{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T00:38:33Z","timestamp":1774312713804,"version":"3.50.1"},"reference-count":45,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2018,5,13]],"date-time":"2018-05-13T00:00:00Z","timestamp":1526169600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Much has been done in the last 50 years to achieve a better understanding of the psychosocial causes and other factors influencing the manifestation of mental illness, but there has been a conspicuous omission. Although gross environmental deficiencies were exposed in old mental institutions, 70 years ago the more subtle maladaptive settings that reinforce chronicity in mental illness have often been forgotten. In this review, the potential of systematic environmental manipulation as a treatment (nidotherapy) and other similar forms of management, used many times in the past but now mainly in forensic settings, is examined. There is now accumulating evidence, reinforced by controlled trials, that planned environmental change, preferably carried out with the full cooperation of the patient, can be a major contributor to therapeutic benefit. It is also very cost-effective. All forms of the environment, physical, social and personal, can be addressed in making assessments, and once a planned way forward has been chosen, progress can be monitored by personnel with limited mental health experience. These interventions have applications in general mental health and occupational health services and deserve much wider use.<\/jats:p>","DOI":"10.3390\/ijerph15050972","type":"journal-article","created":{"date-parts":[[2018,5,14]],"date-time":"2018-05-14T02:57:20Z","timestamp":1526266640000},"page":"972","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["The Importance of Nidotherapy and Environmental Change in the Management of People with Complex Mental Disorders"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0358-1459","authenticated-orcid":false,"given":"Peter","family":"Tyrer","sequence":"first","affiliation":[{"name":"Centre for Psychiatry, Imperial College, London W12 0NN, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2018,5,13]]},"reference":[{"key":"ref_1","unstructured":"Goffman, E. (1961). Asylums, Doubleday."},{"key":"ref_2","first-page":"377","article-title":"The need for residential care of the mentally handicapped","volume":"9","author":"Kushlick","year":"1975","journal-title":"Br. J. Psychiatry"},{"key":"ref_3","first-page":"70","article-title":"Psychiatry in the Thirties","volume":"226","author":"Slater","year":"1975","journal-title":"Contemp. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1108\/TC-02-2017-0007","article-title":"Milieu approaches and other adaptations of therapeutic community method: Past and future","volume":"38","author":"Pearce","year":"2017","journal-title":"Ther. Communities"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1111\/j.1939-0025.1971.tb01129.x","article-title":"Milieu characteristics of successful psychiatric treatment programs","volume":"41","author":"Ellsworth","year":"1971","journal-title":"Am. J. Orthopsychiatry"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"959","DOI":"10.1192\/bjp.113.502.959","article-title":"The clinical effects on a population of chronic schizophrenic patients of administrative changes in hospital","volume":"113","author":"Letemendia","year":"1967","journal-title":"Br. J. Psychiatry"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1097\/00005053-197610000-00004","article-title":"A comparative evaluation of two day hospitals. Goal attainment scaling of behavior therapy vs. milieu therapy","volume":"163","author":"Austin","year":"1976","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_8","first-page":"349","article-title":"Why are the results of milieu therapy for schizophrenic patients contradictory? An analysis based on four empirical studies","volume":"58","author":"Vaglum","year":"1985","journal-title":"Yale J. Biol. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"137","DOI":"10.3109\/00952997909007040","article-title":"Therapeutic communities, old and new","volume":"6","author":"Jones","year":"1979","journal-title":"Am. J. Drug Alcohol Abuse"},{"key":"ref_10","unstructured":"Rapoport, R. (1960). Community as Doctor, Tavistock."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1192\/pb.26.2.65","article-title":"Therapeutic community research: Past, present and future","volume":"2","author":"Haigh","year":"2002","journal-title":"Psychiatr. Bull."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1097\/00131746-200307000-00004","article-title":"The value of therapeutic communities in the treatment of personality disorder: A suitable place for treatment?","volume":"9","author":"Rutter","year":"2003","journal-title":"J. Psychiatr. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1002\/pmh.1293","article-title":"The lessons and legacy of the programme for dangerous and severe personality disorders","volume":"9","author":"Tyrer","year":"2015","journal-title":"Personal. Ment. Health"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1192\/bjp.bp.116.184366","article-title":"Democratic therapeutic community treatment for personality disorder: Randomised controlled trial","volume":"210","author":"Pearce","year":"2017","journal-title":"Br. J. Psychiatry"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1002\/cbm.2200120607","article-title":"Managing the unmanageable: Psychotherapy in Grendon Prison","volume":"12","author":"Morris","year":"2002","journal-title":"Crim. Behav. Ment. Health"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1108\/IJPH-08-2016-0036","article-title":"The potential of prison-based democratic therapeutic communities","volume":"13","author":"Bennett","year":"2017","journal-title":"Int. J. Prison. Health"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1002\/cbm.1835","article-title":"A joint offender personality disorder strategy","volume":"22","author":"Joseph","year":"2012","journal-title":"Crim. Behav. Ment. Health"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1080\/02668734.2014.940253","article-title":"Psychologically informed planned environments (PIPE): A group analytic perspective","volume":"28","author":"Brown","year":"2014","journal-title":"Psychoanal Psychother."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1108\/14608791211238412","article-title":"Psychologically informed environments and the \u201cEnabling Environments\u201d initiative","volume":"15","author":"Haigh","year":"2012","journal-title":"Hous. Care Supp."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1159\/000073032","article-title":"The principles of nidotherapy in the treatment of persistent mental and personality disorders","volume":"72","author":"Tyrer","year":"2003","journal-title":"Psychother. Psychosom."},{"key":"ref_21","unstructured":"Tyrer, P. (2009). Nidotherapy: Harmonising the Environment with the Patient, RCPsych Press."},{"key":"ref_22","first-page":"27","article-title":"Managing mood disorders and comorbid personality disorders","volume":"18","author":"Bajaj","year":"2005","journal-title":"Curr. Opin. Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1177\/0020764004040959","article-title":"The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings","volume":"50","author":"McCabe","year":"2004","journal-title":"Int. J. Soc. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"566","DOI":"10.1093\/occmed\/kqu113","article-title":"Personality disorders in the workplace","volume":"64","author":"Tyrer","year":"2014","journal-title":"Occup. Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Quick, J.C., and Henderson, D.F. (2016). Occupational stress: Preventing suffering, enhancing well-being. Int. J. Environ. Res. Public Health, 13.","DOI":"10.3390\/ijerph13050459"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1192\/bjp.bp.110.083733","article-title":"Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis","volume":"199","author":"Leamy","year":"2011","journal-title":"Br. J. Psychiatry"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1111\/j.1468-3148.2011.00666.x","article-title":"Person-centred active support\u2014Increasing choice, promoting independence and reducing challenging behaviour","volume":"25","author":"Hutchinson","year":"2012","journal-title":"J. Appl. Res. Intellect. Disabil."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1002\/pmh.1370","article-title":"Nidotherapy in the successful management of comorbid depressive and personality disorder","volume":"11","author":"Spears","year":"2017","journal-title":"Personal. Ment. Health"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1016\/j.biopsych.2013.09.006","article-title":"Gene \u00d7 environment interaction studies have not properly controlled for potential confounders: The problem and the (simple) solution","volume":"75","author":"Keller","year":"2014","journal-title":"Biol. Psychiatry"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1001\/jamapsychiatry.2013.4166","article-title":"Peer deviance, parental divorce, and genetic risk in the prediction of drug abuse in a nationwide Swedish sample: Evidence of environment-environment and gene-environment interaction","volume":"71","author":"Kendler","year":"2014","journal-title":"JAMA Psychiatry"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1002\/gepi.21910","article-title":"Computing a synthetic chronic psychosocial stress measurement in multiple datasets and its application in the replication of G \u00d7 E interactions of the EBF1 Gene","volume":"39","author":"Singh","year":"2015","journal-title":"Genet. Epidemiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1136\/bmj.321.7262.694","article-title":"A framework for the design and evaluation of complex interventions to improve health","volume":"321","author":"Campbell","year":"2000","journal-title":"BMJ"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1065","DOI":"10.1176\/ajp.153.8.1065","article-title":"Day hospital\/crisis respite care versus inpatient care, Part I: Clinical outcomes","volume":"153","author":"Sledge","year":"1996","journal-title":"Am. J. Psychiatry"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Bitter, N., Roeg, D., van Assen, M., van Nieuwenhuizen, C., and van Weeghel, J. (2017). How effective is the comprehensive approach to rehabilitation (CARe) methodology? A cluster randomized controlled trial. BMC Psychiatry, 17.","DOI":"10.1186\/s12888-017-1565-y"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1177\/0020764008095934","article-title":"Integration of nidotherapy into the management of mental illness and antisocial personality: A qualitative study","volume":"56","author":"Spencer","year":"2010","journal-title":"Int. J. Soc. Psychiatry"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1017\/S1121189X00001019","article-title":"Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: Randomized controlled trial","volume":"18","author":"Ranger","year":"2009","journal-title":"Epidemiol. Psichiatr. Soc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1111\/jir.12360","article-title":"Nidotherapy compared with enhanced care programme approach training for adults with aggressive challenging behaviour and intellectual disability (NIDABID): Cluster-randomised controlled trial","volume":"61","author":"Tyrer","year":"2017","journal-title":"J. Intellect. Disabil. Res."},{"key":"ref_38","first-page":"9","article-title":"Nidotherapy in the treatment of substance misuse, psychosis and personality disorder: Secondary analysis of a controlled trial","volume":"35","author":"Tyrer","year":"2011","journal-title":"Psychiatr. Bull."},{"key":"ref_39","unstructured":"Kelling, G., and Coles, C. (1998). Fixing Broken Windows: Restoring Order and Reducing Crime in Our Communities, Touchstone."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1177\/0004867414565477","article-title":"Mental health facility design: The case for person-centred care","volume":"49","author":"Golembiewski","year":"2015","journal-title":"Aust. N. Z. J. Psychiatry"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1177\/0004867415598845","article-title":"Nidotherapy: The expansion of environmental treatment","volume":"49","author":"Tyrer","year":"2015","journal-title":"Aust. N. Z. J. Psychiatry"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1016\/S2215-0366(15)00279-5","article-title":"Growing Better Lives: Peace, quiet and yurts","volume":"2","author":"Langford","year":"2015","journal-title":"Lancet Psychiatry"},{"key":"ref_43","unstructured":"Eliot, T.S. (1915). The Love Song of J. Alfred Prufrock, Poetry Society."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1111\/hsc.12269","article-title":"Understanding readmission to psychiatric hospital in Australia from the service users\u2019 perspective: A qualitative study","volume":"25","author":"Duhig","year":"2017","journal-title":"Health Soc. Care Community"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/j.socscimed.2018.01.032","article-title":"A systematic review of the methodological and practical challenges of undertaking randomised-controlled trials with cognitive disability populations","volume":"200","author":"Mulhall","year":"2018","journal-title":"Soc. Sci. Med."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/15\/5\/972\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T15:04:04Z","timestamp":1760195044000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/15\/5\/972"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,5,13]]},"references-count":45,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2018,5]]}},"alternative-id":["ijerph15050972"],"URL":"https:\/\/doi.org\/10.3390\/ijerph15050972","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,5,13]]}}}