MULTISYSTEMIC THERAPY (MST):

BASES OF SUCCESS IN TREATING SERIOUS CLINICAL PROBLEMS

IN CHILDREN AND ADOLESCENTS

Scott W. Henggeler, Ph.D., Director

Family Services Research Center

Department of Psychiatry and Behavioral Sciences

Medical University of South Carolina

Charleston

FAMILY SERVICES RESEARCH CENTER

– Scott W. Henggeler, Ph.D., Director– Cynthia Cupit Swenson, Ph.D., Associate Director– Sonja K. Schoenwald, Ph.D.– Phillippe B. Cunningham, Ph.D.– Colleen Halliday-Boykins, Ph.D.– Elizabeth Letourneau, Ph.D.– Jeff Randall, Ph.D.– Melisa D. Rowland, M.D.– Lisa Saldana, Ph.D.– Ashli Sheidow, Ph.D.– Jason Chapman, Ph.D.

FSRC MISSION:

To develop, validate, and study the dissemination of clinically effective and cost effective mental health and substance abuse services for youths presenting serious clinical problems and their families

OTHER MST-RELATED ORGANIZATIONS

• MST SERVICES (has license with Medical University of South Carolina for transport of MST technology and intellectual property)

Mission: Assists organizations in development of MST programs and builds (or provides) internal capacity of organization to maintain quality assurance system

• MST INSTITUTE

Mission: To facilitate the dissemination of evidence-based practices with high treatment fidelity

• NETWORK PARTNERS in Ohio, Hawaii, Colorado, Tennessee, Pennsylvania, Connecticut, and Norway

Disclosure Statement

• Presenter is stockholder in MST Services Inc., which has the exclusive licensing agreement through the Medical University of South Carolina for the transport of MST technology and intellectual property.

STRUCTURE OF MST

Treatment targets serious juvenile offenders at high risk for out-of-home placement and their families

MST team includes 3-4 master’s level therapists and a 50% time supervisor

Therapists provide services 24/7 Therapists carry caseloads of 4-6 families each for an

average of 4 months Services are provided in homes and other community

settings MST team is supported by intensive quality assurance

system to optimize youth outcomes

CRITICAL COMPONENTS OF MST

1. Addresses the known causes of antisocial behavior comprehensively -- at youth, family, peer, school, and community levels

2. Provides intensive treatment where problems occur – in homes, schools, and neighborhoods

3. Views caregivers as central to achieving favorable youth outcomes – family-based

4. Intensive quality assurance system supports MST program fidelity and youth outcomes

5. MST provider organizations are accountable for family engagement and youth outcomes

Principles of MST1. Finding the Fit2. Positive & Strength Focused3. Increasing Responsibility4. Present-focused, Action-oriented & Well-

defined5. Targeting Sequences6. Developmentally Appropriate7. Continuous Effort8. Evaluation and Accountability9. Generalization

Environment of Alignment and Engagementof Family and Key Participants

Measure

Re-evaluatePrioritize

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

PUBLISHED MST OUTCOMES

10 Randomized Trials and 1 Quasi-Experimental Trial Published (>1000 families participating)

3 with violent and chronic juvenile offenders 1 with substance abusing or dependent juvenile offenders 2 with juvenile offenders 1 with juvenile sexual offenders 2 with youths presenting serious emotional disturbance 1 with maltreating families 1 with adolescents with poorly controlled diabetes

Approximately 10 additional randomized trials are in progress

OVERVIEW OF MST OUTCOMES ASSOCIATED WITH:

Criminal Behavior & Violence

Adolescent Substance Abuse

Adolescent Sexual Offending

Mental Health

Child Maltreatment

PUBLISHED OUTCOMES FOR CRIMINAL BEHAVIOR

4 Randomized and 1 quasi-experimental trials with serious juvenile offenders

• Decreased recidivism (25% to 70%) for as long as 13 years post treatment

• Decreased self-reported criminal offending• Decreased out-of-home placement (47% to 64% reductions)• Decreased behavior problems• Improved family relations Considerable cost savings (Washington State Institute on Public

Policy)1. MST $64,000/youth15. Bootcamps ($ 7,910)/youth

Simpsonville, SC Project

MST

UsualServices

0%10%20%30%40%50%60%70%80%90%

100%110%

0 0.4 0.8 1.2 1.5 2 2.4Years Post Treatment

Per

cent

age

of O

ffen

ders

N

ot R

e-A

rres

ted

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

Per

cent

of O

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ders

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MST Substance-Related Clinical Outcomes

• Serious juvenile offenders: two trials – decreased self-reported substance use– fewer drug-related arrests at 13-year follow-up

• Diagnosed substance abusing/dependent juvenile offenders– decreased self-reported substance use– increased attendance in regular school settings– 98% (57 of 58 families) treatment completion (– Incremental costs of MST offset by savings incurred

from reductions in days of out-of-home placement at 12 months

Long-Term Outcomes for Substance Abusers

• 4-year treatment effects for violent criminal behavior (.15 versus .57 arrests per year)

• higher rates of marijuana abstinence for MST participants at 4-years post treatment (55% versus 28%)

MST 12-MONTH OUTCOMES FROM JUVENILE DRUG COURT

RANDOMIZED TRIAL (N=161)

Compared with regular drug court, MST had:

• fewer positive screens 20% versus 60% (2,000 screens)

• less self-reported alcohol and polydrug use

• marginally decreased mental health symptoms (CBCL)

MST OUTCOMES ASSOCIATED WITH ADOLESCENT SEXUAL

OFFENDING• Study with N=16:

3 year rearrest data for sexual offending favoring MST (12.5% versus 75%)

• Replication study with N=48:8-year rearrest data for sexual offending favoring MST (12.5% versus 41.7%)

• 66% decrease in days incarcerated• Effectiveness study underway in Chicago

MST MENTAL HEALTH OUTCOMES-Alternative to

Psychiatric Hospitalization Study• Decreased youth externalizing • Improved family functioning• Increased school attendance• At 4 months post referral MST youth had a 72%

reduction in days hospitalized and a 49% reduction in days in other out-of-home placements

• Higher consumer satisfaction• Positive effects dissipated by 1.5 years

• Similar findings in (N=36) replication study in Hawaii

MST OUTCOMES ASSOCIATED WITH CHILD MALTREATMENT

• Improved parent-child interactions

Current Trial with Child Physical Abuse

• Effectiveness Trial (MST versus Group Behavioral Parent Training) with 160 families with an indicated case of physical abuse

BASES OF MST SUCCESS

1. Addresses multidetermined nature of serious clinical problems

2. High ecological validity of intensive services

3. Intensive quality assurance (improvement) system

4. Integration of evidence-based intervention models

5. Caregiver viewed as key to long term outcomes

6. Program accountability for family engagement and outcomes

1. MST ADDRESSES MULTIDETERMINED NATURE OF SERIOUS CLINICAL PROBLEMS

Decades of Rigorous Research Show Serious Adolescent Problems Linked with:

Individual adolescent characteristics Family functioning Caregiver functioning Association with deviant peers School performance Indigenous family support network Neighborhood characteristics

MST:

Addresses risk factors across the social ecology (comprehensive services)

Builds protective factors across the social ecology

Accomplishes such on an individualized basis

2. MST SERVICES HAVE HIGH ECOLOGICAL VALIDITY AND ARE

INTENSIVE

Home-Based Model of Service Delivery: Services provided in home, school, and

community settings (where problems occur) Overcomes most barriers to service access Increases validity of assessment data Increases validity of outcome data Helps engage family in treatment Enhances treatment generalization

INTENSIVE SERVICES:

Low therapist caseloads (4-6 families) 24 hour/7 day availability of therapist 60 to 100 hours of direct therapist-family

contact over 4 months Therapists work in teams with significant

clinical support

3. OVERVIEW OF MSTQUALITY ASSURANCE

SYSTEM

• System is predicated on linkage between therapist fidelity to MST treatment protocols and child/family outcomes

• Such a linkage is supported by 6 published studies

MST QUALITY ASSURANCE SYSTEM

To Promote Treatment Fidelity, Achieve Outcomes, and Address Barriers to Outcomes

• Specified treatment protocol ( Henggeler et al., 1998, Guilford Press)

• Specified supervisory protocol (Henggeler & Schoenwald, 1998)

• Specified consultation protocol (Schoenwald, 1998)

• Ongoing consultation to address organizational barriers to program success

Supervisor TherapistYouth/Family

MSTConsultants/

MST Institute

Manualized

SupervisoryAdherenceMeasure

TherapistAdherenceMeasure

Organizational Context

Manualized

Manualized

Internet communicationPerson to Person communication

MST QUALITY ASSURANCE SYSTEM

Manualized

MST QUALITY ASSURANCE SYSTEM

• On site 5-day orientation training• Quarterly booster training• Clinicians work within MST teams for peer support• On site clinical supervision from MST-trained

supervisor• Weekly consultation with MST expert via

conference call• Standardized adherence ratings from caregiver via

internet system <www.mstinstitute.org>• Expert coding of audiotaped treatment sessions for

adherence (research studies only)

Supervisor TherapistYouth/Family

MSTConsultants/

MST Institute

Manualized

SupervisoryAdherenceMeasure

TherapistAdherenceMeasure

Organizational Context

Manualized

Manualized

Internet communicationPerson to Person communication

MST QUALITY ASSURANCE SYSTEM

Manualized

4. INTERVENTION STRATEGIES USED WITHIN MST

MST Programs Rely on Evidence-Based Interventions:

Behavior therapy Cognitive behavior therapy Pragmatic family therapies Pharmacological interventions (e.g., ADHD) Community Reinforcement Approach (Budney

& Higgins)

BUT, Evidence-Based Interventions Are Used Within:

Social ecological conceptual model Program commitment to remove barriers to

service access Intensive quality assurance View that caregivers are key to long-term

outcomes Program philosophy that emphasizes provider

accountability for outcomes

5. CAREGIVERS ARE VIEWED AS THE KEY TO LONG-TERM OUTCOMES

Hence: Most clinical resources devoted to developing

capacity of caregiver to achieve goals Significant clinician attention devoted to

delineating and overcoming barriers to effective parenting (e.g., caregiver mental health problems, substance abuse, stress)

Focus on family versus youth

6. MST PROGRAMS ARE ACCOUNTABLE FOR ENGAGEMENT

AND OUTCOMES

High Accountability Requires Access to Resources: High salaries Low caseloads Strong clinical support Strong organizational support Sharing in program success (i.e., reducing

placements) Opportunity to enhance competencies when success

rates are low

SCIENCE TO PRACTICE: TRANSPORT OF MST TO COMMUNITY SETTINGS

MST Services – licensed through the Medical University of South Carolina – supports MST program development and provides or supports ongoing training and quality assurance worldwide

301 licensed MST programs in 30 states and 8 nations

Statewide initiatives in Connecticut, Hawaii, Ohio, and South Carolina. Nationwide initiatives in Norway and Denmark

MST programs serve 10,000 serious juvenile offenders annually, 3% of the eligible population

MAJOR CHALLENGES TO DISSEMINATION

Funding structures often favor incarceration and residential treatment over community-based services

Clinical services differ significantly from the status quo (e.g., home- and family-based; 24/7 availability of therapists)

Training and quality assurance standards emphasize treatment fidelity and provider accountability, which contrast with existing practices and are often not desired

Perhaps the key research and implementation issue is determining what promotes the effectiveness of dissemination sites, which have varying outcomes

POLICY IMPLICATIONS

1. Shift Funding from Ineffective Institution-Based Services to Intensive and Effective Community-Based Services

70% of current service dollars spent on out-of-home placements

Savings can fund:

higher salaries for effective clinicians

prevention programs

early intervention programs

Policy Implications - continued

2. Change training and clinical practice

Currently: Minimal outcome accountability “Train and hope” approach to technology transfer dominates Degrees are licenses to practice as one desires until

retirement

Change to Performance Contracts to Promote: Accountability Outcomes Use of evidence-based practices

QUESTIONS OR MORE INFORMATION

• Research Related: Scott W. Henggeler <henggesw@musc.edu>

• Publication Requests: <musc.edu/fsrc>

• Dissemination/Site Development:

Marshall Swenson, 843 856-8226 <marshall.swenson@mstservices.com>