Allen J Frances M.D.

Saving Normal

What to Do When Treatment Doesn't Work

Enviromental changes can make it much easier to live with illness

Posted Jul 29, 2016

At the very dawn of modern medicine, 2,500 years ago, Hippocrates made his most important and robust finding: 1/3 of patients get better without treatment; 1/3 don't get better even with treatment; and only 1/3 actually benefit from treatment.

The ratios do vary depending on the type of disease, it's severity and chronicity, and the power and specificity of the available treatments. Whenever a disease is chronic and/or severe, spontaneous recovery is less likely, treatment will more likely be needed, and full response to treatment is less likely. But on average, Hippocrates' "rule of thirds" stands up remarkably well to systematic study and has been medical lore for hundreds of generations of doctors.

One of my early papers (written more than 35 years ago and titled, "No Treatment As A Prescription of Choice") reflected Hippocrates' caution that mindlessly piling on treatments often benefits little and instead can add a substantial burden of side effects to the patient's already heavy burden of illness. 

Unfortunately, Hippocratic humility has increasingly been replaced by the hubris of modern medicine. Many clinicians hold the unconscious and unwarranted assumption that there is a cure for every illness and recklessly add on new treatments whenever previous ones have failed.

Careless polypharmacy prevails throughout medicine and is particularly prevalent and dangerous in the elderly. Doctors rarely follow the Hippocratic dictum to "First do no harm."

Peter Tyrer is the former editor of the British Journal of Psychiatry and a leader in the development of the UK's NICE psychiatric treatment guidelines. He will describe his effort to restore Hippocratic humility and common sense to psychiatric practice.

Professor Tyrer writes: "We are prone to trumpet our advances in medicine and slow to acknowledge where we have made little progress."

Treatment of mental illness started from an almost non-existent base 200 years ago and perhaps it is not surprising that we still have so much left to learn.

If we take the whole range of mental illness, from common disorders such as anxiety and depression, to severe disorders such as schizophrenia, and the hinterland of other conditions, such as personality disorder and intellectual disability, then approximately 50% of all patients with mental illness either have no satisfactory treatments available or often fail to respond to existing ones that may help others.

What do we normally do about this in psychiatry?  We use terms like treatment-resistance and treatment-refractory, but this is merely an admission of our failure to have a solution.

The problem is that, in our therapeutically enthusiastic age, we do not admit failure as readily as we should. We persist in treatment, usually by giving whatever has failed previously in more dosage or by adding new treatments that have little chance of success, but a high risk of side effects.

The sad conclusion, still denied by some, is that in the most severe mental illnesses, such as schizophrenia and the autistic group of disorders, we have made no real advances in treatment efficacy for 50 years.

What I call "nidotherapy" is a way of adapting optimally to this impasse. The term is derived from ‘nidus’ (the Latin name for nest). The idea is to undertake a  collaborative and systematic manipulation of the person's environment to make for a better fit to minimize the negative impact of untreatable mental illness on both the individual and others.

Patients with persistent mental illness take to this intervention well and usually love the idea. When asked if they would rather have more treatment or change aspects of their physical, social and personal environment, they almost always embrace the latter option with enthusiasm. 

As therapists we often fail to realize how important the environment is in both maintaining and reinforcing mental illness. When it is altered in mutual collaboration with a therapist, there are often dramatic changes. General social functioning and mental symptoms often improve, and treatments that never worked before now seem to provide benefit. Clinical trials have also shown nidotherapy to be remarkably cost-effective.

Many environmental changes can be effected at low cost and may replace much more costly health interventions. 

So how is this treatment given, and can it be mastered easily? In brief, it can, but some people are natural nidotherapists and others, no matter how much training they receive, are hopeless. There are four components: person understanding, environmental analysis, preparation of the nidopathway (the plan for environmental change), and, finally, the monitoring and adjustment phase.

The first is often the most difficult. One of the essentials of nidotherapy is genuine collaboration ending with a joint plan that is supported equally by therapist and patient. This cannot be done without a really good understanding of the patient and their problems, achieved by exploring how they arose, getting a feel of personality features, probing hidden corners of difficulty often unexpressed, and allowing a free and open discussion of hopes, aims and goals.

Environmental analysis takes over at this point, and looks at all the factors in the physical, social and personal that may be preventing life satisfaction, and the changes that might be possible to change these for the better.

Once this has been done, the planned program for environmental change (the nidopathway) is prepared with an appropriate timetable. This has to be both realistic and feasible. Often the nidotherapist is needed to be an advocate at this point. Many people with persistent mental illness are not very good at putting their points of view forward, and because they are faced with a wall of opposition from professionals, often retreat into passive discontent. But their views about environmental change may well be right, and if they are supported in nidotherapy by appropriate advocacy the opposition can be overcome.

The final phase involves review and monitoring of the pathway. Often adjustments need to be made to the original plan, and sometimes it may be changed radically, but always the changes need to be owned by the patient.

It will not escape the reader that this whole process can be carried out by people themselves or by their friends and relatives. Some input from health professionals is needed for guidance, but not too much except in those with more severe mental disorders. So the option of widespread adoption of this treatment is possible, and this could include whole populations.

If you wish to know more about this exciting treatment please look at the website www.nidotherapy.com.  There is now greater interest in this development, and it is being thought of in dementia, added to the management of personality disorder, and also in autism and intellectual difficulty. It may sound corny to say that it offers hope to so many who feel in despair, but it does."

Thanks, Peter. Hippocrates also said: "It is more important to know the patient who has the disease than the disease the patient has." True even more today than when first proclaimed 2500 years ago. Knowing the patient means also knowing how he interacts with his family and within his social context.

Sad to say, common sense is too often one of the first casualties of medical training. The focus on learning the details of complex technical interventions distracts from responding to the obvious, understanding the personal, and finding simple practical solutions.

A patient's psychiatric symptoms often provoke vicious cycles reverberating in his relations with others—social rejection and symptom exacerbation interacting and amplifying one another. We can't always effect significant reduction of the patient's symptoms—but we usually can, by altering the environment, substitute virtuous for vicious cycles. Relationships are often much more flexible and amenable to change than are people.

Thanks again, Peter, for reminding us that giving up on curing the illness doesn't mean giving up on helping the patient.

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