Multisystemic Family Therapy Theory of Social Ecology Multi-determined nature of human behavior...

Multisystemic Family TherapyMultisystemic Family Therapy

Theory of Social EcologyTheory of Social Ecology

Multi-determined nature of human behaviorMulti-determined nature of human behavior

Ecological validityEcological validity

Reciprocal Nature of Human InteractionReciprocal Nature of Human Interaction

(Bonfenbrenner’s 1979)(Bonfenbrenner’s 1979)

Multi-determined nature of Multi-determined nature of human behaviorhuman behavior

FamilyFamily

PeerPeer

SchoolSchool

NeighborhoodNeighborhood

Broad View of Contextual InfluencesBroad View of Contextual Influences

E.g., mother’s employer, school boardE.g., mother’s employer, school board

Contributors to DelinquencyContributors to DelinquencyWithin Systems & Between Within Systems & Between

SystemsSystems Within systemsWithin systems

Lax parental supervisionLax parental supervision

Association with delinquent peersAssociation with delinquent peers

Between systemsBetween systems

Lack of caregiver knowledge about friendsLack of caregiver knowledge about friends

Conflict between family and schoolConflict between family and school

(Henggeler et al., 2009)(Henggeler et al., 2009)

Ecological ValidityEcological Validity

Understand youth functioning real worldUnderstand youth functioning real world

HomeHome

ClassroomClassroom

CommunityCommunity

First hand sourcesFirst hand sources

Caregivers, siblings, teachers, Caregivers, siblings, teachers, coachescoaches

Reciprocal Nature Reciprocal Nature of Human Interactionof Human Interaction

Parent asks teen to do choresParent asks teen to do chores

Child complains, argues, does them poorlyChild complains, argues, does them poorly

Parent – easier to do him/herselfParent – easier to do him/herself

Child learns complaining worksChild learns complaining works

Main Agent of ChangeMain Agent of Change

CaregiversCaregivers

Example:Example:

Uses family strengths: love of child, social Uses family strengths: love of child, social supportsupport

Overcome stressors: parental substance Overcome stressors: parental substance abuse, stress, hopelessnessabuse, stress, hopelessness

Increase caregiver effectivenessIncrease caregiver effectiveness

ExampleExample

Help parents design effective interventionsHelp parents design effective interventions

That support prosocial behaviorThat support prosocial behavior

Effective caregiversEffective caregivers

Supportive schoolSupportive school

Involved extended familyInvolved extended family

Support from neighborsSupport from neighbors

New Generations of Family TherapyNew Generations of Family Therapy

1)1) Systemic focusSystemic focus

2)2) Not just family: wider systemsNot just family: wider systems

3)3) Include biological factors: Use of Include biological factors: Use of medicationmedication

4)4) Emphasis on therapeutic allianceEmphasis on therapeutic alliance

(Lebow, 2005)(Lebow, 2005)

New Generations of Family New Generations of Family TherapyTherapy

5)5) Shaping interventions to research on Shaping interventions to research on specific issuesspecific issues

6)6) Sustaining change – engagement in Sustaining change – engagement in sports, prosocial groupssports, prosocial groups

7)7) Emphasizing family strengthsEmphasizing family strengths

8)8) Considering client goalsConsidering client goals

New Generation of Family New Generation of Family TherapyTherapy

9)9) Tracking outcomesTracking outcomes

10)10) Attending to cultureAttending to culture

Prefer therapists from culturePrefer therapists from culture

Research on CausesResearch on Causes

Not amenable to interventionsNot amenable to interventions

Genetic loadingsGenetic loadings

Prenatal exposure to toxinsPrenatal exposure to toxins



TeenTeen

ADHD, impulsivityADHD, impulsivity

Positive attitudes to delinquencyPositive attitudes to delinquency

Lack of guiltLack of guilt

Negative affectNegative affect



FamilyFamily

Poor supervisionPoor supervision

Parental substance abuseParental substance abuse

Parental mental health problemsParental mental health problems

Inconsistent or lax disciplineInconsistent or lax discipline

Poor affective relations with teenPoor affective relations with teen



PeersPeers

Association with drug-using or Association with drug-using or delinquent peersdelinquent peers

Poor relationship with peers, peer rejectionPoor relationship with peers, peer rejection


Research on CausesResearch on Causes School levelSchool level

Academic difficulties, low grades, held backAcademic difficulties, low grades, held back

Behavioral problems – truancy, suspensionsBehavioral problems – truancy, suspensions

Negative attitudes towards schoolNegative attitudes towards school

Inflexible school: zero-toleranceInflexible school: zero-tolerance



NeighborhoodNeighborhood

Availability of weapons & drugsAvailability of weapons & drugs

High environmental and psychosocial High environmental and psychosocial stress (e.g., violence)stress (e.g., violence)


Research on MST Mechanisms Research on MST Mechanisms of Changeof Change

High therapist adherence

MST

Improved familyFunctioning &

Parental monitoring

Decreased association with delinquent peers

Decreased delinquent behavior

(Henggeler et al., 2009)

Clinical ImplicationsClinical Implications Address caregiver functioningAddress caregiver functioning

Empower families to address teen problemsEmpower families to address teen problems

Must deal with delinquent peer issueMust deal with delinquent peer issue

Improve school or vocational performanceImprove school or vocational performance

Develop indigenous support systemDevelop indigenous support system


Therapist Attitude to FamiliesTherapist Attitude to FamiliesDon’tDon’t

Blame familiesBlame families

Ignore familiesIgnore families

Label familiesLabel families

Give up on familiesGive up on families


Basic MST Team StructureBasic MST Team Structure

2 to 4 therapists2 to 4 therapists

SupervisorSupervisor

Each therapist: 4 to 6 familiesEach therapist: 4 to 6 families

Intensive home-and community-based txIntensive home-and community-based tx

3 to 5 months: 60 hours3 to 5 months: 60 hours

Home Based Model Home Based Model

24 hour, 7 day a week availability24 hour, 7 day a week availability

9 Treatment Principles 9 Treatment Principles

1) Finding the fit between problems and the 1) Finding the fit between problems and the systemsystem

Example: therapist developed fit circle Example: therapist developed fit circle hypothesizing roles played by school, hypothesizing roles played by school, caregiver, peer, individual & community caregiver, peer, individual & community factors in development and maintenance factors in development and maintenance of problem behaviorsof problem behaviors

(Henggeler, 2009)(Henggeler, 2009)

Treatment Principles Treatment Principles 2) Positive and strength focused2) Positive and strength focused

Therapeutic contacts should emphasize Therapeutic contacts should emphasize system strengthssystem strengths

Example: Therapist leveraged father’s Example: Therapist leveraged father’s commitment to son and son’s desire for commitment to son and son’s desire for father’s respect to facilitate commitment father’s respect to facilitate commitment to treatmentto treatment


Treatment PrinciplesTreatment Principles3) Increasing responsibility3) Increasing responsibility

Interventions designed to increase Interventions designed to increase responsible behavior and decrease responsible behavior and decrease irresponsibleirresponsible

Example: Goals were 1) Increase Example: Goals were 1) Increase attendance at school, stop using drugs, attendance at school, stop using drugs, and comply with father’s rulesand comply with father’s rules


Treatment PrinciplesTreatment Principles

4) Present focused, action oriented and 4) Present focused, action oriented and target well-defined problemstarget well-defined problems

Example: Treatment targets that can be Example: Treatment targets that can be measured. Attending school measured by measured. Attending school measured by school records. Stopping drugs confirmed school records. Stopping drugs confirmed by urine tests. Teen’s anger over mother’s by urine tests. Teen’s anger over mother’s abandonment not a treatment target.abandonment not a treatment target.

Treatment PrinciplesTreatment Principles5) Targeting sequences within and between 5) Targeting sequences within and between

multiple systems that maintain problemsmultiple systems that maintain problems

Examples: Poor home-school link Examples: Poor home-school link father/son conflict - ineffective monitoringfather/son conflict - ineffective monitoring

father/school conflict - father avoiding father/school conflict - father avoiding school; school judging fatherschool; school judging father

youth/school conflict – youth insufficiently youth/school conflict – youth insufficiently supervised at school; youth avoided supervised at school; youth avoided schoolschool



6) Developmentally appropriate6) Developmentally appropriate

Example: Plan included awards and Example: Plan included awards and consequences appropriate for a teen – access consequences appropriate for a teen – access to music, video games, cell phone use, to music, video games, cell phone use, transportation, and moneytransportation, and money


7) Continuous effort7) Continuous effort

Interventions require daily or weekly effort Interventions require daily or weekly effort by family membersby family members

Example: home/school daily report card; Example: home/school daily report card; home behavioral plans require daily efforthome behavioral plans require daily effort



8) Evaluation and accountability8) Evaluation and accountability

Efficacy is evaluated continuously from multiple Efficacy is evaluated continuously from multiple perspectivesperspectives

Example: Monitoring drug use through urine Example: Monitoring drug use through urine screens, school attendance through school screens, school attendance through school records, curfew compliance through father, son, records, curfew compliance through father, son, and probation reportsand probation reports


Treatment PrinciplesTreatment Principles9) Generalization9) Generalization

Interventions designed to promote treatment Interventions designed to promote treatment generalization and long-term maintenance of generalization and long-term maintenance of change by empowering family to address change by empowering family to address members’ needs across systemsmembers’ needs across systems

Example: Father learned to communicate with Example: Father learned to communicate with school, better access social supports, obtain school, better access social supports, obtain urine drug screens and develop behavioral urine drug screens and develop behavioral interventionsinterventions (Henggeler, (Henggeler, 2009)2009)

Training and SupervisionTraining and Supervision 5 day initial orientation5 day initial orientation

Majority of learning – working with families Majority of learning – working with families and supervision by on-site supervisor and and supervision by on-site supervisor and off-site consultantoff-site consultant

Weekly meeting with supervisor who uses a Weekly meeting with supervisor who uses a protocol for reviewing casesprotocol for reviewing cases

Weekly discussion with consultantWeekly discussion with consultant

Referral behaviorReferral behavior MST Analytic

Process

Referral behaviorReferral behavior

Desired outcomes of

family

MST Analytic Process


Desired outcomes of

family

Overarchinggoals



Desired outcomes of

family

Overarchinggoals

Fit



Desired outcomes of

family

Overarchinggoals

Fit

IntermediaryGoals

Prioritize



Desired outcomes of

family

Overarchinggoals

Fit

IntermediaryGoals

Prioritize

Interventiondevelopment



Desired outcomes of

family

Overarchinggoals

Fit

IntermediaryGoals

Prioritize


Interventionimplementation

Do



Desired outcomes of

family

Overarchinggoals

Fit

IntermediaryGoals

Prioritize


Interventionimplementation

Do

Assessment

Measure

Re-evaluate


Prime FeaturesPrime Features

Never give up on familiesNever give up on families

Failed interventions are team’s responsibilityFailed interventions are team’s responsibility

AssessmentAssessment

Background Information FormBackground Information Form

GenogramGenogram

Reasons for referral: ProblemsReasons for referral: Problems

FrequencyFrequency

IntensityIntensity

DurationDuration

Impact Impact Meets with stakeholders: Family, Meets with stakeholders: Family,

teachers, probation officers, etc.teachers, probation officers, etc.

GenogramGenogram

63

3840 FJose Ricardo

History of arrest

59

36 M38

201915 13 16 Rick ADHDMia

Father’s parents live in Puerto Rico and write but do not visit

Ricardo & brother Jose emigrated 5 years ago

AssessmentAssessment

Strengths & Needs AssessmentStrengths & Needs Assessment

In each system: family, school, etc.In each system: family, school, etc. Case SummaryCase Summary

Referral BehaviorsReferral Behaviors

Behavior Frequency Intensity Duration

Marijuana Use 3 – 4 times a week 1 – 2 blunts shared with 2 peers

Approx. 16 months

Truancy 2 – 3 times a week Skips entire day

Started last school year (12 mos. ago)

Aggression – fights with peers

Two incidents Client had stitches, black eye

Incidents were 3 and 8 mos. Ago

Father-son conflict – both are verbally aggressive

1 – 2 times a week Both scream, youth uses rude language; lasts 1 – 2 minutes

(Henggler, 2009)

Desired OutcomesDesired Outcomes

Participant Goal

Rick Get off probationGet dad to stop nagging

Ricardo (father) Rick go to schoolRick get a jobRick make him proud

Mia Rick do goodRick stop getting in troubleRick stop fighting

Jose (Uncle) Rick stay away from bad kidsRick stop smoking dope

Probation officer Rick stay in schoolRick stop using drugsRick stop fighting

(Henggler, 2009)

System Strengths & WeaknessesSystem Strengths & WeaknessesSystemic Strengths Systemic Weaknesses

Individual: Athletic – likes baseballSocial – leaderWants a job

ImpulsiveVerbally & physically aggressiveFailing classesThinks can’t stop marijuana

Family: Father committed to sonSister well-behavedUncle supportive

Father authoritarianFather & son hyigh conflictFather history of arrestMother drug useMother gone

School: Willing to work with teen as long as he tries to improveHas a baseball teamPE teacher/coach interested

Negative peers are at schoolLow supervision in free timeSchool negative to familyTeen may not be sports eligibleSchool not in contact with father

System Strengths & WeaknessesSystem Strengths & WeaknessesSystemic Strengths Systemic Weaknesses

Peers:Positive friends 2 years ago still go to schoolOne friend has jobCousin Joe may be role model – has jobHas one prosocial peer he’d like to spend time with – plays baseball

Most peers are not in school or skipMost friends use marijuana & alcohol2 friends in fights

Community:Recreation center in neighborhoodLittle sister goes to churchLady next door potential support for father

Father authoritarianFather & son hyigh conflictFather history of arrestMother drug useMother gone

Weekly ReviewWeekly Review

1)1) Therapist describes overarching goalsTherapist describes overarching goals

2)2) Therapist lists previous intermediary goals & Therapist lists previous intermediary goals & whether met in last weekwhether met in last week

3)3) Therapist lists barriers to intermediary goals Therapist lists barriers to intermediary goals experienced in last weekexperienced in last week

4)4) Explains advances on gains in last weekExplains advances on gains in last week

5)5) Revise “fit” with new infoRevise “fit” with new info

6)6) Therapist states new intermediary goalsTherapist states new intermediary goals

(Henggeler, 2009) (Henggeler, 2009)

Weekly ReviewWeekly Review

Overarching GoalsOverarching Goals

School - No unexcused absencesSchool - No unexcused absences

No disruptive behaviorNo disruptive behavior

Passing gradesPassing grades

Marijuana – StopMarijuana – Stop

No fightingNo fighting

Father and son – reduced conflictFather and son – reduced conflict


Previous Intermediary GoalsPrevious Intermediary GoalsMet Partially No

Therapist & father attend IEP meetingStrategize approaching teachersDevelop school report card for teachersAll teachers agree to complete cardSet another meeting

MetMetMet

MetPartial

Father to collect urine for drug screen Partial

Father and teen to try three strategies when conflict arises Partial

Cousin J to take teen to job interview Not

Review peer sheet with father Not

Barriers to Intermediary GoalsBarriers to Intermediary Goals

English teacher not in IEP conference – teen failing in her class plus behavioral problems – need teacher buy-in on card

Teen left school early 2 days – came out in conference

Father collected urine but unsure how to read results – didn’t call therapist – gave teen privileges as if screen were clean

Teen disrespectful and didn’t follow through with conflict plan

Cousin had to work unexpectedly and couldn’t take teen to job interview

Advances in TreatmentAdvances in Treatment

Coach attended IEP – seemed fond of teen – willing to help

Teachers and father agree on a more vocational track

Teachers seem willing to fill in brief report card each day

Teen set up another time to go with cousin for job interview

Father had neighbor help twice this week – check to see if teen home

Father rewarded son this week for making curfew

Teen: Why should I try? I’m going to fail anyway.

Teen left school

early 2 x

Unable to use conflict resolution

plan

Behavior plan for home/school link not in place – no consequences

Left after PE, before English – easy to escape

Left with 2 peers – went to house of one unsupervised

Father thinking teen trying to make him mad – felt hopeless

Father’s anger makes teen feel he’s winning

Father uses intolerant tone; teen disrespectful

Reassessment of Fit between Problems & Intermediary Goals

Marijuana Use

Fit Circles

Insufficient structure – too much down time

Poor impulse control

Mom’s drug history – drugs normalized

Drug-usingpeers

Poor parental supervision

Family conflict

New Intermediary GoalsNew Intermediary Goals

Therapist to follow-up with English teacher

Therapist to check with father on daily report cardSee if teachers comply with planSee if father able to follow through with consequences

Father to call coach about teen not skipping out after P.E.

Father to call peer’s mom and ask not to allow teen there during school

Work on conflictAsk father/son why not follow through on conflict planShift roles in role playThought replacement when father discouragedPizza for family to facilitate engagement

Therapist to collect random urine drug screen this week

(Henggeler, 2009)

Support for TherapistsSupport for Therapists

Initial 5 day orientation trainingInitial 5 day orientation training

Quarterly booster trainingQuarterly booster training

Weekly on-site supervisionWeekly on-site supervision

Weekly consultationWeekly consultation

Engaging Multi-problem FamiliesEngaging Multi-problem Families

EmpathyEmpathy Spending nonclinical time with familySpending nonclinical time with family Cognitive assistsCognitive assists

Father as childFather as child WarmthWarmth FlexibilityFlexibility ReframingReframing

ReframingReframing1) Echo family’s point of view1) Echo family’s point of view

““I know you think your baby is crying I know you think your baby is crying because she knows you had a bad day because she knows you had a bad day and and she’s just trying to upset you.”she’s just trying to upset you.”

2) Offer an alternative2) Offer an alternative

““Lots of babies get gas sometimes. Lots of babies get gas sometimes. I’ve heard a lot of moms say their I’ve heard a lot of moms say their babies are babies are fussy right after they eat.”fussy right after they eat.”

3) Check to see family’s response.3) Check to see family’s response.

““Do you think that might be part of Do you think that might be part of what’s going on?”what’s going on?”

Nonclinical StrategiesNonclinical Strategies

Family PhotosFamily Photos

FoodFood

Helping with practical needsHelping with practical needs

5 minute sessions5 minute sessions

Dimensions of Family RelationsDimensions of Family Relations

WarmthWarmth

ControlControl

Parenting StyleParenting Style

WarmthWarmth ControlControl AuthoritativeAuthoritative HighHigh HighHigh

AuthoritarianAuthoritarian LowLow HighHigh

PermissivePermissive HighHigh LowLow

NeglectfulNeglectful LowLow LowLow

AuthoritativeAuthoritative

Responsive to reasonable needsResponsive to reasonable needs

Maturity demands appropriate to developmentMaturity demands appropriate to development

Clear expectations – school performanceClear expectations – school performance

AuthoritarianAuthoritarian

Directive and over-controllingDirective and over-controlling

Require unquestioning obedienceRequire unquestioning obedience

Severe punishment, sometimes physicalSevere punishment, sometimes physical

Directive teaching styleDirective teaching style

No child participation in decisionsNo child participation in decisions

Permissive Permissive

Little structure and disciplineLittle structure and discipline

Few demands for mature behaviorFew demands for mature behavior

Tolerate antisocial behaviorTolerate antisocial behavior

Warm and responsive, but not demandingWarm and responsive, but not demanding

NeglectfulNeglectful

Little discipline or affectionLittle discipline or affection

Little concern or interest in parentingLittle concern or interest in parenting

Are not responsive to child’s needsAre not responsive to child’s needs

Do not expect responsible behaviorDo not expect responsible behavior

Outcome StudiesOutcome Studies

Study Population Comparison Follow-Up

MST Outcomes

Henggeler et al., 1986N = 57

Delinquents DiversionServices

Post-tx Family relations Behavior problems Association with delinq. peers

Brunk et al., 1987N = 33

MaltreatingFamilies

Behavioral ParentTraining

Post-tx Parent-child relations

Henggeler et al., 1991

Serious juvenile offenders

Individual counseling; community services

3 yrs Alcohol and drug use Drug-related arrests


Violent & chronic juvenile offenders

Community services

59 weeks

Family relations Peer relations Recidivism (43%) Out of home placement (64%)

Outcome Studies - RecentOutcome Studies - RecentStudy Population Comparison Follow-

UpMST Outcomes

Stambaugh et al., 2007N = 267

Serious emotional disturbance

Wraparound 18 mo. Symptoms Out-of-home placement (54%)


Substance abusing teens in drug court

4 Tx conditions including family court with usual services

12 mo. Post entry

Substance abuse

Timmons-Mitchell et al., (2006)N = 93

Juvenile offenders at imminent risk of placement

Usual community services

18 mo. Youth function Substance use Rearrests (37%)

Rowland et al., 2007N = 31

Serious emotional disturbance

Hawaii’s intensive Continuum of Care

6 mo. Post entry

Symptoms Minor crimes Days out of home (68%)

Outcome Studies- Sexual OffendersOutcome Studies- Sexual OffendersStudy Population Comparison Follow-

UpMST Outcomes

Borduin et al. 1990N = 16

Adolescent sex offenders

Individualcounseling

3 yrs Sexual offending Other criminal offending

Borduin & Schaeffer(2001) N = 48Prelim

Adolescent sex offenders

Usual community services

9 yrs Behavior problems & symptoms Family relations Peer relations Academic performance

Borduin & Schaeffer, in pressFull

Caregiver distress Recidivism for sex crimes (83%) Recidivism for other crimes (50%) Days incarcerated (80%)

Outcome Studies – Sex OffendersOutcome Studies – Sex Offenders

Study Population Comparison Follow-Up

MST Outcomes

Letourneau et al., in press

Juvenile sex offenders

Usual sex-offender specific tx

12 mos post-tx

Sexual behavior problems Delinquency, substance abuse & externalizing symptoms Out-of-home placements

34 Studies of MST34 Studies of MST33 Showed Decreases:33 Showed Decreases:

Factors StudiedFactors StudiedSymptomsSymptomsRearrestsRearrestsSubstance abuseSubstance abuseOut-of-home placementsOut-of-home placementsSexual behavior problemsSexual behavior problemsExternalizing symptomsExternalizing symptomsSexual crime recidivismSexual crime recidivism


34 Studies of MST34 Studies of MST

33 Showed Decreases33 Showed Decreases

Factors Studied:Factors Studied:Inpatient admissionsInpatient admissionsMedical charges & direct care costsMedical charges & direct care costsAttempted suicideAttempted suicideViolent crimeViolent crimeAssociation with delinquent peersAssociation with delinquent peersSsychiatric symptomatologySsychiatric symptomatology


34 Studies of MST34 Studies of MST33 Showed Increases:33 Showed Increases:

Factors Studied:Factors Studied:

Improved family relationsImproved family relationsImproved parent-child interactionsImproved parent-child interactionsImproved peer relationsImproved peer relationsIncreased school attendanceIncreased school attendanceHigher consumer satisfactionHigher consumer satisfactionImproved academic performanceImproved academic performanceIncreased social competenceIncreased social competence

34 Studies of MST34 Studies of MST

33 Showed Increases:33 Showed Increases:

Factors Studied:Factors Studied:

Blood glucose testingBlood glucose testingMetabolic controlMetabolic controlYouth functioningYouth functioning

1 Study1 Study(Sundell et al., 2008)(Sundell et al., 2008)

Compared to child welfare services in Compared to child welfare services in SwedenSweden

No outcomes favoring either txNo outcomes favoring either tx

Low treatment fidelityLow treatment fidelity

Multisystemic Family Therapy Theory of Social Ecology Multi-determined nature of human behavior...

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