NIDUS-UK
Additional Resources
Reading about nidotherapy
Anybody who picks up a newspaper or magazine today is likely to come across at least some mention of a change in environment to help mental health. Perhaps the most common comes under the heading of green care – the encouragement for people to explore the wildness of nature in all its aspects in order to commune with the elements and readjust your mental health. There are many other similar suggestions, taking part in new sporting activities, sailing and rowing, climbing and trekking, learning how to bake, horticulture and flower arranging. Together these activities are now viewed as ecotherapy. But the evidence that they are beneficial for long-term mental health disorders is not as strong as it looks, despite a great deal of tub-thumping (Chalquist, 2009; Alvarsson et al, 2010). Take for example, the results of a recent MIND study, not a formal paper but widely cited – ‘a nature walk reduced symptoms of depression in 71% of participants, compared to only 45% of those who took a walk through a shopping centre’. What does this tell us, and what relevance does it have to nidotherapy? It merely says that a nature walk is more immediately satisfying than a shopping centre one – it does not specify the shopping centre (some are much more enticing than others). It does not say how long the improvement lasts for or to what extent. If we extended this to nidotherapy we would first identify whether a regular nature walk was a top priority for the individual and, if it was, it could become a regular activity. This decision would probably be made by the individual concerned and would constitute self-nidotherapy. My father, at every weekend after lunch on Sunday said, ‘I think its time for our walk’; adding a comment to show he would not be put off by the weather, ‘the heavy rain is lessening and we can all wear boots’, the gale is no problem and we need a bit of fresh air’, ‘the snow is only two foot deep and you boys can make a snowman’. So we dutifully trooped out for our regular weekend exposure to the elements and our dose of mental satisfaction. The walk was as much a parental environmental priority to him as a home football match for a fanatical supporter.
But this form of nidotherapy is not worthy of separate description; we make environmental decisions like this every day. We choose the places we want to visit, we join with people we like, and the activities we enjoy. Formal nidotherapy is needed when we are in a tizzy about the many environments we have been placed in or chosen, and do not know which to change and how. In so many with chronic mental illness the choice is even more difficult. A myriad of emotions, thoughts and impulses also battle for attention and often the environmental changes that may help are forgotten in the wake.
Diluted forms of nidotherapy
Nidotherapy requires the person receiving treatment to be the instigator, or at least the full approver, of the environmental change or changes that are being considered. It therefore differs greatly from the paternalistic approaches of the past - ‘doctor knows best and says you should leave town and spend three months in the country’ - and even including recommendations for prolonged bed rest that were commonplace after heart attacks (a practice now realised to have no value). Ecotherapy is dilute nidotherapy. It is offered to people as a general panacea but not necessarily selected by the patient. Diluted nidotherapy can be represented as a shop where only a few items are on sale. Some may be wanted but many others regarded as unhelpful or even derided. Social prescribing is such an option. A person who has become stuck in medical or mental health care can now be referred to a link worker for social prescribing; in effect, being offered a range of environmental activities that are feasible in that area. But this is diluted nidotherapy as the activities are not priority ones chosen by the patients; they are selected from a menu of options chosen by the social prescriber (Tyrer & Boardman, 2020). They may be ones that are considered important by the patient but most will not be linked to the primary environmental changes that are central to nidotherapy.
Those who are interested in knowing more about nidotherapy will find relatively little outside the main books on the subject (Tyrer, 2009; Tyrer & Tyrer, 2018, and their translations into Swedish and German) and in articles in many journals, including Acta Psychiatrica Scandinavica (Tyrer, 2002), Psychotherapy and Psychosomatics (Tyrer et al, 2003), Epidemiology and Psychiatric Sciences (orginally in its Italian name)(Ranger et al, 2009), Advances in Psychiatric Treatment (Tyrer & Bajaj, 2005), Journal of Intellectual Disability Research (Tyrer et al, 2017), World Psychiatry (Tyrer, 2019), International Journal of Social Psychiatry (Spencer et al, 2010), Lancet Psychiatry (Tyrer &Boardman, 2020) and the International Journal of Environmental and Public Health (Tyrer, 2018).
It takes very little thought to realise that a set of papers with one author dominating is not an ideal way to assess the value of nidotherapy independently. A product champion always tends to oversell. But some of the important papers, or sections from them, are added below. I also attach a set of comments, some positive, some neutral and some mildly critical, from others who have written about nidotherapy in the last twenty years.
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‘Nidotherapy is based on overt trust and optimism, which are freely shared with the patient. It is perhaps the ultimate personalized medicine, because its primary therapeutic strategy is the full appreciation of the patient as a unique person in his or her own environment’ (Pallanti, S. American Journal of Psychiatry, 2010).
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Alvarsson, J. J., Wiens, S., & Nilsson, M. (2010). Stress recovery during exposure to nature sound and environmental noise. International Journal of Environmental Research and Public Health, 7(3), 1036-1046.
Chalquist, C. (2009). A look at the ecotherapy research evidence. Ecopsychology, 1(2), 64-74.
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But this form of nidotherapy is not worthy of separate description; we make environmental decisions like this every day. We choose the places we want to visit, we join with people we like, and the activities we enjoy. Formal nidotherapy is needed when we are in a tizzy about the many environments we have been placed in or chosen, and do not know which to change and how. In so many with chronic mental illness the choice is even more difficult. A myriad of emotions, thoughts and impulses also battle for attention and often the environmental changes that may help are forgotten in the wake.