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March 22, 2020 by Phoebe Friesen, PhD & Christina Wusinich, MS

An Integration of Open Dialogue and Intentional Peer Support in Parachute NYC: Voices of Enrollees and Network Members

Parachute NYC

From 2012 to 2018, Parachute NYC offered a “soft landing” for people experiencing psychiatric crisis in New York City. Along with a respite center, Parachute mobile teams consisted of teams of health care professionals, including peer specialists, psychiatrists, social workers, and family therapists, who were each trained in the principles of Open Dialogue and Intentional Peer Support. Open Dialogue, developed in Western Lapland in Finland, espouses a practice of healing through polyphonic (many voices) dialogue within a non-hierarchical network, tolerating uncertainty, and treating every utterance as meaningful and rational. Intentional Peer Support, developed by and for peer specialists, embraces crisis as opportunity, mutual accountability within partnerships, and trauma-informed care. Parachute represented the first instance in which peer specialists were integrated into the Open Dialogue model.

Network Meetings

Parachute mobile teams offered home-based care in the form of “network meetings,” which were adapted to the needs of each enrollee, but usually involved the individual experiencing distress, 2-3 Parachute team members, and any family members or friends interested in taking part (network members). The frequency, format, and content of each meeting was tailored to the enrollee and network’s current situation, with discussions featuring the views of all present who were interested in speaking, including multiple perspectives from Parachute team members. All services were free of charge, regardless of enrollees’ existing coverage.

Network meetings featured many characteristics central to Open Dialogue, including a lack of hierarchy. This meant each attendee’s view had value in the conversation; for instance, a psychiatrist’s perspective was not privileged over the perspective of a peer specialist or enrollee. Bringing multiple perspectives into one dialogue meant one person could view an individual’s crisis as related to mental illness, another could view it as a spiritual crisis, and another could understand it as a reaction to a past trauma, and each of these views would be respected. The focus of network meetings was not to determine who was right or force one narrative onto the enrollee and network; instead, these meetings provided a space to practice allowing multiple perspectives to exist simultaneously so those involved could learn how to navigate crisis and distress in light of differences. Further, to facilitate transparency, Parachute team members would openly share their reflections on what was taking place during meetings. Topics that can be challenging and provoke disagreements within families, such as medication or inpatient care, were approached openly, and care involving loss of liberty was considered as a last resort.

Our Research

While evidence and enthusiasm related to the promise of Open Dialogue has been mounting in recent years, some have called out for more rigorous research to be conducted and others have documented the difficulties of implementing a program based on Open Dialogue in New York, a very different setting than Western Lapland. Little data has been published that includes the voices of those who have participated in the program, however.

In 2017, while pursuing graduate school in New York, we each heard that the Parachute program was soon going to be discontinued (at least in its current form) and that no data related to the experiences of participants had been or was likely to be published. In hopes of giving voice to those who had experienced the program firsthand, we initiated a program of qualitative research with those who were enrolled or involved in Parachute.

After taking into account the advice and priorities of those working on the existing Parachute teams, and with the support of several colleagues, we spoke to 8 enrollees and 10 network members, who had been involved with Parachute for on average 1.5 years, and asked them about their experiences. The results were recently published in the Community Mental Health Journal (please reach out to either of us if you cannot access a copy online).

Results

Reflections on the Parachute Approach

Interviewees reported that they valued the accessibility and flexibility of Parachute as well as their relationships with, and the lack of hierarchy within, the Parachute team. One enrollee explained,

Whatever you feel like talking about, that’s what you talk about. They [the Parachute team] don’t force you to talk about things you don’t want to talk about. It’s up to you to decide how much you want to recover; that’s how they present the visit. They explain the questions and you decide how much you want to talk about it. It’s helpful.

Responses to the structure of network meetings and Parachute’s approach to medication were mixed, with a few interviewees struggling with what they felt was a lack of urgency and others experiencing the approach as holistic.

Relationships with the Parachute Team

Many interviewees spoke of the Parachute team as advocates, “down-to-earth”, and “open-minded”. Many appreciated having multiple providers that could each offer a different perspective or form of expertise, particularly the peer specialists, who, in one person’s view, can make “you feel less alienated.” Another enrollee said,

[The Parachute team] didn’t make me feel like a crazy person, and, you know, they did try to help me to the best of their ability with whatever my issues were.

Some network members felt the advocacy of Parachute teams was limited to the enrollee and didn’t extend enough to family members, and another worried about a lack of cohesion across the team members’ approaches.

Self‐understanding and Network Relationships

Many enrollees and network members reported that Parachute improved their self-understanding and relationships with each other. One network member said,

What they really helped to do is to provide a vehicle or an opportunity for communication between myself and my son, so it’s not like two ships passing in the night, and one night a week it was an opportunity to sit down and exchange ideas.

Another network member described it as “a healing process for the whole family.”

Discussion

An important component of Open Dialogue is the notion of tolerating uncertainty so that possibilities remain open and the psychological resources of the enrollee and network can contribute to solutions, rather than being closed off within a single narrative or explanation. Our interviews suggest that some enrollees and network members had different experiences with the presence of uncertainty, some struggling with the lack of structure, goals, and “urgency,” and others finding the process “enriching” and without “any pressure.”

In a discussion of Open Dialogue, Seikkula and Olson emphasize that “uncertainty can be tolerated only if therapy is experienced as safe.” It may be that some network members who struggled with uncertainty within the Parachute process did not experience the therapeutic environment as safe, particularly when Parachute was the primary provider for their loved one. This also aligns with a recent review of research on Open Dialogue, which found that “some families found the format of the approach challenging and confusing.”

In our data set, these disparate experiences of the structure of network meetings appear to be linked to differences in attitudes towards psychiatric medications and how they were addressed within care provided by the Parachute team.

These findings may relate to the fact that Parachute participants were largely recruited from inpatient settings, where the biomedical model and an emphasis on pharmacological treatment tends to guide care. Therefore, the shift to a dialogical model may have felt abrupt for some enrollees or network members.

This form of recruitment differs from the implementation of Open Dialogue in Finland, where those trained in the model are the first responders when an individual is in crisis and where this approach is offered at the time of an individual’s initial crisis, as opposed to after years of interaction with a biomedical mental health care system, as was the experience for all Parachute participants.

For most interviewees, network meetings appear to have provided a route by which those experiencing distress and their networks could take time to reflect, be heard, and gain a better understanding of what their loved ones were going through. Importantly, several enrollees reported that the process of engaging in network meetings improved lines of communication within the network and improved relationships between those enrolled and those in their network.

This positive impact on network members suggests that the Open Dialogue or Parachute model may produce a sort of ripple effect, in which the program’s benefits extend to both enrollees and network members. While this finding may be intuitive, it has not been well documented to date, and further research is needed to better understand when and how these models should be integrated into care for individuals in distress or crisis.

We hope these findings spur discussion and further research into the impact of Parachute and other programs that utilize the principles of Open Dialogue and Intentional Peer Support.


Phoebe Friesen is an Assistant Professor in the Biomedical Ethics Unit and Department of Social Studies of Medicine at McGill University. She is trained as a philosopher, and has broad interests in psychiatry, feminist philosophy of science, and medical ethics. She is currently working on projects that consider how communities might be given more agency in processes of research ethics oversight, the ethical and epistemic justifications underlying democratizing psychiatric research, and moral dimensions of the placebo effect.

Christina Wusinich is an interdisciplinary researcher currently on fellowship at the NIMH. She is interested in relationships between structural factors and individual psychological differences, in areas ranging from depression to homelessness and community mental health care. She is interested in mixed methods approaches and has experience with quantitative and neuroscience methods as well as qualitative work. Christina is dedicated to advocating for more democratic, ethical, and multi-narrative clinical practice and research and facilitating collaboration and critical dialogue between service users, providers, and researchers.

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