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Minnesota’s NAVIGATE program showing early success in treating first-episode psychosis

The Twin Cities NAVIGATE team
Courtesy of Melissa Dalhoe
The Twin Cities NAVIGATE team includes, from left to right: Christa Reader, Craig Chapman, Melissa Dalhoe, Scott Curran, Kayla James and Melissa Rosewall.

Research has shown that when detected and treated in its earliest stages, psychosis is a condition that can be managed. The only problem is that until recently, American medical systems tended to wait a dangerously long time until diagnosing and treating psychosis, meaning that people suffering with the condition experienced a range of negative outcomes, including hospitalizations, loss of work, disruption in school, increased substance use and family frictions.  

A program now up and running at the University of Minnesota and Hennepin County Medical Center aims to take a more proactive, comprehensive approach to the treatment of people experiencing their first-episode of psychosis. The treatment model, known as NAVIGATE, was developed by researchers at the Feinstein Institute for Medical Research at the Long Island Jewish Medical Center. Piper Meyer-Kalos, director of the Minnesota Center for Chemical and Mental Health, was part of the team that led the research.

This winter, Twin Cities NAVIGATE staff put the word out to physicians, schools, clinics and emergency rooms that a new program would be available for individuals between the ages of 15 and 40 who are experiencing early-stage psychosis. The response was quick and enthusiastic, said Melissa Dalhoe, LICSW, co-director of the NAVIGATE program at the University of Minnesota.

“Since February we’ve received 112 referrals for first-episode psychosis services,” she said. “We were expecting to have three to five people enrolled in the team in May. Right now we are at about 15 people per team. Clearly there’s a need that has surfaced. It’s been very exciting.”

The sooner the better

For Dalhoe and her colleagues, this response is exciting because they believe that early treatment is key to positive outcomes for people experiencing psychosis.

“In the United States on average, individuals go months to years after first experiencing psychosis symptoms before actually receiving care,” Dalhoe said. “Our culture has been that we wait for someone to be in active crisis before we offer them care. Usually that happens in the ER or in the hospital.” This is like waiting to treat a person for cancer after the cancer has metastasized, she explained.

The NAVIGATE approach tries to identify people in the early stages of psychosis before their disease progresses and makes treatment more complex.

“We have been taking time to reach out to people who may be first contacts for individuals experiencing psychosis — schools, universities, homeless shelters — so we can try to help them before their illness gets harder to treat,” Dalhoe said.  

Prompt, comprehensive treatment has been shown to help people recover faster — and reduce personal impact as well as public cost, Dalhoe added.

“The sooner the treatment,” she said, “the better the outcome.”

How NAVIGATE works

In the NAVIGATE model, an individual experiencing their first episode of psychosis is matched with a team of experts who are trained to help them come to terms with and develop a treatment plan for their mental illness.

The program, Dalhoe said, “is evidence-supported multidisciplinary care. Each person’s treatment team consists of a case manager, a prescriber for medication, an individual resiliency trainer for one-on-one counseling, family psychoeducation and support, and a supportive employment and education specialist.”

The idea is that each member of the treatment team addresses key parts of an individual’s life that can be negatively affected by a psychotic episode.

Melissa Dalhoe
Courtesy of Melissa Dalhoe
Melissa Dalhoe

The prescriber helps the patient find the right medication for managing their symptoms. The resiliency trainer provides individual support and counsel. Family psychoeducation helps guide family members through their loved one’s crisis, and the employment and education specialist helps rebuild professional connections so the individual can return to normal life as soon as possible.

This all-hands-on-deck approach is time consuming at first, but is designed so that individuals can eventually step away from the program.

“Care is intensive up front for the first six months,” Dalhoe said. “Then people taper off to monthly check-ins. As we have people work through our program, their involvement will fade away.”

Dalhoe explained that NAVIGATE team members are all about individual recovery, so they take a flexible approach to treatment.

“Many members of this population experience paranoia, suspicion, fear or difficulty trusting new people, so meeting them where they are at is important when building a therapeutic relationship,” she said. Individuals can come into clinic for treatment, or can meet with therapists at home, in school or elsewhere in the community.

So far, the NAVIGATE approach has been successful, Dalhoe said.

“We’ve been able to engage participants before they’ve required a hospital stay,” she said. “One may have had one emergency room visit, but they have not required a hospitalization for psychosis.” This is considered a great achievement, she added: “If we can avoid those kinds of situations, it is good not only from a financial perspective, but also good for an individual who is experiencing these symptoms. Hospitalization can be quite traumatizing and can set recovery back. To be able to keep care in the community has been beneficial.”

Getting the word out

A big part of the Minnesota NAVIGATE program’s success so far can be credited to successful communication with the community before the program was launched, Meyer-Kalos said.

“Since they’ve started these teams and put the information out, they’ve gotten steady referrals,” Meyer-Kalos said. Effective communication to a range of existing community programs and care providers has helped to spread the word that the services were available. “These teams are designed to serve up to 30 active people at a time. In about three to four months, they are already halfway full.”

Piper Meyer-Kalos
Piper Meyer-Kalos

This positive response shows that a need for this kind of treatment is out there, and the people running the programs did a good job explaining what they had to offer, she added.

“The rate of referrals in for these programs in Minnesota is unprecedented. People here are recognizing these services, what they are and who they are designed for. In other states that are also running NAVIGATE programs, they’ve had to go out and find people. This is one of the best teams in the U.S. in the way they function.”

Dalhoe said that NAVIGATE staff took a “grassroots” approach to letting the public and providers understand what the program had to offer.

“Referrals have come from all over,” she said. “A provider, a clinic, a therapist can refer someone to our program just by calling. We also have received referrals from people experiencing psychosis as well as from families. We’ve made it clear that we’ll accept a referral any way we can.”

The wider the NAVIGATE program’s reach, the better, Meyer-Kalos said.

“This is an illness that suffers from a lot of stigma and fear. This program offers hope for people who are experiencing psychosis for the first time. We see that people get better when they work with these teams. They do amazing things, and we want as many people to know about them as possible.”

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Comments (3)

why a prescriber?

The program, Dalhoe said, “is evidence-supported multidisciplinary care. Each person’s treatment team consists of a case manager, a prescriber for medication, an individual resiliency trainer for one-on-one counseling, family psychoeducation and support, and a supportive employment and education specialist.”

Or we might choose to use Finland's Open Dialogue treatment method which has been used in Finland since the '80's, avoids the use of psychotropics and has largely emptied Finnish mental health hospitals in contrast to Minnesota which cannot open enough mental health beds to stay ahead of its burgeoning mental illness epidemic. Just sayin'...

"The approach de-emphasizes the use of drugs and focuses instead on developing a social network of family and helpers and involving the patient in all treatment decisions. Ongoing research shows that over 80% of those treated with the approach return to work and over 75% show no residual signs of psychosis. Official government statistics comparing 22 health districts in Finland found that Dr. Seikulla's district was the only one not to have any new chronic hospital patients in a two year period and led the National Research and Development Center for Welfare and Health to award a prize for "over ten years ongoing development of psychiatric care." "

Early intervention

Yes, many decades ago, Harry Stack Sullivan emphasized the enormous value of timely, expert early intervention.

Reliance on psychotropic drugs has increased, not merely because they may be effective when used appropriately, but because of deficiencies in the availability of expert psychotherapists and of adequate insurance coverage for psychotherapy.

I hope the program described in the article can help make up for those deficiencies--and the Finnish program described by Mr. Miller sounds like something worth investigating.

open dialogue

It is true that we are drastically short of psychiatrists in MN as well as most mental health professionals. Another really wonderful aspect of Open Dialogue is that it is managed by family members and an individual's social circle in addition to someone familiar with the process (which could easily be a peer supporter). Psych medications are not typically a part of the process for more than a small period. Given the side effects of most psych meds this is something of a god-send. Here are some sources from which to learn more about open dialogue.

https://www.psychologytoday.com/blog/hide-and-seek/201507/open-dialogue-...

http://www.mindfreedom.org/kb/mental-health-alternatives/finland-open-di...,

http://willhall.net/opendialogue/