Earlier this year Crystal Gonzalez, 25, started hearing voices. “I forgot that this is reality,” says Gonzalez, who lives with her mum and sister in the South Bronx, in New York City. Gonzalez has been diagnosed as bipolar, and as having a borderline personality disorder, histrionic personality disorder and obsessive compulsive disorder (OCD). Since the age of 14, her trips to the psychiatric ward had been routine.
She is not alone, mental distress is related to one in every eight emergency department cases in the US. This translates into nearly 12m visits every year, according to the Agency for Healthcare Research and Quality, an independent thinktank. Spending on these patients was $38.5bn (£24.9bn) in 2014, double what it was in 2003.
Earlier this year, Gonzalez’s therapist told her about another option to hospital. She went instead to a Parachute NYC respite centre – one of four across New York’s five boroughs. It is at the heart of a radical approach to psychosis that is attempting to end the cycle of hospitalisation across the city and is about to piloted in the UK.
Established in early 2013 by the New York Department of Health and Mental Hygiene (DHMH), the Parachute programme’s approach is “open dialogue”, in which a team of therapists and social workers encourage patients and their families to develop their own route to achieving recovery. Practitioners say the approach rejects hierarchy, encouraging equal and open dialogue between everyone in the group. It isn’t about getting “better”, but learning to live with acute distress and developing ways of managing it.
Open dialogue was developed in the 1980s in western Lapland by the Finnish psychologist Jaakko Seikkula. Within a few years, this remote area of northern Europe went from experiencing one of the worst incidence rates of schizophrenia in Europe to having the best documented therapeutic outcomes in the western world. One study showed that after two years of starting therapy more than 80% of participants had no noticeable psychotic symptoms.
The Parachute NYC programme is the first time open dialogue has been implemented in a major urban environment. In addition, it has pioneered peer support as part of the mix. Peer mentors help create a shared experience, says Leslie Nelson, 52, who works as a full-time paid peer in one of Parachute’s mobile open dialogue teams. “It’s just an amazing process for so many of us. Because the person locks on to you. They ask me: ‘You were like this?’ They can’t believe where I am now and they’re inspired by that.”
Gonzalez says of the peer mentors: “They give you tools, they go into their own lives and tell you about their struggles. That gives you strength because some of these people have gone through way worse than you have and they are able to live with it.”
In New York, all the indicators seem to show that the programme is meeting its professed aims: to save money and reduce rates of hospitalisation. Parachute is funded by a $17.6m, three-year grant from New York State and is run by separate providers including Riverdale Mental Health Association and Community Access. According to the most recent figures, it has served around 900 people in its respite centres and a further 700 people through its four mobile treatment teams, who travel to people’s houses and meet their family over a period of a year. In addition, 20,000 people have accessed its peer support helpline. Of its clients, 92% have previously used mental health services, two-thirds have had an inpatient hospitalisation and 77% have gone to A&E in the last five years.
The DHMH estimates that for every patient who has used the service, it saves $13,500 a year by keeping them out of hospital. Following its success, the mobile teams have secured state funding to continue working for another two years, while providers say patients will soon be able to pay for a stay in one of the respite centres through Medicaid, the US social health programme for people with limited incomes.
Research to be published later this year by the Nathan Kline Institute, a New York-based mental health thinktank, also shows there’s been a noticeable increase in the quality of life for people who have gone through Parachute.
These ideas are now going to be tried in the UK where community mental health services are poorly funded and overstretched. NHS trusts in Kent and Medway, Nottingham, North East London and North Essex are planning to launch a £500,000 pilot next year.
“Parachute is a really good example for us to follow,” says Russell Razzaque, associate medical director at the North East London NHS trust who is leading the UK programme. “The numbers in Finland look great, but Parachute in New York shows it works in a demographic that’s more similar to the one we work in.
“There’s a realisation that our current way of working just isn’t sustainable,” Razzaque adds. “We have more and more people within our services who are chronic and in here for 10, 20, 30 years, so we have a big in-door and a very small out-door.”
The pilot hopes to initially serve about 200 people. Razzaque says that as well as saving money, he wants to create a system which is kinder to patients and allows people to make decisions for themselves. “We really need our services to be more focused on getting people to stand on their own two feet,” he says.
“It’s challenging work, it’s a big shift, a big departure. Right now we are just slapping people with a label saying we’re going to have to look after you for the rest of your life,” he says. “Open dialogue suggests there might be a different way of treating people. Let’s see if that’s doable.”
Back in the Bronx, Gonzalez hasn’t been back to hospital since her two-week stay at the Parachute respite centre three months ago. She says that’s the longest time she’s been away from a psychiatric ward since she was 14. She’s even thinking about training to become a peer mentor. “They made me feel empowered, they made me feel good about myself,” she says. “It’s something I think I could do for other people. It’d help me become a person again.”