My first successful patient
Nidotherapy: why lagom is not
enough
Peter Tyrer, Imperial College, London
• Man aged 35, worked at agricultural research
institute. Depressed for 2 years. Seen in outpatient clinic. Had not received any previous
treatment. Fully asessed 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..........................................................
Stockholm 29 May 2013
Stockholm 29 May 2013
Man 35 år, arbetat vid institutet för jordbruksforskning. Nedtryckt
under två år. Sett på poliklinik. Hade inte fått någon tidigare
behandling. Fullt bedömas och när han hade klassiska depressiva
symtom lades på amitriptylin 50 mg stiger till 100 mg dagligen.
Inget svar efter fyra veckor, ökade till 150 mg dagligen visade
dramatisk förbättring efter ytterligare fyra veckors behandling.
Jag avslutade han hade svarat på min behandling
Expressed wish
to change her life
men
Moved to
new address
Stockholm 29 May 2013
Stockholm 29 May 2013
What made the difference in these
two cases
• It was not the excellence of the therapy
• It was not the excellence of the therapist
• It was not the excellence of the assessment
Det var patienten antingen besluta
att behandlingen inte var tillräckligt
och miljön behövde ändras, eller en
positiv miljömässig förändring bara
hände av en slump
• It was the patient either deciding that treatment
was not enough and the environment needed to
be changed, or a positive environmental change
just happened by chance
Stockholm 29 May 2013
Stockholm 29 May 2013
Origin of nidotherapy
Definition
• 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.
• 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)
• 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
Stockholm 29 May 2013
Stockholm 29 May 2013
10 principles of nidotherapy
Reverse Darwinism
•
1. All people have the capacity to improve their lives when placed in the right environment
2. Everyone should have the chance to test themselves in environments of their own
choosing
3. When people become distressed without apparent reason the cause can often be found
in the immediate environment
• Darwinism – everyone fights to get their place
in natural environments and the most adapted
win, the rest fall by the wayside and perish
4. A person's environment includes not only place but also other people and self
5. Seeing the world through another's eyes gives a better perspective than your eyes alone
6. What someone else thinks is the best environment for a person isn't necessarily so
7. All people, no matter how handicapped, have strengths that can be fostered
8. A person’s environment should never be regarded as impossible to change
•
9. Every environmental change involves some risk but this is not a reason to avoid it
• Nidotherapy - we create a highly specific,
often artificial, environment in which those
unadapted for natural environments can
thrive and prosper
10. Mutual collaboration is required to change environments for the better
Stockholm 29 May 2013
Stockholm 29 May 2013
In which conditions is nidotherapy
likely to be helpful?
Our provisional ordering of diagnostic
suitability for nidotherapy
• 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
Stockholm 29 May 2013
Intellectual disability
Autistic spectrum disorder
Personality disorder
Dementia
Depression (chronic)
Cocaine dependence
Alcohol dependence
Schizophrenia
Attention deficit hyperactivity disorder
Obsessive compulsive disorder
Phobias
Post-traumatic stress disorder
Anorexia nervosa
Panic disorder
Bipolar disorder
Stockholm 29 May 2013
Why this order of preference?
Framework for evaluation of complex interventions
• 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 treatmentseeking personality disorders: Type R and Type S.
Journal of Personality Disorders, 17, 265-270
Nidotherapy is here
Campbell, M. et al. BMJ 2000;321:694-696
Stockholm 29 May 2013
Stockholm 29 May 2013
Copyright ©2000 BMJ Publishing Group Ltd.
Case study to illustrate nidotherapy
•
•
•
Mr K was 29 when we first saw him. He was frequently in contact with services
and was said to have paranoid schizophrenia. He had no friends and was
apparently unemployable, as everywhere he had worked he had become
involved in heated arguments with fellow workers, was said to be ‘paranoid
and super-sensitive’ and dismissed. When assessed in more detail he was felt
to have Asperger’s syndrome, as he had rigid ideas about how people should
behave, had high standards and was critical of those others if they did not
match his own, and disliked very much indeed people monitoring and
interfering with his tasks when he felt confident he was doing them well.
After a full environmental analysis it was decided that his ideal environment
was one in which (i) he had as little contact with other people as possible, (ii)
he had occupational tasks that involved diligence and vigilance as the main
performance targets, and (iii) the amount of change in his life should be kept
to a minimum.
Mr K var 29 när vi först såg honom. Han var ofta i kontakt med tjänsterna och
sades ha paranoid schizofreni. Han hade inga vänner och var tydligen oanställbar,
som överallt hade han jobbat hade han blivit inblandad i heta diskussioner med
arbetskamrater, sades vara "paranoid och super-känsliga" och ogillas. När
bedömas närmare han ansågs ha Aspergers syndrom, eftersom han hade stela
idéer om hur folk ska bete sig, hade hög standard och var kritisk mot de andra om
de inte matchar hans eget, och ogillade väldigt mycket folk övervakning och
störande med sina arbetsuppgifter när han kände sig säker på att han gjorde dem
väl.
Efter en fullständig miljöanalys beslöts att hans ideal miljö var en där (i) han hade
så lite kontakt med andra människor som möjligt, (ii) att han hade
arbetsrelaterade uppgifter som involverade flit och vaksamhet som de
huvudsakliga målen, och (iii) mängden av förändring i sitt liv bör hållas till ett
minimum.
Vad hände?
What happened?
Stockholm 29 May 2013
Stockholm 29 May 2013
Outcome
• After a great deal of discussion and advice we enabled
him to get a job as a night security guard in a large car
park. He continues to live in a self-contained flat close by
and has worked at the same post for seven years
Efter en hel del diskussion och rådgivning vi det
möjligt för honom att få ett jobb som en natt
säkerhetsvakt i en stor parkeringsplats. Han fortsätter
att leva i en fristående lägenhet i närheten och har
arbetat på samma post i sju år.
• He no longer has any contact with psychiatric services
Han har inte längre någon kontakt med psykiatrin
• We are only worried now as he may be promoted to a
day job involving more contact with people!
Vi är bara orolig nu när han kan befordras till en dag
jobb som innebär mer kontakt med människor!
Stockholm 29 May 2013
Stockholm 29 May 2013
What made the difference?
• We did not try to treat him for any mental illness
Vi försökte inte att behandla honom för någon
psykisk sjukdom
• We listened to him and understood exactly what
were his likes and dislikes
Vi lyssnade på honom och förstod exakt vad
var hans sympatier och antipatier
• He respected us more more for making this effort
Han respekterade oss mer mer för att göra
denna insats
• He helped in finding a solution – it was not
imposed
Stockholm 29 May 2013
Han hjälpte till att hitta en lösning - det var
inte införs
Stockholm 29 May 2013
Phase 1 – the components of
nidotherapy
• Selection of patients
• Form of treatment (individual, group, staff)
• Components of treatment
Environmental analysis
Creating a nidopathway
Setting timetables
Monitoring and modifying the nidopathway
• Selection of therapists (usually a secondary issue)
Selection of patients
• Nidotherapy is not a treatment of the person; it is
a treatment of the environment. So the first task
in nidotherapy is to judge whether it is the
patient or the environment that needs to be the
main priority
• In autistic spectrum disorder we think the most
important requirement is to have a stable
physical environment at the time it is introduced
Stockholm 29 May 2013
Stockholm 29 May 2013
What factors come into the choice
of nidotherapy?
Environmental analysis
• 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?
Stockholm 29 May 2013
• 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
Stockholm 29 May 2013
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 person
3. It involves genuine partnership and involves the
messenger as much as the message
4. It comprises environmental judgement and advocacy
5. It dissolves boundaries between people
Dessa understryka försök att göra miljöförändringar så
systematiskt som möjligt:
1. Inga påtryckningar att ändra personen (för att behandla
behandlingsbart)
2. Det förändrar miljön, inte personen
3. Det handlar om verkligt partnerskap och innebär
budbäraren så mycket som meddelandet
4. Det består miljödom och opinionsbildning
Fem. Det löser gränser mellan människor
Stockholm 29 May 2013
Stockholm 29 May 2013
Environmental change only
Environmental advocacy
• 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
Stockholm 29 May 2013
• 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
Stockholm 29 May 2013
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
Stockholm 29 May 2013
Stockholm 29 May 2013
Best evidence of nidotherapy being
successful
Framework for evaluation of complex interventions
• In those with the triple diagnosis of
personality disorder, substance dependence
and psychosis
Nidotherapy is here
• No other ‘treatment’ has been shown to be of
real value here
Campbell, M. et al. BMJ 2000;321:694-696
Stockholm 29 May 2013
Stockholm 29 May 2013
Copyright ©2000 BMJ Publishing Group Ltd.
Inpatient stays and total cost of services used over 12 months follow-up
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
Inpatient stays (nights)
(n=15)
Mean
SD
Mean
SD
54
75
139
135
difference (95% CI)
15,173
15,786
31,105
27,290
14,990
27,871
26,986
-16,932
3,159
1,628
2,065
1,256
1,094
1,076
1,704
1,170
875
-94
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
181
787
2
7
179
18,963
19,010
33,668
27,022
Hospital costs (£)
p-value
-85
10,938
Health care (£)
-15,932
Community health
services (£)
Medication (£)
Criminal Justice (£)
(-30,791 to
Total costs (£)
Stockholm 29 May 2013
Control group
(n=19)
Mean
Social and voluntary services (£)
• Our main outcome in this trial was in-patient
bed use
Nidotherapy group
-14,705 1,380)
0.072
Stockholm 29 May 2013
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’ Conclusions
Further research is needed into the possible benefits or
harms of this newly-formulated therapy. Until such
research is available, patients, clinicians, managers, and
policymakers should consider it an experimental therapy.
Reference:
Chamberlain I, Sampson S. Nidotherapy for people with
schizophrenia
Cochrane Database of Systematic Reviews
2012: CD009929. doi:10.1002/14651858.CD009929.
Stockholm 29 May 2013
Stockholm 29 May 2013
Schizophrenia Bulletin vol. 39 no. 1
pp. 17–21, 2013
• Författarnas slutsatser
Ytterligare forskning behövs i de eventuella fördelar
eller
skador av detta nyligen formulerat terapi. tills en sådan
forskning finns, patienter, läkare, chefer, och
beslutsfattare bör överväga det en experimentell
behandling.
referens:
Chamberlain I, Sampson S. Nidotherapy för personer
med schizofreni
Cochrane Database of Systematic Reviews
2012: CD009929. doi: 10.1002/14651858.CD009929.
Stockholm 29 May 2013
More information on nidotherapy
Visit www.nidotherapy.com for general information:
And click on Media to see a BBC film (40 mins) of
someone with a complex diagnosis of personality
disorder, autistic spectrum and obsessive-compulsive
features in treatment with nidotherapy
ve
Stockholm 29 May 2013