why nidotherapy is worth considering for autistic spectrum disorder … · 2016-11-18 · all...
TRANSCRIPT
Why nidotherapy is worth considering for autistic spectrum
disorder and intellectual disability ?
Peter Tyrer, Imperial College
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 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 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 10. Mutual collaboration is required to change environments for the better
Copyright ©2000 BMJ Publishing Group Ltd.
Campbell, M. et al. BMJ 2000;321:694-696
Framework for evaluation of complex interventions
Phase 0 constitutes the principles of nidotherapy, we have some way to go before the end
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
What factors come into the choice of 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?
Our provisional ordering of diagnostic suitability for nidotherapy
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
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 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
True acceptance
• We do not normally ‘get inside the head’ of patients to find out what they really want in life. In nidotherapy we do this by (i) seeing people in their own environments, not artificial ones that suit the therapist only, (ii) liking them for what they are, not what you would want them to be, (iii) harnessing your own skills as a therapist to help to articulate those who are often inarticulate.
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
Genuine partnership
• By getting a good understanding of what patients want and need you are able to work out with them what environmental changes are needed
• This involves environment in all its forms
• It may even extend to the taking of medication (as this can influence the personal and social environment markedly)
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
Does it work?
• Yes, for people whom have failed with every other treatment
• For example, take the combination of chronic psychotic and personality disorder
• This analysis (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
Mean change in bed usage at baseline and one year after randomisation
Vertical bars denote 0.95 confidence intervals
control (n=21)
nidotherapy (n=26) baseline one year
0
20
40
60
80
100
Results of main trial of all patients (52 randomised)
P=0.07
And this has cost implications
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
Why nidotherapy for intellectual developmental disorder and autism?
• Because these conditons are egosyntonic and need adaptation, not change
• In such circumstances it is wise to attempt to alter the circumstances to try and minimise the problems it creates for the outside world as well as for the individual, rather than change the person.
How nidotherapy might prevent aggressive challenging behaviour
• In people with intellectual disability this behaviour has lots of causes – frustration, depression, need for attention, inability to express a range of needs in any other way, personality problems, basic physiological needs (eating, drinking , sex)
• Nidotherapy helps to identify these and provide solutions
NIDABID project (Nidotherapy for aggressive behaviour in intellectual
disability)
• Cluster randomised controlled trial
• Participants: 20 care homes for people with ID (totalling 120 residents)
• Treatments: (i) Enhanced care programme approach, (ii) nidotherapy
Procedure
• Randomisation of care homes by independent statistician (Dr Obi Ukoumunne, Peninsula Medical School, Exeter)
• 4 visits by either (i) CPA trainer (Group 1), (ii) nidotherapist (Group 2) over course of 4-6 months with purpose of training staff
• Independent blind assessments of each resident at monthly intervals at each care home over 9 months
Study timetable
• December 2010 – randomisation
• December 2010 – June 2011 (training of staff in the two treatment approaches)
• Follow-up of residents at monthly intervals (November 2010 – February 2012)
• Assessments of violent episodes (Quantification of Violence Scale), Modified Overt Aggession Scale (MOAS), new Problem Behaviour Check-List (27 items), costs of care
Behaviour absent Minor and often
frequent behaviour
but little disruption to
others
Moderate problem
behaviour creating
distress and disruption
Serious problem
behaviour leading to major
concerns and risk to others
Extreme behaviour leading to
threat of loss of life or
permanent injury and damage
0 1 2 3 4
Personal Violence
Score (0-4):
No verbal abuse and no
form of violent
behaviour
Verbal abuse Threatened violence or
minor assault with no
lasting injury or breaking
of skin
(e.g. slapping, pushing)
Physical assault with likelihood
of, or consequent, injury with
temporary handicap or
psychological damage (e.g.
bruising, fear avoidance)
Physical assault with permanent
or life-threatening injury (e.g.
poking through eyes, stabbing,
loss of consciousness)
Property Violence
Score (0-4):
No damage Minor damage with no
serious consequences
(e.g. tearing paper)
Moderate damage with
need for minor repairs
(e.g. breaking front
window)
Serious damage requiring major
property repairs or creating
some risk to others
Very serious damage with
threat to life or limb (e.g. arson,
floor
collapse)
Self-Harm
Score (0-4):
No self-harm Minor harm with no
breaking of skin (e.g.
minor head banging)
Moderate self-harm with
breaking of skin,
scarring or small
overdose but no long
term
Serious self-Harm with potential
of risk of death
(e.g. swallowing bleach, poking
own eyes)
Suicidal act or violent self-harm
leading to death or permanent
handicap
Problem Behaviour Check List Patient Code/Identifier: ________________ Date: _________________ Assessor: ______________
Initial results
• Preliminary findings shows differences between the two treatment methods
Analysis of quantification of violence scores in nidotherapy and care
programme groups
F(9, 189) =3.55, p=.00043
Vertical bars denote 0.95 confidence intervals
nidotherapy (n=10)
CPA (n=10)
baselinemonth 1
month 2month 3
month 4month 5
month 6month 7
month 8month 9
TIME
-10
-5
0
5
10
15
20
25
30
35
40
Me
an
QO
V s
core
s
Preliminary analysis of data from NIDABID study (scores for each care home summed)
Problems in project • Some care homes very good at understanding the
principles of nidotherapy and already implementing the principles, but others disinterested and difficult to motivate
• Often a negative therapeutic attitude along the lines of ‘nothing for these people will ever change’
• Decision made to show the residents’ potential by making a film of a play
New developments
• Nidotherapy for autistic spectrum disorders is going down very well in Sweden:
Nidohandledarutbildning - course program (11th-13th June, 2012, Stockholm) And my colleagues there have asked me to pomote their book:
The ultimate guide for care givers - Adults with Autism Spectrum Disorders By Anna Sjölund & Susanne Bejerot Illustrations: Ossian Humble Translated from the original Swedish by Amanda Hicks
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