Abstract
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.
Highlights
The malign influence of negative environments in promoting chronicity in people with mental illness was exemplified most clearly by Erving Goffman [1]
The adjective “short-term” may seem a little inaccurate but all the treatments concerned are given in specific settings with a view to improving mental health but with no long-term environmental focus in mind, but with the expectation that any relief offered might extend to the longer term
One of the oldest structured environmental treatments is the therapeutic community, which itself owes a great deal to milieu therapy
Summary
The malign influence of negative environments in promoting chronicity in people with mental illness was exemplified most clearly by Erving Goffman [1]. The necessary process of deinstitutionalisation followed, initiated by pioneers in services for the intellectually disabled [2], and followed shortly afterwards by the community psychiatry movement This was a time of great therapeutic enthusiasm and there was a gradual dismantling of the coercive elements of these settings, that forced patients to define themselves as mentally ill, change their thinking and behaviour, suffer humiliations, accept restrictions, and adjust to institutional life. A cheerful atmosphere, soft gentle sounds and the warmth of friendship in congenial surroundings All this this was forgotten as mental hospitals hospitals became overcrowded, therapeutic. The notion of the environment as an agent of change had not disappeared, and its thread places of reform to ones of disposal and became ripe for the criticisms of Goffman and others.
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