MultisystemicFamily TherapyJane F. Gilgun, PhD, LICSW

Professor

School of Social Work

University of Minnesota, Twin Cities, USA

Topics

• Basics

• Theoretical Foundations

• Implementation Procedures

• Principles

• Engagement

Basics

• $30,000,000 in funding from NIH

• Home based

• Small caseloads of 4-6 families

• Providers on duty 24/7 for 3-4 months

• Intensive supervision

• Provider engages with family members and others in the various settings in which clients live their lives

• Used in

• child protection & juvenile offending

• Juvenile sex offender treatment

• Drug abuse treatment

• Ecological systems are the client

Basics

• Similar to functional family therapy

• But MST includes engagement in multiple systems (!)

• As the name blasts out

• Uses many other treatment models

• SFT, medication, cognitive-behavioral, behavioral therapy

• Strict Protocol/Fidelity to Model a Must

• Individualization a Must

Theoretical Foundations

• systems theory

• social-ecological models of behavior

• Specifically

• Brofenbrenner’s ecological model

• Structural family therapy

• Strategic family therapy

Ecosystemic

& Developmental

Historical Forces,Culture, Values

Community Resources

Religious/Spiritual Institutions

Parents’Work

School

Extended Family/Social Networks

Peer group

Family

Child

Social

history

Specific Ecologies of Interest

• Families

• Peer Groups

• Schools

• Neighborhood hang outs

Reciprocal Interactions

• Like attachment theory

• Like family systems theory

• Young persons influence parents

• Parents influence young persons

• Young persons influence sibs

• Sibs influence young persons

• Young person influences peers

• Peers influence young persons

• Young persons influence teachers

• Teachers influence young persons

Relevance of Constructivism

• Schemas, belief systems, and actions

• Mutual interaction among the various systems

• Persons construct meanings and belief systems from their experiences within these various systems

• Meanings and belief systems are encoded in brains

• Interpretations of experiences are individual

• Individual interpretations influence interpretations of others

• The above are Jane Gilgun’s additions

Relevance of Common Factors Model

•Relationship with treatment providers rather remote

• “Extratherapeutic” events obviously most powerful

• The above are Jane Gilgun’s additions

Applications to MST

• An ecological treatment model that

• Takes into consideration key systems

• Seeks to engage key people in systems

Implementation Procedures

• (1) a set of principles that guide the formulation of clinical interventions,

• (2) a family-friendly engagement process,

• (3) a structured analytical process that is used to prioritize interventions,

• (4) evidence-based treatment techniques that are integrated into the MST conceptual framework,

• (5) a home-based delivery of services that enables the provision of intensive services,

• (6) a highly supportive supervision process, and

• (7) quality assurance process to promote treatment fidelity.

Principle 1

• “The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic contexts”

• On-going assessment of key systems• I (Jane) suggest looking at systems of beliefs

• Not just interactions in various ecologies

• Looks at strengths and needs

• Develop hypotheses about what maintains the problem

Principle 2

• “Therapeutic contacts emphasize the positive and use systemic strengths as levers for change.”

• Identify positives in each system

• Ask how they can be used to deal with the problematic issues

Principle 2

• “Therapeutic contacts emphasize the positive and use systemic strengths as levers for change.”• Identify positives in each system

• Ask how they can be used to deal with the problematic issues

• Importance of supervision• Identify negative views of families and other systems

• Jane: Good place to apply solution focused & narrative therapy ideas• Expand practitioners

• Views on solutions—expands visions of possibilities & ways to get there

• Family stories—bring out stories practitioners may overlook

Principle 3

• “Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members.”

•Promote competence

• Child

• Parental

Principle 3

• “Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members.”

• How?• Child

• Positive relationships with parents, sibs, peers, teachers

• Engagement in positive activities

• Supportive services such as tutoring, art lessons, sports clinics

• Parents

• Positive relations within families, work, communities

• Increase interest in child’s activities

• Increase supervision of child

Principle 4

• “Interventions are present-focused and action-oriented, targeting specific and well-defined.”

• Based on behavior therapy

• Define target behavior clearly

• How to measure behavior

• How to measure change in the behavior

• Use clearly-defined interventions

Principle 5

• “Interventions target sequences of behavior within and between multiple systems that maintain the identified problems.”

• Principles of SFT

• Extended to patterns of interactions in systems other than families

• in schools

• Courts

• Recreation centers

• Public spaces in general

• Etc.

Principle 6

• “Interventions are developmentally appropriate and fit the developmental needs of the youth.”

• Examples

• young person doesn’t know how to use the bus

• Parents don’t know how to find housing

• Jane:

• Challenge and provide supports, both

• This is a basic developmental principle

Principle 7

• “Interventions are designed to require daily or weekly effort by family.”

• Daily tasks that build upon successes of previous tasks

• Practice in sessions

• Homework during the week

Principle 8

• “Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.”

• Me: Sounds like solution-focused therapy• Interact with others in ways that represent a desired change

• Show all participants how to evaluate the changed interactions

• When new interactions don’t seem to work, provider has the task of identifying barriers—but must work with participants

• Also important to work out new solutions/interactions

Principle 9

• “Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members' needs across multiple systemic contexts.”

• Parents supervise/monitor children in all systems in which children participate

• Parent-child relationship more important than provider relationships with participants

Engagement

• Engage family members and significant others in the ecologies of interest

• Engagement can be difficult for very good reasons

• Identify barriers and work with them

• Families may be comfortable in their own homes

• An on-going process

Assessment

• standard intake assessment

• presenting problem,

• a history of prior services (inpatient and outpatient),

• the child's developmental history (language, social development, motor skills)

• Me (Jane): should do sexual development, history of friendships

Assessment• a medical history (accidents, injuries, allergies,

health problems),

• a school history (grade, special services, expulsions/suspensions, behavioral problems), and

• a trauma history (abuse or neglect, accidents, community or family violence).

• mental status examination is conducted with the child to gain an understanding of possible psychiatric symptoms, and

• A genogram

A Structured Analytic Process

• Operationalizes the 9 treatment principles

• Assess the referral behaviors from multiple points of view

• Including court and school records

• Interview all persons who are relevant

• Recruit relevant persons for participation in treatment

• Interview each of them

• Ask them to identify strengths

• What changes are necessary to bring about success

A Structured Analytic Process

•Next: Prioritize• “Prioritize those interactions and

relationship changes that are necessary by identifying the "fit" of the problem behaviors within the context of the youth's natural ecologies.”• Hypothesize about how the “problem” fits

with the relevant ecologies• This is systems analysis—very important to

understand and do

A Structured Analytic Process

• Fit Factors with dysregulation showing as anger outbursts

• (1) The child has low skills for managing frustration;

• (2) the parent and child escalate each other in their interactions (i.e., coercive interaction sequences);

• (3) parental management of the outbursts exacerbates the problem; and

• (4) the school is frequently leaving messages for the parent concerning the child's difficulties at school, thereby precipitating conflict between the parent and child that escalate to

Identify Drivers & Create Processes• Drivers: factors associated with the behaviors

• Identified by all those involved in the treatment

• Example: how is parents’ responses related to anger outbursts/dysregulations?

• If behaviors stop, may have to little else in other system

• Often, issues persist in other setting such as schools

• All in treatment process evaluate outcomes

• Also identify drivers of successful outcomes

• And drivers of less than optimal outcomes

• Processes repeated

• Drivers, fit, encourage new responses, evaluation, identification of barriers, implementation, etc.

Techniques

•All have been evaluated and have some indicators of effectiveness

• SFT, behavioral therapies, CBT, medication for some conditions

Service Delivery

• Low caseloads of three to six families per clinician (2-15 hours per week, titrated to need).

• 2. Therapists work within a team of three to four practitioners, though each clinician has his or her own caseload.

• 3. Treatment occurs daily to several times a week, with sessions decreasing in frequency as the family progresses.

Service Delivery

• 4. Treatment is time-limited and generally lasts 4-6 months, depending on the seriousness of the problems and success of the interventions.

• 5. Treatment is delivered in the family's natural environment: in their home, community, or other place convenient to the family.

• 6. Treatment is delivered at times convenient to family; thus, therapists work a flexible schedule. 7. Therapists are available to clients 24 hours per day, 7 days per week, generally through an on-call system.

Supervision

•Weekly 3-hrs

• Supervisor available 24/7

•Can meet with family or others with provider

• Supervisor is “responsible for building the therapists' capacity to be effective.”

Supervision Sessions

• Structured

• Goal directed

• Group format

• Team members do crisis calls night and weekend

• Provider completes a weekly summary sheet for each family

Ian’s Resources:A Positive “Fit” Model

ResourcesEarly Secure Relationship with Mother

Pleasant, coopertive personality

Ian's Relationship

with Case Manager

Father's Relationship

with Case Manager Services of

ACE

Mutual Interests with

Father

Good Peer Relationships

A Model of Neighborhood Collaboration• Neighborhood Solutions Project, actually

implemented in North Charleston, SC

• Initiated & funded by state

• Money went to MST developers

• Purpose: reduce out of home placements

• By working with persons in settings of interest

• They engaged police

• Medicals services

• MST treatment teams

A Model of Neighborhood Collaboration• Identify areas of high crime, juvenile

arrests rates, maltreatment reports, and poverty, and

•design a study to evaluate the effects of developing and implementing a collaborative project using evidence-based interventions to address these neighborhood problems

A Model of Neighborhood Collaboration• Four Groups

• Youth at risk for placement because of delinquency

• Youth at risk for school suspension or expulsion

• Comparison group from another community similar to these youth

• “High-functioning youth” from community

A Model of Neighborhood Collaboration• Identify Neighborhood Leaders• Multiple meetings of various

compositions• Develop trust• Listen. • Never promise something you cannot

deliver.• Don't do too much too soon.• A Thought: Don't throw money at us:,

instead empower us and give us your time

A Model of Neighborhood Collaboration

• Identify Collaborators• Police• Schools• (Religious Institutions)• (Youth Workers)

• More on trust• practiced visibility,• accessibility, • persistence, and flexibility, • always took the time to be with people.

Reference

• Cupit Swenson;Scott W. Henggeler;Ida S. Taylor;Oliver W. Addison (2005). Multisystemic Therapy and Neighborhood Partnerships: Reducing Adolescent Violence and Substance Abuse. Kindle Edition.