Nidotherapy: a cost‐effective systematic environmental intervention
Authors: Peter Tyrer
Journal: World Psychiatry (2019)

The notion of nidotherapy is a familiar one in mental health, although the word itself may be unusual to many. The familiarity derives from the awareness that the environment is important in both helping and hindering recovery from mental illness. The added component of nidotherapy is that it describes the systematic and collaborative manipulation of the environment to carry out this task1. The word is derived from the Latin nidus, or nest, as a bird's nest is ideally placed to accommodate whatever object is placed within it. It also carries with it the connotations of comfort and homeliness, encapsulated in the German word gemütligkeit, which has no good equivalent in English. The practice of nidotherapy involves manoeuvring all aspects of the environment to make a better fit between the person and setting2. In this context all aspects of the environment – physical, social and personal – become relevant. This wide range is necessary as, to put it in its most literal sense, feeling at home in yourself encapsulates all three of these environments. The adjectives "systematic" and "collaborative" are highly relevant here as, although health professionals may think of, and often use, environmental changes in the course of helping people, they rarely do this in a coherent jointly planned way. Nidotherapy in a minor form is practised by all. We choose our occupations, our places to live, our sexual partners, and our leisure activities, and in so doing we are clearly manipulating our environment. These choices are too straightforward to be regarded as therapy, but for many with severe mental illness environmental options are much more limited, and in the most extreme examples are not obviously present at all. In professional nidotherapy practice, the environmental problems that are presented are not straightforward. They are best described as puzzles, as they represent a set of complex interacting problems that require close scrutiny and analysis before solution. Many of them come under the heading of desired but resisted environmental changes (DRECs) as opposed to other changes3. This is where the skills of nidotherapy come into play. When there is resistance to a feasible change that is wanted by both therapist and patient, this can be created by the patient, those close to the patient, the system in which the patient is placed, or by excessive concern over risk. The last of these is a very frequent block to change in those with severe mental illness, as the patient's wish for greater autonomy collides with concern about potential dangers. The practice of nidotherapy is relatively straightforward in principle, but can provoke challenges in practice. It has four components: the development of a therapeutic relationship, so allowing a good understanding of wishes and needs; environmental analysis involving physical, social and personal environments; the establishment of a plan for change (the nidopathway); and subsequent monitoring of the pathway2. The challenges include the difficulties of getting good relationships with people who feel they have been persistently let down, the logistical problems of effecting suitable change when others block it for manifold reasons, and the need for flexibility if the original environmental plan is thwarted. The collaborative element is very important. The role of the nidotherapist is to act as a guide for the patient, not a leader or director of change. The environmental decisions are made by the patient and owned accordingly. This is of particular relevance when problems arise in the nidopathway. If the patient is committed to make the change work, he/she is more likely to overcome difficulties that hinder implementation, as cognitive dissonance will then always err on the side of the planned nidopathway. Who should practise nidotherapy is an easier question to answer. In practice we have found that, although experienced practitioners may be needed to help in choosing the time of treatment and the changes needed, other professionals, especially those at the coalface of care, are better able to implement the changes. In this respect, carers are often ideally placed to ensure that changes are adhered to and motivation maintained2. One of the assets of nidotherapy is that coalface practitioners can be found in all countries and do not require additional financial investment, so one consequence is that nidotherapy is very cost-effective4. Many disorders can be treated by nidotherapy, and it can be described as a transdiagnostic treatment. In general, it is reasonable to consider nidotherapy when a problem is either not amenable to known evidence-based therapies (e.g., intellectual disability, most personality disorders)5-7 or has failed to respond to such treatments, for which the most evidence is in schizophrenia8. Most practitioners recognize that many chronic disorders persist because they are embedded in toxic situations. But, at this point, they all too frequently accept these situations as impossible to change, and indulge in what can be only called passive palliative therapy: "You have to accept the place you are in; we can support you as much as possible until things improve". This is not an acceptable answer if change is feasible, which is the case more often than not. Currently the evidence base for environmental interventions is fairly limited. This seems to be due to a paradoxical combination of complexity (there are so many possible environmental changes and their interactions that you cannot accommodate all of them), and simplicity (all environmental changes are straightforward and require no special skills). So, a wide-ranging group of environmental interventions in forensic mental health – from therapeutic communities, programmes to enable environments, and what has become known as social prescribing9 – have remained the province of qualitative research and only rarely have received formal evaluation. Social prescribing is the most recent of these, and is currently being promoted in some countries, including the National Health Service in England, as an aid to primary care. The idea is simple. Expensive health professionals with limited time to help with common problems, including prevention as well as treatment, can be assisted by others incurring lower costs in giving advice and support. In some areas social prescribing specialists have also been appointed. Nidotherapy is informed, systematic and sophisticated social prescribing. As such, it deserves a place in all mental health services.