Day 97 : Book Excerpt : Nidotherapy: Harmonising the Environment with the Patient

Nidotherapy (the ‘i’ is long) is a treatment born of despair and desperation. It has been used to date mainly for a group of people with chronic mental illness who have been in the long-term care of psychiatric services in the UK. In describing this population it is necessary to put it into context. Before 1970 mental healthcare was generally split into two groups: a large group of patients in mental hospitals (asylums; it reached a maximum of 150,000 in 1964) who had major mental illness (psychoses, dementias and learning (intellectual) disability), many of whom stayed for many years, and another, larger group who were often characterised unfairly as the ‘worried well’ – as they were neither particularly worried nor particularly well – who lived in the community and were not generally stigmatised as being mentally ill, possibly because the full nature of their troubles was rarely admitted overtly. Most active psychiatric care was given to the second group, many of whom were classified as having either depression or neurotic or stressrelated problems, and as much was given in public (National Health Service) as in private care. Of course treatment for the other group was also given, and there was some crossover between the two, but the treatment for the more severe psychoses was mainly pharmacological and given for those in psychiatric hospitals. Most of the new drug treatments had been introduced between 1950 and 1970 and for a time they were regarded with such high hopes that other treatments were lost in their shade (Sargant, 1966). Gradually, from about 1972 onwards, but only partly as a result of this new therapeutic optimism, the deinstitutionalisation of the mental hospital began, and those in the first hospital group (I will call it thus for short) were returned to the community in one form or another. Large institutions were regarded as bad and counter-therapeutic, and good community services, with a small institutional base linked to a clear geographical catchment area (Thornicroft & Tansella, 2004) were the new form of care for these patients. Oddly enough, the optimism behind this was so great that before long the term ‘recovery’ replaced ‘rehabilitation’ and ‘long-term care’ (see chapter 8) and the notion that no one with a mental illness should be regarded as immune from recovery became almost a politically correct mantra.

This pervasive optimism developed its own momentum. People were not allowed to rest under the label of any form of chronic mental illness. As Berrios has noted, a whole new vocabulary developed to fit this new attitude, which he summarised as psychiatric mercantilism:

In the ‘developed’ Western world, ‘treatment’ and ‘cure’ are embedded in ‘medical acts’ which are being increasingly re-defined as scientific and mercantile transactions (‘health’ has become a ‘commodity’, patients ‘clients’, clinicians ‘purveyors of health’). This new approach demands that the medical act be measured and priced and rendered economically efficient. Like the selling of faulty goods, ‘lack of response’ to treatment is increasingly being considered as a violation of a putative trade descriptions act. Courts need ‘operational criteria’ to decide on whether a breach of trust has occurred, and these are being provided by the so-called treatment guidelines which bodies of experts are increasingly compiling. Non-response to treatment can only be called ‘treatment-resistance’ if the guidelines have been complied with, and this lets the therapist off the hook. In social and legal terms, the notion of ‘treatment resistance’ can thus be used as an alibi as it transfers the responsibility for the lack of response from the therapist to the disease or the patient.

So with this philosophy of care it is very difficult to admit to failure. In both the USA and the UK assertive community or outreach teams were introduced to cope with those who had not responded to conventional care, now rebranded as evidence-based psychiatry, to acknowledge that most standard interventions had been tested and had showed evidence of effectiveness, preferably in randomised trials.

This was the rocky terrain in which nidotherapy was developed. In the teams where it was practised there was no new therapy, only an enthusiastic model of care that involved teams from different disciplines and good collaborative working. But this was not always enough, and when the key purpose behind the introduction of these teams, a saving in the use of psychiatric beds, was not achieved there was an urgent need to find something new. But when time after time each new therapy was thrown back as unacceptable or ineffective some radical changes in both approach and attitude were indicated.

~~Nidotherapy: Harmonising the Environment with the Patient -by- Peter Tyrer