Exercise 2.1 (p. 23)

Question 1. Is this patient suitable for referral for nidotherapy? The answer to this question is probably ‘yes’. Some might argue that the diagnosis of paranoid schizophrenia is a strong possibility and that a full course of antipsychotic drug treatment possibly with additional psychological therapy such as cognitive–behavioural therapy is necessary before direct treatment options are abandoned. However, there is little to suggest that the patient might respond to this therapy and there is little chance that this would be adhered to even if it was given at first in adequate dosage under compulsion. The reasons for preferring nidotherapy at this stage are: (a) there is a clear environmental focus to the problem; (b) the obvious standard means of dealing with the problem have failed; and (c) if the environment was changed to the patient's satisfaction the clinical problem would, at least at this early stage in assessment, apparently be solved.

Question 2. What information is needed before nidotherapy can be started?

Close examination of the past history of the patient to determine whether any improvement has been shown with treatment in the past. This would give some clue as to whether direct treatment would be of benefit if given more energetically or from a different standpoint with regard to the patient's cooperation.

Question 3. What would be the essential elements that would need to be considered before taking him on for care?

Trust and openness. It is imperative that the potential nidotherapist is not seen as another health worker trying to ‘diagnose the condition’ but as someone who will, as dispassionately as possible, find out what changes are wanted by the patient and for all of these to be seriously considered. This can be gleaned to some extent from discussions with the clinicians who have already been involved in care, but really needs a preliminary face-to-face meeting at a place of the patient's choosing, very likely his home, to have an open discussion.

Exercise 3.1 (p. 30)

Question 1. How would you go about analysing Dwain's environmental needs in the light of his indifference to the environment?