Multisystemic Therapy 04/00 Multisystemic Therapy (MST) For additional information see .

Multisystemic Therapy 04/00

Multisystemic Therapy (MST)

For additional information seewww.mstservices.com


Primary Goals of MST Reduce youth criminal activity Reduce other types of antisocial

behavior such as drug abuse and sexual offending

Achieve these outcomes at cost savings by decreasing rates of incarceration and out-of-home placements


MST Research and Dissemination Family Services Research Center (FSRC)

Research Center at the Medical University of South Carolina (MUSC), Dr. Scott Henggeler, Director

MST Services MUSC affiliated organization offering assistance in MST

program development and training through licensing agreements with the MUSC and the FSRC

MST Institute Independent non-profit organization providing quality

control expertise, data, and tools to all interested parties


MST “Champions” & Advocates OJJDP - Office of Juvenile Justice and

Delinquency Prevention Washington State Institute of Public Policy

MST: most cost effective approach to reducing crime

“Blueprints for Violence Prevention” MST selected as one of the 10 “Blueprint”

programs by Delbert Elliott, Center for the Study and Prevention of Violence, University of Colorado


MST Research and Development

Theoretical underpinnings Research findings on delinquent

behavior MST research findings


MST Theoretical Assumptions

Children and adolescents are embedded in multiple systems that have direct and indirect influences on their behavior.

Influences are reciprocal and bi-directional

Based on Bronfenbrenner, Haley , and Minuchin


Ecological Models

Child

Neighborhood

Family Peers

School


Ecological Models

Child

Family

Peers

School

Neighborhood

Treatment Providers


Causal Models of Delinquency & Drug Use

Condensed Longitudinal Model

Family

School

DelinquentPeers

DelinquentBehavior

Prior DelinquentBehavior

Low Parental MonitoringLow AffectionHigh Conflict

Low School InvolvementPoor Academic Performance

Elliott, Huizinga & Ageton (1985)

-

-

+

+


Needs of Violent & Chronic Juvenile Offenders and Their Multiproblem Families

Improve parental discipline practices Increase family affection Decrease association with deviant peers Increase association with prosocial peers Improve school/vocational performance Engage in positive recreational activities Improve family-community relations Empower family to solve future difficulties


The Missouri Delinquency ProjectCharles M. Borduin, (PI), University of

MissouriBarton J. Mann, University of Illinois - Chicago

Lynn T. Cone, University of MissouriScott W. Henggeler, Medical University of South

CarolinaBethany R. Fucci, University of MissouriDavid M. Blaske, University of Missouri

Robert A. Williams, University of Missouri


Participants: 200 Offenders and Their Families

Averaged 4.2 previous arrests 64% had been incarcerated previously

for at least 4 weeks Average age = 14.8 years 67% male, 33% female 30% African-American, 70% Caucasian 47% lived with only one parental figure


Service/Treatment Options

Multisystemic Therapy 77 completers 15 dropouts

Individual Therapy 63 completers 21 dropouts

Usual probation services for refusers 24 refusers


Service Delivery vs. Treatment

Service Delivery Models

Family Preservation

Inpatient Outpatient Residential

Treatment Foster Care

Treatment Models

Multisystemic Therapy

Cognitive Therapy Family Therapy Psychodynamic

Therapy Behavior Therapy


Delivery of Multisystemic Therapy Treatment Site In the field (home, school,

neighborhood and community)

Treatment Total behavioral health care

Treatment Duration 3 to 5 months in most cases

Case Management Function Service provider rather than brokerof services

Provider Single therapist (as part of &supported by generalist team)

Clinical Staff: Client Families 1:4-6 (avg. 15 families/ yr/ therapist)

Staff Availability 24 hr/ 7day/ wk team availability

Treatment Outcome Responsibility of staff & agency

Expectations of Outcome Immediate, maximum effort byfamily & staff to attain goals


MST Case Example

15 year old minority youth Referral to MST for truancy,

aggressive behavior at home and school, multiple shopliftings, and drug abuse

Lives with mother, stepfather, and three younger siblings


MST Treatment Principles

Nine principles of MST intervention design and implementation

Treatment fidelity and adherence is measured with relation to these nine principles


Principles of MST

1. Finding the FitThe primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.

2. Positive & Strength FocusedTherapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.


Principles of MST

3. Increasing ResponsibilityInterventions should be designed to promote responsibility and decrease irresponsible behavior among family members.

4. Present-focused, Action-oriented & Well-definedInterventions should be present-focused and action-oriented, targeting specific and well-defined problems.


Principles of MST

5. Targeting SequencesInterventions should target sequences of behavior within and between multiple systems that maintain identified problems.

6. Developmentally AppropriateInterventions should be developmentally appropriate and fit the developmental needs of the youth.


Principles of MST

7. Continuous EffortInterventions should be designed to require daily or weekly effort by family members.

8. Evaluation and AccountabilityInterventions efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.


Principles of MST

9. GeneralizationInterventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.


Instrumental Outcomes at Post-treatment

Increasing family cohesion and adaptability

Increasing family supportiveness Decreasing family hostility Decreasing parental symptomatology Decreasing behavior problems in youth

Multisystemic Therapy was significantly more effective at:


Ultimate Outcomes at Four-Year Follow-Up

Preventing violent offending Preventing other criminal offending Preventing drug-related offending Decreasing seriousness of committed

crimes

Multisystemic Therapy was significantly more effective at:


Missouri Delinquency Project

MSTCompleters

MSTDropouts

IT Completers

IT Dropouts

Refusers0%

20%

40%

60%

80%

100%

120%

0 0.6 1.1 1.7 2.2 2.8 3.3 3.9 4.4 5

Years Past Treatment Termination

Perc

en

t o

f O

ffen

ders

No

t R

e-A

rreste

d


The Role of Treatment Fidelity

Standard Training for MST clinical staff

5-Day on-site orientation to MSTWeekly MST consultations:

viewed as the core of the training program -- true on-the-job training

Quarterly on-site booster training



Examined the effects of MST in the absence of ongoing weekly MST consultation.

Adherence measure: 26 item questionnaire completed by the youth’s caregiver/parent.

Results: adherence to the MST treatment model varied greatly without weekly MST consultation.

Client outcomes: where treatment adherence was high, outcomes were substantially better.



MST treatment adherence predicted:

decreased criminal activity decreased incarceration decreased adolescent emotional

distress increased parental emotional distress



Implications of research: High adherence is essential for obtaining

outcomes with difficult clinical populations Traditional training and supervisory protocols are

not sufficient for obtaining high adherence To obtain the strongest possible outcomes, MST

programs should “institutionalize” adherence monitoring and on-going training for staff


Bridging the Gap: University to Community

University-based research projects often show promising results which can not be replicated by community-based programs

MST has successfully made this transition Positive university-based research Positive community-based research Focusing on the implementation of effective

community-based MST programs


Community-based Dissemination Efforts

Program Replications California Connecticut Colorado Delaware* Florida Ireland (No.) Kansas Louisiana Manchester (UK)

Maryland Michigan* Minnesota Missouri New York* Nebraska North Carolina Ohio*

* Clinical Trials

Oregon Pennsylvania* South Carolina* Tennessee* Texas* Washington Washington D.C. Ontario, Canada* Norway*


Critical Elements of Implementation

Continuous Focus on Outcomes Fidelity to the Treatment Model Accessibility of Treatment

What influences these critical elements? Interagency collaboration Organizational support of the program Operational practices and policies


Influences of Other System Stakeholders

Funding structure in place Ability of MST therapist to take the

“lead” in clinical decision making Key stakeholders usually include:

Juvenile Justice, Family Court, Mental Health, Social Welfare, School systems, parent groups

Clearly defined target population, program goals, and referral process


Influences within the Provider Organization

Clear understanding of MST at all levels Commitment to implement MST fully Target MST compatible populations Willingness to modify policies and

dedicate resources to achieve outcomes Commitment to training and supervision Policies (e.g. flex-time, transportation) Resources (e.g. pay, cellular phones)


Influences within the Clinical Context/Team

Clinical supervisor: committed, credible authority Distinct and dedicated MST staff Low caseloads (4-6 families per clinician) Weekly group supervision per MST protocol Weekly MST consultation for clinical team Adequate on-call coverage system MST training for all staff who can influence treatment Outcome-based discharge criteria Therapists: strengths and barriers


Why is MST Successful? Treatment targets known causes of

delinquency: family relations, peer relations, school performance, community factors

Treatment is family driven and occurs in the youths’ natural environment

Providers are accountable for outcomes Therapists are well trained and supported Significant energies are devoted to developing

positive interagency relations

Multisystemic Therapy 04/00 Multisystemic Therapy (MST) For additional information see .

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