Experiences of Parachute NYC: An Integration of Open Dialogue and Intentional Peer Support

Abstract

Guided by the principles of Open Dialogue and Intentional Peer Support (IPS), Parachute NYC was designed to provide a “soft landing” for people experiencing psychiatric crisis. From 2012 to 2018, Parachute’s teams of clinicians and peer specialists provided home-based mental health care to enrollees and their networks (family, friends), seeking to engage and improve their natural support networks. This qualitative study examined the experiences of enrollees and network members who participated in Parachute. Participants 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. Responses to the structure of network meetings and Parachute’s approach to medication were mixed, with a few participants struggling with what they felt was a lack of urgency and others experiencing the approach as holistic. Many enrollees and network members reported that Parachute improved their self-understanding and relationships with each other.

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Community Mental Health Journal
https://doi.org/10.1007/s10597-020-00556-0
ORIGINAL PAPER
Experiences ofParachute NYC: AnIntegration ofOpen Dialogue
andIntentional Peer Support
ChristinaWusinich1 · DavidC.Lindy1,2· DavidRussell3,4· NeilPessin1· PhoebeFriesen1,5
Received: 30 August 2019 / Accepted: 24 January 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Guided by the principles of Open Dialogue and Intentional Peer Support (IPS), Parachute NYC was designed to provide
a “soft landing” for people experiencing psychiatric crisis. From 2012 to 2018, Parachute’s teams of clinicians and peer
specialists provided home-based mental health care to enrollees and their networks (family, friends), seeking to engage and
improve their natural support networks. This qualitative study examined the experiences of enrollees and network members
who participated in Parachute. Participants 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. Responses to the structure of network meet-
ings and Parachute’s approach to medication were mixed, with a few participants struggling with what they felt was a lack
of urgency and others experiencing the approach as holistic. Many enrollees and network members reported that Parachute
improved their self-understanding and relationships with each other.
Keywords Parachute· Open Dialogue· Intentional Peer Support· Community mental health· Peer specialist· Qualitative
Introduction
Individuals diagnosed with serious mental illness are often
reliant on crisis-based care and lack access to adequate out-
patient care (Hackman etal. 2006; Merrick etal. 2010). In
response to this problem, Parachute NYC was launched in
2012 by the Fund for Public Health in New York, Inc. part-
nered with the New York City Department of Health and
Mental Hygiene. The Parachute program aimed to provide
a “soft landing” for people experiencing psychiatric crisis
across New York City and was designed to utilize the natural
support network in an enrollee’s life and minimize emer-
gency medical service use by fostering supportive communi-
ties (Pope etal. 2016; Working Group 2015).
Parachute NYC was implemented at a large, not-for-profit
home- and community-based healthcare organization in
New York City, and through 2018, with federal grant fund-
ing from the Centers for Medicare and Medicaid Services,
individuals and their networks (family, friends) received
regular home visits, called “network meetings,” from Para-
chute mobile teams.1 These meetings consisted of two or
three Parachute team members, including peer specialists
and other health care professionals, such as social workers,
family therapists, and psychiatrists or nurse practitioners.
The network members present for home visits were fam-
ily members and/or close friends who were invited by the
enrollee and wished to participate. All services were free
of charge, regardless of enrollees’ existing coverage. Those
enrolled in Parachute were 16years of age or older, had been
given a diagnosis of a serious mental illness, and had at least
* Christina Wusinich
christinawusinich@gmail.com
1 Visiting Nurse Service ofNew York, Community Mental
Health Services, 286 Lenox Ave., NewYork, NY10027,
USA
2 College ofPhysicians andSurgeons, Columbia University,
1051 Riverside Drive, NewYork, NY10032, USA
3 Center forHome Care Policy & Research, Visiting Nurse
Service ofNew York, 5 Penn Plaza, 12th Floor, NewYork,
NY10001, USA
4 Department ofSociology, Appalachian State University, 209
Chapell Wilson Hall, 480 Howard Street, Boone, NC28608,
USA
5 Present Address: Biomedical Ethics Unit, Social Studies
ofMedicine, McGill University, 3647 Peel St., Montreal,
QCH3A1X1, Canada
1 At its inception, Parachute was also associated respite centers and a
“warm” line operated by peer specialists, but we chose to focus on the
centerpiece of Parachute, the mobile teams.

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one person from their natural support system who agreed to
participate in network meetings. Many enrollees and families
served by Parachute were racial and ethnic minorities, and
many were from low-income households (Working Group
2015).
The Parachute Model
These network meetings were guided by two models in
which Parachute team members received training: Open Dia-
logue and Intentional Peer Support (IPS). Open Dialogue,
previously known as the Need AdaptedTreatment Model
(NATM),was developed in the 1980s in Finland with the
aim of supporting individuals experiencing psychosis for
the first time. The model 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 (Alanen etal.
1991; Aaltonen etal. 2011; Anderson 2002; Seikkula and
Arnkil 2006). IPS is an approach to offering support devel-
oped by and for peer specialists which embraces crisis as
opportunity, mutual accountability within partnerships, and
trauma-informed care (Mead etal. 2013; Mead and Mac-
Neil 2005). IPS seeks to disrupt the traditional model of one
person helping another and replace it with a framework in
which both parties are able to learn from and support each
other, to shift from a focus on the individual towards a focus
on the relationship, and to emphasize hope rather than fear
(Mead 2010). While there is a wealth of resources on the IPS
website and fidelity measures have been developed, research
is limited, particularly in regard to service user experiences
with IPS-trained providers (Intentional Peer Support2019;
MacNeil and Mead 2003). The Parachute model was unique
in that all team members, not only peer specialists, were
trained in IPS.
The frequency, format, and content of network meet-
ings were tailored to the enrollee’s needs. This meant that
care looked different across enrollees and their networks.
It was common to begin with weekly network meetings,
reduce frequency over time as less support was needed,
and increase frequency when enrollees were in crisis. The
two or three team members who attended network meet-
ings were kept relatively consistent, and usually included
a peer specialist, a psychiatrist or nurse practitioner, and
one other health care professional, with particular team
members brought in for certain needs (e.g. medication-
related) or on request of the enrollee. The content of each
meeting was tailored to the enrollee and network’s current
situation, challenges, and concerns and featured the views
of all present who were interested in speaking, includ-
ing multiple perspectives from Parachute team members.
While meetings most often took place in the home, other
group activities (e.g. a picnic) took place on occasion.
Network meetings also featured many characteristics
central to Open Dialogue, including a lack of hierarchy.
This meant each attendee’s view had value in the conver-
sation; for instance, a Parachute psychiatrist’s perspective
was not privileged over the perspective of a peer special-
ist, enrollee, or network member. Bringing multiple per-
spectives 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 under-
stand 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 pro-
vided a space to practice allowing multiple perspectives
to exist simultaneously and to 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. When further support was con-
sidered appropriate, a Parachute-run respite center was uti-
lized whenever possible. Parachute represented the first
instance in which peer specialists were integrated into the
Open Dialogue model. The centrality of this role, and the
training team members received in IPS, allowed for an
environment in which peer specialists were integrated into
the team and in which a peer perspective of lived experi-
ence was valued in meetings.
A limited amount of research has been published
on Parachute, most of which has documented the chal-
lenges the program faced during implementation (Pope
etal. 2016; Hopper etal. 2019; Working Group 2015).
Researchers from the Nathan S. Kline Institute for Psy-
chiatric Research were embedded in Parachute during
the period of 2012 to 2015 and tasked with performing a
mixed methods (ethnographic and outcome based) study
of the project. A detailed white paper documents how the
program came into being and the challenges that arose
during implementation (Working Group 2015). A recent
commentary reflects many of the barriers to implementa-
tion documented in the white paper, including inconsist-
ent training of staff members, unmet material needs of
enrollees and families, and what the authors call “systemic
indifference to the program’s vision,” which resulted in
difficulties in working with related systems (e.g. mental
health courts) and challenges in implementing a flexible,
dialogical program into a world of managed care (Hopper
etal. 2019, p. 2).

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Evidence forOpen Dialogue
Over the past several decades, as the mental health system in
Western Lapland in Finland has been transformed through
widespread adoption of the Open Dialogue model, enthu-
siasm in other countries has grown, especially among ser-
vice users and those critical of standard treatment models
in psychiatry (Mackler 2014; Olson2019; Whitaker 2017).
Research in Finland suggests that between the 1980s, when
the model began to be implemented, to the 1990s, the inci-
dence of schizophrenia in Western Lapland dropped from
35 out of 100,000 to 7 out of 100,000 (Seikkula etal. 2001).
Evidence alsosuggests that those enrolled in the program
have demonstrated high rates of recovery, with more than
80% of those enrolled returning to work or school within two
years and no longer experiencing symptoms of psychosis
(Seikkula etal. 2011). Antipsychotics were only prescribed
in 33% of cases, which is significantly lower than the stand-
ard of care in many Western countries (Seikkula etal. 2011,
2003); for example, a comparison in Stockholm found 93%
of cases of first episode psychosis were treated with antip-
sychotics (Svedberg etal. 2001).
While these results seem promising, a recent synthesis
of the literature raised doubts about the quality of the data
from Finland, suggesting that the research “lacked meth-
odological rigor and presented a high risk of bias” because
there were no control groups, the authors had been involved
in outcomes analysis, and there was a lack of clarity sur-
rounding which data was included and why (Freeman etal.
2018).2 While most quantitative evidence on Open Dialogue
has been collected in Finland, additional—albeit quite lim-
ited—research suggests that the model can be successfully
adapted to other settings and that outcomes, in terms of both
functional engagement and symptoms, are positive (Buus
etal. 2017; Gordon etal. 2016; Granö etal. 2016).3
Qualitative research involving Open Dialogue is limited,
with most consisting of case reports, focus groups or inter-
views with small sample sizes, or studies that have a limited
scope (Bøe etal. 2013, 2014, 2015; Freeman etal. 2018;
Lidbom etal. 2014). There are also several case studies
that have been published by the Finnish team, which illu-
minate the practice of Open Dialogue in greater detail than
the quantitative literature (Seikkula 2002; Seikkula etal.
2006, 2001).4 Much of this qualitative literature examines
the processes by which dialogical therapies might lead to
change and understanding within individuals experiencing
distress, thus helping to unpack the mechanisms by which
Open Dialogue might prove effective for individuals and
their networks. However, this research has only minimally
sought out the perspectives of individuals and their families
who have received care based on the Open Dialogue model.
This study sought to explore the perspectives of individu-
als enrolled in Parachute and their networks through in-depth
qualitative interviews. Our primary research objective was
to describe the impact of Parachute on both enrollees and
network members and was directed by the following topics:
(1) how features of Parachute were received (e.g. home vis-
its, the Open Dialogue-based approach, access to a team of
providers that included a peer specialist), (2) how Parachute
was received in the context of previous mental health care
experiences, and (3) how Parachute did or did not facilitate
change in perceptions of self and network relationships.
Methods
Study Design andApproach
This study was designed to address the above questions
through qualitative interviews with Parachute service users
(i.e. enrollees and network members) and sought to engage
with enrollees and network members in a way congruent
with Parachute’s philosophy, such as avoiding diagnostic
language in interview questions. Consistent with Parachute
terminology, in this article, the “enrollee” is the individual
enrolled in Parachute, and “network members” are friends
and family of the enrollee who were invited to participate in
network meetings.
Prior to developing this study protocol, the researchers
met with all three Parachute mobile teams (three were still
operating in 2017 when the research was initiated, based
in the Bronx, Manhattan, and Queens) and members of the
administration on several occasions. All research procedures
were approved by the institutional review board of the health
care organization through which Parachute was provided.
The authors declare that there are no known conflicts of
interest and certify responsibility for this manuscript.
Data Collection
All recruitment, data collection, and analysis were con-
ducted by this study’s first and senior authors(CW, PF),
who are researchers with no prior relationship to Parachute.
Recruitment and data collection took place between July
and November 2017, and analysis was conducted in 2018.
Individuals were eligible if they were 18years of age or
older, spoke English, and had engaged as an enrollee or
2 It is also worth noting that skepticism towards the practice among
psychiatrists is significant, particularly the step away from reliance on
psychiatric medication (Yeisen etal. 2019).
3 As noted by Freeman etal. questions of fidelity loom large in all
adaptations of the model (Freeman etal. 2018). The Parachute Pro-
gram is no exception.
4 Some qualitative literature has also examined the experiences of
professionals (health care and other) within network meetings based
on the Open Dialogue model (Holmesland etal. 2010, 2014).

Community Mental Health Journal
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network member with a Parachute mobile team. Recruitment
occurred through flyers advertising the research, which were
distributed by Parachute team members to enrollees and net-
work members. Those who wished to participate contacted
the researchers directly by phone or email, and Parachute
team members played no further role and were unaware of
who took part. Enrollees and networks members completed
written consents at the time of the interview and were com-
pensated with a $50 gift card.
Eighteen individuals took part in an in-person qualitative
interview. These occurred at a time and place convenient and
comfortable for the interviewee(s) (e.g. their home, a cof-
fee shop in their neighborhood). There were 12 interviews
in total; eight interviews were one-on-one with an enrollee
or network member, and four involved a combination of an
enrollee and network members. Interviews were intention-
ally designed to be flexible and accessible so as to replicate
the Parachute model of care. Researchers were guided by
a set of open-ended interview questions (e.g. Were there
any aspects of Parachute that you found to be especially
challenging/beneficial? Have your relationships with your
network members changed during your time enrolled in
Parachute, and if yes, how so?) that sought to explore inter-
viewees’ experiences with Parachute in the context of their
previous interactions with mental health care. Interviews
were conducted until theme saturation was reached (Guest
etal. 2006).
Data Analysis
All interviews were audio-recorded and transcribed verba-
tim. After reviewing and correcting transcripts for accuracy,
analysis was conducted with NVivo software (Version 12,
2018) using a grounded theory approach (Padgett 2017). Ini-
tially, the researchers coded four interview transcripts inde-
pendently, generating their own codes and impressions of
themes, and then discussed their analyses in order to develop
a shared codebook. Further analysis of different transcripts
led to several subsequent revisions of the codebook. Once
the researchers were satisfied that inter-rater reliability of
the codebook had been achieved, all interviews were coded
with the final codebook.
Results
Participants
During the recruitment period, there were 74 individuals
enrolled in the Parachute program. In total, 8 Parachute
enrollees and 10 network members took part in interviews.
The majority of network members were parents of Para-
chute enrollees, and others were spouses, children, siblings,
and in-laws. Approximately half of the research participants
identified as female and half as male. While we did not col-
lect demographic data at the time of the interview, a concur-
rent sub-study that surveyed this same sample found that
30% of participants identified as Black/African American,
20% as Hispanic/Latinx, 40% as White/Caucasian, and 10%
as both Hispanic/Latinx and White/Caucasian. This data
also indicated that these Parachute enrollees had been using
Parachute services for about 1.5years on average (range
2–36months), had first had contact with the mental health
system between ages 9 and 50 (mean age = 23), and had
experienced 1 to 35 psychiatric hospitalizations in their life-
times (mean = 8).
Themes
Themes from interviews are organized into three main areas:
reflections on the Parachute approach, relationships with the
Parachute team, and self-understanding and network rela-
tionships. Quotations are attributed to Parachute enrollees
(E#) or their network members (NM#); numbers do not
reflect enrollee-network member relationships in order to
maintain confidentiality.
Reections ontheParachute Approach
Interviewees often spoke of aspects of Parachute that are
unique in comparison to other experiences they have had
with mental health care. Four aspects of Parachute that came
up frequently within interviews were the nature of network
meetings, the accessibility of care, the speed and structure
of the process, and the approach to psychiatric medication.
Network Meetings Several enrollees and network members
spoke about their experience of network meetings, in which
the individual experiencing distress and members of their
chosen network (e.g., family, friends) meet with two or three
members of the Parachute team to engage in dialogue. 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. (E1)
Features that are central to the Open Dialogue approach
arose in interviews, including the lack of hierarchy present
in network meetings:
I mean there is no like pecking order…I always feel
when we’re sitting here, talking with them, it’s not just

Community Mental Health Journal
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he’s ill, we’re not. It’s that he’s who he is, we’re who
we are, and how are we, you know, dealing with life.
(NM1)
Another unique aspect of the process that was mentioned
was the way in which the Parachute team openly reflected
on what they have observed in the meeting. Parachute team
members would share their thoughts and experiences with
everyone in the meeting instead of just with other Parachute
team members or network members, which one network
member welcomed: “It’s much more personal, in terms of
sharing” (NM2).
Accessibility The topic of home-based care came up fre-
quently. Interviewees noted that the home visits were “really
convenient” (E6), “beneficial” (E9), and “key to helping
families” (NM9). One enrollee spoke about how much it
meant to have meetings at home: “The beauty of it is, they
came to my home, and I really needed that at the time…I
was not able to get washed, dressed and come to the office
so, the visits to my home were paramount, really helpful”
(E6).
Others contrasted the setting of their home with that of
a clinic or hospital, where they would feel less safe or com-
fortable and less “open to speak” (E7). A network member
explained, “It was important to do it [hold network meet-
ings] in a setting that was like a safe place for us, intimate,
you know–home” (NM9). Similarly, another network mem-
ber said, “Them coming to visit the house is one of the awe-
some aspects of Parachute…’cause like the hospital is very
like, you know, intimidating” (NM11).
The availability of the teams was also mentioned fre-
quently, with enrollees and network members emphasizing
how important it was to be able to call or text Parachute team
members when they were distressed. Many also brought
up unconventional interactions they had with the team as
especially meaningful, such as taking the whole family out
for lunch, helping an enrollee get their social security card,
or picking up medication from the pharmacy (NM12, P13,
NM14).
Speed andStructure Several enrollees and network mem-
bers commented on the speed of the process, noting the
lack of “pressure” compared to other programs (E7) and
the additional time that it took to feel that the program was
“working” and that “maybe this could be helpful” (E3). For
some, this slowing down was connected to a sense of holism
within the process:
Not relying on, you know, ‘Oh, you take a pill,’…and
problem solved…It was a slow process but it worked…
It’s more complex; [the Parachute team] was looking
at the whole situation in the individual, the family, the
history, you know--the whole environment. (NM9)
In contrast, one network member considered the speed of
the process an impediment to its effectiveness, particularly
when it was the only care being provided:
After the last time [the enrollee] was hospitalized
where they [the Parachute team] became like her pri-
mary care kind of thing there. That’s when it seemed
like, ‘Okay, well now we really have to have more
of a sense of urgency,’ and that was one thing that I
would say I did not see with Parachute--it’s the sense
of urgency. (NM10)
Some interviewees appreciated the lack of clearly defined
structure and the flexibility it provided:
They’re gonna be working with you, and where you’re
at, and they’re not gonna force you to do anything, and
they always just want the best for you. Whatever’s the
best for you in that current moment, they will try and
work for it. (NM5)
On the other hand, other network members criticized the
lack of structure, noting that it would be helpful to have
clearly defined goals for team meetings:
I will call them advocates and friends, but I also
describe them [the Parachute team] as slightly con-
fusing because their purpose -- Even [the enrollee]
said their purpose isn’t as clear…there’s one day when
[Parachute team member] was like, ‘Maybe we need to
establish our purpose.’ And I feel like that is important
probably from the beginning. (NM11)
Medication The way psychiatric medication was handled
in Parachute was mentioned frequently in interviews, with
some differences between the experiences of enrollees and
network members. Enrollees often spoke about how they
appreciated that network meetings were not “overly clini-
cal and strict on medication,” especially compared to other
outpatient and psychiatric services they had received (E6).
One network member recognized the importance of offer-
ing treatment that went beyond medication but was also
concerned that discussions about medications were not wel-
come within network meetings:
The fact that they don’t address the medication openly,
it’s almost a little radical…It’s like if you have a bro-
ken leg and you don’t want to talk about the cast that
you need to wear or you know like…if we completely
ignore that there is an issue, then we keep in the same
cycle…I would describe them as radical but still con-
fusing like not enough stability or like a plan to move
ahead with the great idea of ‘yeah, we wanna treat
these people as people, we want to treat everyone
as people,’ but what-- where do you go from there?
What’s your plan with that? Because you can’t just

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come and be like, ‘Oh well we don’t want to mention
medication,’ and then walk out the door. (NM11)
One enrollee mentioned how his parents refused to speak
to Parachute after they supported the enrollee in tapering
his medication, which was followed by a rehospitalization
(E7). Another network member discussed a different experi-
ence with tapering: “The doctor’s really good at–first time
we met him, he realized [the enrollee] don’t need all that
[medication]. He lowered it” (NM14). One network member
shared that the Parachute team helped anenrollee gradu-
ally recognize the importance of medications during their
meetings (NM11). Several interviewees spoke about how
helpful it was when the Parachute team would pick up their
medications at the pharmacy (NM14), give them injections
at home (E2), or even pay for medications when they could
not afford them (NM7).
Relationships withtheParachute Team
Several themes arose in interviews related to the Parachute
team, which was described as “easy going” (E13, NM14,
NM12), “down-to-earth” (NM9), and “open-minded”
(NM10). The strongest themes associated with relation-
ships to the Parachute team involved advocacy on behalf of
the enrollee, non-stigmatizing attitudes towards diagnostic
labels, peer support, and the presence of multiple providers
on the Parachute team.
Advocacy The Parachute team were seen by many as advo-
cates. One enrollee spoke of how impressed their psychi-
atrist at a hospital was when the Parachute team attended
their discharge meeting (E9). Another network member
told a story of a Parachute team member advocating for an
enrollee when he became distressed before a surgery, de-
escalating the situation and preventing the police, surgeon,
and director of the hospital from filing an incident report
(NM1).
Some network members felt that the advocacy of the team
was too limited, focusing on the enrollee at the expense of
the network. One network member expressed, “I get the
advocacy, but then I just feel like, ‘Are you only an advocate
for, you know, the person that you’re coming for?’” (NM11).
Other network members became interested in advocacy
as a result of Parachute meetings. An enrollee told us, “I
think because Parachute played a quite important step in
[my parents], you know, like actually becoming interested
in advocacy, and they went to NAMI [National Alliance on
Mental Illness] meetings” (E7).
Stigma and Diagnosis Several enrollees commented that
they felt like more than merely their diagnosis when they
were with the Parachute team:
[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. And that’s what it’s about, maybe like actually
helping a person. And I think that Parachute has the
ability to do that and these hospitals don’t. (E3)
Peer Support Experiences with peer specialists were
overall very positive, with many interviewees comment-
ing on the importance of having someone there who was
relatable (E9, NM10, E13) and who had shared experi-
ences (E3, E7). Another enrollee explained that having a
peer specialist on the team “makes you feel less alienated”
(E6). Others spoke about how the role of the peer special-
ist was unique and could not be provided by someone else:
“It’s much better hearing it from somebody who actually
knows that you can get over it. You know, you can like
achieve what you wanna achieve and actually recuperate”
(E7). Another enrollee felt that it was “good connections”
that mattered more than the fact that a peer had shared
experiences (E3). One network member spoke about how
having a peer specialist present inspired empathy for their
family member, while another thought the peer special-
ist on the Parachute team’s experiences, who was older
and male, were perhaps too different from his daughter’s
(NM13).
Multiple Providers Enrollees’ experiences of having mul-
tiple providers on the Parachute team were generally posi-
tive, with one enrollee remarking how two people means
“more minds… more advice” (E6), one commenting that
it was “stronger support…two brains thinking at the same
time” (E13), and another noting “it was like a double, it’s
like I got multiple services and support” (E15). The com-
bination of having both a health care professional and a
peer specialist was found to be especially helpful by some:
Like with my therapist it’s kind of nice to have some-
one with, someone who’s trained in psychology lis-
ten to your thoughts and give you feedback. And then
it’s also nice having someone like a peer who’s had
similar experiences just kind of a one to one basis
just as, you know, another person just like you…just
listen and give you advice. (E6)
One network member offered a contrasting perspective,
indicating that they struggled with what felt like a lack of
unity in the team:
You could kind of feel each person’s individual, you
know, goal and take on how they approach a situa-
tion as opposed to, like a cohesive unit kind of thing
(NM10).

Community Mental Health Journal
1 3
Self‑understanding andNetwork Relationships
Several enrollees and network members spoke about how
their experiences with Parachute changed how they under-
stand themselves and each other, as well as how their rela-
tionships operate.
Self‑understanding Several enrollees noted that Para-
chute provided a place to grow and to consider new ways
of understanding themselves and their experiences. For
instance, enrollees spoke to how they no longer see them-
selves as “broken” (E7) and that the questions asked by
Parachute team members “really made me think critically
about my experiences and that really helped me to move for-
ward” (E3). Network members noticed changes in enrollees’
thinking as well, with one noting that the enrollee began to
know “how to cope” when their mood changes (NM14) and
another indicating that the program “helped [the enrollee] to
be acknowledged for who he was and how he felt” (NM1).
Another network member described how their understand-
ing of “mental illness” has evolved: “I think I have a more
balanced perspective, and it’s really not black and white
what’s the best approach to handle mental illness” (NM11).
Parachute had a positive ripple effect in that it not only
helped the enrollee but also aided the network members to
“understand the situation” (NM5).
Network Changes Many interviewees commented on how
their relationships with each other changed as a result of
engagement with the Parachute team, particularly in terms
of communication, which one enrollee indicated was “easier
now” (E1). Network members also elaborated on how the
Parachute team facilitated communication:
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. And I’ve seen him move
from becoming isolated to doing a lot of things for
himself. (NM6)
Put simply, one network member described their Parachute
experience: “It’s a healing process for the whole family”
(NM1).
Discussion
This study contributes to an understanding of how pro-
grams rooted in IPS and Open Dialogue are experienced
by enrollees and their networks and provides the first pub-
lished qualitative findings about service user perceptions of
Parachute NYC. Overall, most enrollees were positive about
their experiences with Parachute and their participation in
network meetings. This aligns with findings from the white
paper published on Parachute, which found in a survey of
enrollees that 84% said they would re-enroll if they were to
experience another crisis, and 92% said they would refer a
friend in crisis to the program (Working Group 2015). This
also aligns with the review of research on Open Dialogue by
Freeman etal. (2018) which concluded that in general, the
model “was welcomed by service users, their networks, and
staff” (Freeman etal. 2018, p. 47). For most, the 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
each other were going through. Importantly, several enroll-
ees reported that the process of engaging in network meet-
ings improved lines of communication within the network,
and improved relationships between those enrolled and those
in their network. This suggests that the model may produce a
sort of ripple effect, in which the program’s benefits extend
to both enrollees and network members. This intuitive and
yet infrequently discussed benefit aligns with research by
Bøe etal. (2015), which also found that experiences with
the dialogical model can have a significant impact on rela-
tionships between individuals in distress and their network
members, leading to new forms of understanding. Similarly,
broader research has found that integrating patient networks
into care leads to higher satisfaction and less burden on the
family (Jeppesen etal. 2005).
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 (Seikkula and Olson
2003). In practice, this means that hypotheses are avoided
and the question of what to do is kept open until “the col-
lective dialogue itself produces a response or dissolves the
need for action” (Seikkula and Olson 2003, p. 408). Our
interviews suggest that 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 (2003) emphasize that “uncertainty can be tolerated
only if therapy is experienced as safe” (p. 408). It may be
that some network members who struggled with uncertainty
within the Parachute process did not experience the thera-
peutic environment as safe, particularly when Parachute was
the primary provider for their loved one. This also aligns
with the review of research on Open Dialogue, which found
that “some families found the format of the approach chal-
lenging and confusing” (Freeman etal. 2018, p. 47). In
our data set, these disparate experiences of the structure
of network meetings appear to be linked to differences in

Community Mental Health Journal
1 3
attitudes towards psychiatric medications and how they were
addressed within care provided by the Parachute team. Net-
work members who struggled with lack of structure within
the meetings also emphasized their concern that the topic of
medications was not foregrounded by the Parachute team,
which one network member perceived as being “like if you
have a broken leg and you don’t want to talk about the cast”
(NM11).
These findings may relate to the fact that Parachute par-
ticipants were largely recruited from inpatient settings,
where the biomedical model and an emphasis on pharma-
cological 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.
Our findings align well with the only other qualitative
data from an adaptation of Open Dialogue in the United
States, which found that network members felt positively
about the model, particularly the reduced focus on medica-
tions and the flexibility of the meetings, but some concerns
were raised about the lack of clear directions related to medi-
cations and the need for supplementary services (Gordon
etal. 2016). These findings also relate to evidence which
has found that patients often have more negative attitudes
towards psychiatric medications, particularly antipsychot-
ics, than their relatives (Jaeger and Rossler 2010; Karthik
etal. 2013).
Additional research could help unpack whether medi-
cation is often seen, particularly by relatives, as a more
goal-oriented form of care than dialogical practice, and if
this might help explain our data. A related question, which
arose during our interviews, is whether Parachute ought to
be offered as a form of primary mental health care for those
experiencing distress or as supplementary service to more
traditional care.
Strengths andLimitations
While there have been some small-scale attempts to imple-
ment the principles of Open Dialogue within the United
States (Gordon etal. 2016), Parachute is the largest in scale
to date and the first to combine this model with principles
of IPS. This contributes to the strengths and novelty of this
research, but it is crucial to stress limitations regarding the
generalizability of these findings. Significant differences
exist between the implementation of Open Dialogue within
Scandinavian settings, such as Western Lapland and South-
ern Norway, and New York City, given radically different
structures of care in place and population size and compo-
sition. Inclusion criteria for enrollment in Parachute were
also relaxed over time, shifting from a focus on those expe-
riencing early psychosis towards enrolling a broad range
of individuals diagnosed with serious mental illness (Pope
etal. 2016; Working Group 2015). This meant that most
Parachute enrollees, rather than being treatment- and diag-
nosis-naive like many in Western Lapland, had a (sometimes
long) history of engagement with the mental health system,
including hospital settings, where recruitment usually took
place. Even with this broader admission criteria, our results
were largely positive, which may indicate the applicability
of programs like Parachute for a greater variety of situa-
tions than those targeted in Western Lapland programs and
provides a rich area for program development. However,
variability in length of time enrollees interacted with the
mental health care system, including a wide range of lifetime
psychiatric hospitalizations and time enrolled in Parachute,
is worth noting and important to control for in the future.
While no measures regarding fidelity to the Open Dia-
logue or IPS models were collected, it is likely that the
degree of fidelity varied across cases and across mobile
teams (Working Group 2015).5 For example, in some cases,
the individual enrolled did not have a network they wished to
include in meetings and would meet with the Parachute team
on their own or with one member of the team. Although
future iterations of Parachute-like programs should seek to
utilize fidelity measures, critical components from these
models were recorded as existing across all teams, includ-
ing flexibility and mobility, having a multidisciplinary team,
which included a peer specialist and someone who could
manage medications (among other mental health profession-
als), and network meetings characterized by a non-hierar-
chical approach, tolerance of uncertainty, and transparent
communication. Additionally, staff hired after the beginning
of the grant period did not always receive training in both
models. Taken together, this suggests that these findings can-
not easily be compared with the data from Finland or gen-
eralized to represent the models of Open Dialogue or IPS.
This also raises questions regarding how to ensure fidelity
to such a complex and context-specific model, particularly
when providers have previously worked with alternative
models of care; fidelity criteria for Open Dialogue do exist
though (Olson 2014).
Beyond generalizability, this study has several other
limitations. Though the interviews provided a strong range
of positive points and critiques of Parachute, the sample
size is small and there is no control group for comparison.
5 Unfortunately, our data set is too small to investigate differences
across mobile teams, particularly because those working with one
team participated much more frequently than the other two.

Community Mental Health Journal
1 3
While many participants were positive about their experi-
ences, this should be considered in the context of potential
sampling bias, as the Parachute teams were responsible for
distributing recruitment flyers, and interviews often took
place in their homes, a space associated with network meet-
ings. The incentives offered for participation in interviews
hopefully helped to reduce this bias. As we did not collect
data regarding how many flyers were distributed to potential
participants, we are unable to report recruitment rates. How-
ever, there were 74 individuals enrolled in Parachute at the
time of recruitment. Finally, no diagnostic data or outcome
measures were collected, in part to avoid methodologies that
could conflict with the Parachute model, which leans away
from diagnostic language. Such research would be valuable,
however, and should be considered for future iterations of
programs like Parachute, while ideally being informed and
guided by what has been learned in this study.
Strengths of the research can be found in the independ-
ence of the researchers, who were not involved in providing
care or administration of the program. Before each inter-
view, the researchers explained to participants that they were
not part of the Parachute team and anything said within the
interviews would not be disclosed to the team or impact their
care, which hopefully served to reduce bias in what partici-
pants shared. The methodology was developed in collabora-
tion with the Parachute teams, who offered input regarding
what questions were important to ask and how to approach
interviews in the most effective and respectful way. Several
Parachute team members also sought informal feedback on
these questions from enrollees, which was then communi-
cated to the researchers. While we would have preferred
to include those enrolled in Parachute in the development
of research more directly, we were unable to do so due to
time constraints. We would suggest that any future research
on similar programs, or any interventions for that matter,
involve service users and providers in the study design pro-
cess, as they contribute expert perspectives that may be una-
vailable to even the most experienced researchers.
Another strength is that the methodology was intention-
ally aligned with the principles of Open Dialogue and IPS,
as well as the structure of Parachute services, making it more
accessible to potential participants (e.g. since interviews
could take place in their homes) and minimizing the likeli-
hood that participants might feel a clash with the care they
were used to receiving with Parachute (e.g., in language,
framing, measurement). The involvement of network mem-
bers in the research also strengthens the data, allowing both
differences to be illuminated and triangulation to occur, and
because the experiences of staff and service users have typi-
cally been foregrounded in qualitative research into Open
Dialogue, with less focus on the experiences of network
members.
One final strength of this study was its prioritization of
the voices of service users, who are often excluded from
conversations about them and about the services they
receive. Direct feedback about mental health services,
especially those designed for individuals in crisis, can offer
critical information to guide the evaluation and improvement
of existing programs, thus improving the kinds of services
available in communities (Rose 2018).
Conclusion
This research examined the experiences of enrollees and
their networks within Parachute NYC, a unique community-
based mental health program informed by the principles of
Open Dialogue and Intentional Peer Support. Qualitative
interviews revealed that enrollees and their network mem-
bers valued the accessibility of home visits, the flexibil-
ity to discuss whatever topics might arise, and the lack of
hierarchy within the meetings. Responses to the speed and
structure of network meetings, as well as to how medication
was approached within the program, were mixed. Enrollees
tended to value the time spent in dialogue and the dimin-
ished focus on psychiatric drugs, but a few network members
were concerned that the program lacked a sense of urgency
and avoided important conversations about medications.
Relationships with the Parachute team were also an impor-
tant aspect of the intervention, with many remarking on how
they felt the team accepted them and advocated for them,
particularly the peer specialists. Several reported that they
enjoyed the experience of working with multiple providers,
although a few participants felt that there was a lack of unity
within the Parachute teams.
Finally, enrollees and network members explained how
Parachute contributed to their self-understanding and rela-
tionships with each other, reporting that some experienced
an improvement in how they conceptualize mental health
experiences, as well as in their ability to communicate
witheach other. Future research on programs like Parachute
should address the limitations of this study and of previous
research to provide a better understanding of if, when, and
how these models should be integrated into care for indi-
viduals in distress or crisis. Despite this study’s limitations,
these results suggest that a broad range of enrollees and their
network members might derive significant benefit from pro-
grams grounded in Open Dialogue and IPS.
Funding The authors received no financial support for the research,
authorship, and/or publication of this article.

Community Mental Health Journal
1 3
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflicts of
interest.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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