Multisystemic Therapy:

A positive and strength-focused use of the peer relationship in effective interventions

Zoë AshmoreGerard Stuart

Multisystemic Therapy (MST)

• Intensive, community based – aims to keep young person at home, in education, stop offending.

• 3 teams 5 years ago in UK- now 40+ standard.

• 1st team in UK was in Northern Ireland, now 3.

• Central to the MST treatment model is the MST Analytic Process

• 9 principles- means that MST is individualised to the needs of the young person and family.

Environment of Alignment and Engagementof Family and Key Participants

Measure

Re-evaluate Prioritize

Do

IntermediaryGoals

IntermediaryGoals

InterventionDevelopment

InterventionDevelopment

MST Conceptualizationof “Fit”

MST Conceptualizationof “Fit”

Assessment ofAdvances & Barriers to

Intervention Effectiveness

Assessment ofAdvances & Barriers to

Intervention Effectiveness

InterventionImplementation

InterventionImplementation

MSTAnalyticalProcess

ReferralBehavior

ReferralBehavior

OverarchingGoals

OverarchingGoals

Desired Outcomesof Family and Other

Key Participants

Desired Outcomesof Family and Other

Key Participants

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 FOCUSED

Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.

 3. INCREASING RESPONSIBILITY

Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members.

 4. PRESENT-FOCUSED, ACTION-ORIENTED, & WELL-DEFINED

Interventions should be present-focused and action-oriented, targeting specific and well defined problems.

 5. TARGETING SEQUENCES

Interventions should target sequences of behavior within or between multiple systems that maintain the identified problems.

The Guiding Principles of MST

 6. DEVELOPMENTALLY APPROPRIATE

Interventions should be developmentally appropriate and fit the developmental needs of the youth.

 7. CONTINUOUS EFFORT

Interventions should be designed to require daily or weekly effort by family members.

 8. EVALUATION AND ACCOUNTABILITY

Intervention efficacy is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.

 9. GENERALISATION

Interventions 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.

The Guiding Principles of MST (cont’d)

• Single therapist working intensively with 4 to 6 families at a time (not individuals)

• “Team” of 3 to 4 therapists plus a supervisor

• 24hr/ 7 day/ week team availability

• 3 to 5 months is the typical treatment time (4 months on average across cases)

• Work is done in the community, home, school, neighborhood etc. (not office-based)

How is MST Implemented?

• MST staff deliver all treatment – typically no services are brokered/referred outside the MST team

• Never-ending focus on engagement and alignment with the primary caregiver and other key stakeholder (e.g. Social Services, school etc.)

• MST staff must be able to have a “lead” role in clinical decision making for each case

• Highly structured weekly clinical supervision and Quality Assurance (QA) processes

How is MST Implemented? (cont’d)

• Systems Theory (von Bertalanffy 1968)

• Social Ecological Theory (Bronfenbrenner 1979)

• Causal Model of Delinquency (Elliott et al 1985)

• Strategic Family Therapy (Haley 1976)

• Structural Family Therapy (Minuchin 1974)

• MST Theory of Change (Henggeler et al 2009)

• MST draws from research-based treatment techniques:

• Behaviour Therapy• Parent Management Training • Cognitive Behaviour Therapy (CBT) • Pharmacological Interventions (e.g. for ADHD)

Theory and Models

Home & Family

CHILD

ImmediateCommunity/

Neighbourhood

School

Play / Leisure

Health

Church

Peers / Friends

TVAdvertising

Computer /Internet

Whole Child Model

Adapted from Bronfenbrenner’s Ecological model of the Environment

Community and Voluntary Organisations

Extended Family

Police

LAW – International / Domestic Including Rights

Housing

Workplace

Sch

ool

Managem

en

t

Local

Neighbours

Local Media

Family Friends

Loca

l

Statutory

Agencies

Mass Media

Ideology

Adve

rtisin

g

All G

over

nmen

t

Dep

artm

ents

and

Polic

ies

Culture

Information

Technology

Changing Relations with Peers 10

MST Theory of Change

MSTImproved

Family Functioning

Peers

School

Reduced Antisocial

Behavior and Improved

FunctioningCommunity

MST Evidence Base • 30+ years of research including 20 RCTs, 11 independent

evaluations

• Long term studies at 14 & 22yrs showing 33% fewer days spent in custody, 37% less family dispute costs. (Schaeffer & Borduin (2005) Sawyer and Borduin (2011))

• In Norway 2 year follow up, more effective than usual services at reducing out of home placements (Ogden & Hagen (2006))

• Brandon centre RCT compared MST /YOS – greater reductions in non-violent offending after 18 mths Butler et al (2011)

• Outcomes linked to fidelity to MST model (Henggeler et al (1997) Ogden and Halliday- Boykins (2004))

• Start trial began 2010 RCT for 684, reporting Spring 2014

• NICE guidelines, March 2013 for conduct disorder and anti-social behaviour recommend MST for 11 to 17 yr olds

Peers Research

• Family maltreatment, adverse contexts and involvement with deviant peers were risk factors for developing conduct problems (Dodge, Greenberg, Malone, & Group, 2008).

• Anti-social friends continue to reinforce disruptive behaviour and a delinquent peer group make anti-social behaviour more likely to occur (Coleman & Hagell, 2007).

• Young people make riskier decisions when in peer groups than when alone (Gardner & Steinberg, 2005).

• Interventions addressing peers in collaboration with parents can reduce offending. (Huey et al 2000)

Key messages from peer research for young people

• Problems with peer relations are powerful predictors of anti social behaviour (Dodge et al 2006, Lahey et al 2003 Loeber and Farrington 1998)

• Most young people commit crime in context of peer activities

Case study- Jane

• Jane is 15.

• Lives with her mother, and her 17 year-old sister.

• Parents are living apart but are in regular contact and their relationship is good and they work well together.

• Mum has a partner who does not live in the family home. Dad lives with a partner

• Mum also has good support from her sister.

• Low engagement with school by Jane.

• Strong association with negative peer group.

• Limited engagement with pro-social activities in the community.

Case study- Jane (Referral Behaviour)(Baseline)

BEHAVIOUR FREQUENCY INTENSITY DURATION

Verbal abuse Daily High 8 months

Physical Aggression Sporadically Medium 8 months

Theft Sporadically Medium 8 months

Physical Aggression with Peers

Sporadically High 6-8 months

Misuse of Alcohol 3 times per week Medium 6 months

Truancy Almost daily High 5 months

Self-harm Sporadically Medium 6 months

Absconding from the family home

Sporadically High Approx. 6 months

Case study- Jane (Negative Peer “Fit”)

Low affective Relationship at home Limited expectations

from parentHigh conflict at home

Poor home / school linkAccess to alcoholvia peers No consequences

Access to drugs Parent had novia peers links with

peer groupBoredom

Non-attendance at school No positive

re-enforcementLow supervision / monitoring Not engaged in

pro-social activities

Association with

Negative Peer

Group

Case study- Jane (Negative Peer “Fit”)

Low affective Relationship at home Limited expectations

from parentHigh conflict at home

Poor home / school linkAccess to alcoholvia peers No consequences

Access to drugs Parent had novia peers links with

peer groupBoredom

Non-attendance at school No positive

re-enforcementLow supervision / monitoring Not engaged in

pro-social activities

Association with

Negative Peer

Group

Priority Drivers

Driver - Parent had no links with peer groupIntervention:

Intermediary Goal - Mum will develop links with Jane’s peer group

Intervention Steps –

- Mum to identify who Jane’s friends are (social network sites, phone contacts, face to face when they come to the door).

- Mum to introduce herself to these peers.- Mum to explain her concerns regarding Jane and seek peer

support to assist her in keeping Jane safe.- Mum to gather contact details from these peers (phone

numbers, addresses).- Mum to make contact with the parents of Jane’s peers to seek

their support.- Mum to offer reciprocal support to the parents of Jane’s peers

Priority Drivers

Driver - Low supervision / monitoringIntervention:

Intermediary Goal – Mum will increase her supervision and monitoring of Jane

Intervention Steps –

- Mum will set clear limits on those with whom Jane is permitted to associate.

- If Jane is going out mum will ask Jane where she is going, who she is with, what they plan to do, and when she will be home.

- Mum will monitor Jane’s social networking site.- Mum will contact peers to verify what Jane has told her.- Mum will personally verify the information Jane gives her, or

use supports in the community to do so.

• Significant reduction in physical aggression in the family home (only one incident of physical aggression)

• Significantly improved family relationships

• Jane re-engaged with education

• Improved communication between home and school

• Reduction in alcohol misuse (from three times per week to approximately once a month)

• Significant reduction in self harming behaviour – parents reacting to and managing such behaviour more effectively

• Virtual elimination of theft from the home (only one incident which mum appropriately addressed - stolen items were recovered)

Outcomes

• Jane dis-engaged with negative peer group and moved to positive peer group and pro-social activities - she became a leader in the local youth club

• Increased parental capacity to manage and maintain the positive behaviour change

• Jane remained at home

Outcomes

Instrumental Outcomes 2009 – 2012 (n= 86 cases)

• 90.7% at home• 87.2% in school/ training• 83.7% with no new arrests

Conclusion

• MST is effective in intervening in peer domain

• Forensic Psychology – still dominated by secure accommodation and not enough influencing community forensic settings

• Neglecting the powerful pull of peers in reducing offending - few interventions target peers

• Addressing the systemic factors (systems theory / whole child approach) not just individual factors for the young person is more effective - current challenge to services to make these changes, especially statutory sector

For further information on MST:Websites:

www.mstuk.org

www.mstservices.comZoe.ashmore@kcl.ac.uk

Gerard.Stuart@extern.org