare, feels trapped

Family – always feels she has to be there for her children, they worry about her a great deal and don’t understand about her illness

Nidotherapy action plan

Religion – Found high church in London, sympathetic priest

We felt a bit stuck, so we suggested we meet her children with her to see if we could work out a plan together

Family meeting – two main issues addressed, firstly they were all able to cope in life so she didn’t have to worry about them so much-Secondly, and following on from this, they really wanted her to meet someone else, solution…

Internet dating !

What factors come into the choiceof nidotherapy?

• Has the patient got treatable pathology?

• Have all evidence-based treatments been given appropriately and for the right length of time?

• Is the patient keen to have further therapy?

• Could environmental factors be a significant part of the problem?

Environmental analysis

• The aim is to look at every single part of the environment in all its forms

• This involves both therapist and patient in equal measure

• It examines the physical, social and personal environment

General approach to environmental analysis

These underline the attempt to make environmental change as systematic as possible:

1. No pressure to change the person (to treat the

untreatable)2. It changes the environment, not the person3. It involves genuine partnership and involves the

messenger as much as the message 4. It comprises environmental judgement and advocacy5. It dissolves boundaries between people

Environmental change only

• Nidotherapy is not a treatment of the person; it is a treatment (or manipulation) of the environment for the person

• We have failed to understand that managing the environment only is just as much a harbinger of change as treating a symptom

• By focusing on the environment only it is possible to effect change by the back door carried out under the control of the patient, decided by the patient, not the therapist

Environmental advocacy

• People often want changes in their environment but are unable to achieve them for a number of reasons

• The nidotherapist as environmental advocate can make these changes happen by harnessing their skills to the patient’s ones

• Persuasion of others may also be necessary and so then more advocacy is needed

Dissolution of boundaries

• The nidotherapist, whilst maintaining a professional relationship with the patient, often has to prevent the normal distance between patient and therapist from developing as this can be unhelpful

• Just as we may call on a friend to help us with a sticky problem the patient needs to be able to do the same with an environmental one

• But the nidotherapist becomes an environmental aide, not a personal guru

Where do other treatments overlap?

• Dynamic psychotherapy – hardly at all• Cognitive behaviour therapy – a little• Problem-solving – sometimes• Behavioural analysis and therapy – sometimes• Social skills training – a little• Person centred planning - a little• But none of these are environmental treatments

– they are essentially aimed at the person

Best evidence of nidotherapy being successful

• In those with the triple diagnosis of personality disorder, substance dependence and psychosis

• No other ‘treatment’ has been shown to be of real value here

Copyright ©2000 BMJ Publishing Group Ltd.

Campbell, M. et al. BMJ 2000;321:694-696

Framework for evaluation of complex interventions

Nidotherapy is here

Trial evidence

• This scenario (a randomised trial of nidotherapy + assertive outreach therapy versus assertive outreach alone in severe mental illness and personality disorder) is clearly not related to autism but both groups are very treatment resistant

• Our main outcome in this trial was in-patient bed use

Nidotherapy group

(n=19)

Control group

(n=15)

Mean SD Mean SD

Mean

difference (95% CI)

p-

value

Inpatient stays (nights) 54 75 139 135 -85

Health care (£) 15,173 15,786 31,105 27,290 -15,932

Hospital costs (£) 10,938 14,990 27,871 26,986 -16,932

Community health

services (£) 3,159 1,628 2,065 1,256 1,094

Medication (£) 1,076 1,704 1,170 875 -94

Social and voluntary services (£) 3,559 5,622 2,561 4,466 998

Community (£) 1,101 1,288 717 682 383

Accommodation (£) 2,458 5,628 1,844 4,618 615

Criminal Justice (£) 181 787 2 7 179

Total costs (£) 18,963 19,010 33,668 27,022 -14,705

(-30,791 to

1,380) 0.072

Inpatient stays and total cost of services used over 12 months follow-up

The mean saving in costs with nidotherapy in this small study was £250,000

Schizophrenia Bulletin vol. 39 no. 1 pp. 17–21, 2013

Authors’ ConclusionsFurther research is needed into the possible benefits orharms of this newly-formulated therapy. Until suchresearch is available, patients, clinicians, managers, andpolicymakers should consider it an experimental therapy.‍Reference: Chamberlain I, Sampson S. Nidotherapy for people with

schizophrenia Cochrane Database of Systematic Reviews2012: CD009929. doi:10.1002/14651858.CD009929.

More information on nidotherapy

Visit www.nidotherapy.com for general information:

read about the development of nidotherapy in Sweden, Canada, Montenegro, Australia and Iran

And come to the next nidotherapy training workshop in February 2015 (give me your email details later)