Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After...

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Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager, Consultant Clinical Psychologist 16 th May 2013

Transcript of Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After...

Page 1: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Multisystemic Therapy: Using evidence based practice to prevent young people

becoming Looked After Away from Home.

Nicola HornsbyMST Programme Manager,

Consultant Clinical Psychologist16th May 2013

Page 2: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Overview

• Service context for the delivery of MST, use elsewhere in UK and worldwide

• How does MST work?• Fife’s experience of using the model to

target young people at risk of being looked after way from home

Page 3: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

What is “MST”?

• Community-based, time-limited, intensive intervention for antisocial behavior in young people

• Focus is on empowering parents to solve current and future problems

• MST “client” is the entire ecology of the youth - family, peers, school, neighbourhood

• Highly structured clinical supervision and quality assurance processes

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MST: 30+ Years of Evidence-base

• 26 published outcome, transportability and benchmarking studies including 20 randomised trials– 11 with serious juvenile offenders ‐ 7 independent studies

• Large-scale independent RCT: START trial (9 joint LA/NHS sites in England) 700 families now recruited. Due to report first outcome data May 2014. Majority of referrals from Social Care and also Youth Offending Services

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Safeguarding Children across Services: Messages from Research (Ward and Davies 2011)

concluded-

• ‘Although practitioners claim to be using evidence-based interventions, audit and research into actual practice in the field have shown that, despite their stated intentions, this is generally not the case.’

Page 6: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Where is MST Being Used?

• Scotland – 5 teams

• England and N Ireland– 33 teams

• International nationwide infrastructures– Norway and Netherlands

• Teams in Australia, Belgium, Canada, Denmark, Iceland, New Zealand, Sweden, Switzerland and Chile

• Over 34 states in the U.S. including some statewide infrastructures

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Rapid expansion in MST in England over last 6 years, including

approx 16 teams in the last year• Continuing cross government support for MST from Department

for Education, Dept of Health, Youth Justice Board and Cabinet Office

• National Institute for Clinical Excellence recommendation MST for 12-17 year olds with serious conduct problems

• Recognition of need for suite of evidence based programmes and for MST teams to be integrated into wider service redesign for local authorities and health partners

• DfE funding for ‘Intensive Interventions for children in care and on the edge of care and custody’ offers new opportunities for MST development alongside other evidence based programmes such as FFT and MTF

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MST Adaptation Sites

MST-PSB (Problem Sexual Behaviour)• The Brandon Centre, London• Bedford Borough, Central Bedfordshire, Cambridgeshire and

Peterborough • SheffieldMST-Contingency Management for Substance Misuse

(CM)• Brandon Centre, London• CambridgeshireMST-CAN (Child Abuse and Neglect)• Cambridgeshire• London Borough of Greenwich and Oxleas MH Foundation

Trust • LeedsMST-FIT (Families in Transition) DfE

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2013 Scottish Policy Context

• GIRFEC – MST fits well with 10 core components, values and principles and National Practice model

• National Parenting Strategy• Early Years Task Force exploring the potential for a

national roll out of evidence based parenting programmes on a population basis

• Family Nurse Partnerships - EBP government commitment to ensure its availability across Scotland for teenage parents

Page 10: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

MST Theoretical Underpinnings

• Children and adolescents live in a social ecology of interconnected systems that impact their behaviors in direct and indirect ways

• These influences act in both directions (they are reciprocal and bi-directional)

Based on Social Ecological Theory of Uri Bronfenbrenner

Page 11: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Social Ecological Model Community

Provider AgencySchool

NeighbourhoodPeers

Extended Family

SiblingsCHILDFamily

Members

Caregiver

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MST Theory of Change

Page 13: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

MST Assumptions

• Families can live successfully without formal, statutory services

• Change can occur quickly

• Professional treatment providers should be accountable for achieving outcomes

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How is MST Implemented?

Intervention strategies: MST draws from research-based treatment techniques•Behaviour therapy•Parent management training •Cognitive behavior therapy•Pragmatic family therapies

‐ Structural Family Therapy‐ Strategic Family Therapy

Page 15: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

How is MST Implemented?(Cont.)

• Single Practitioner working intensively with 4 to 6 families at a time

• Team of 3 to 4 Practitioner plus a supervisor• 24 hr/ 7 day/ week team availability: on call

system• 3 to 5 months is the typical intervention time

(4 months on average across cases) • Work is done in the community, home, school,

neighbourhood: removes barriers to service access

Page 16: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

How is MST Implemented?(Cont.)

• MST staff deliver all intervention where possible –few services are referred outside the MST team

• Never-ending focus on engagement and alignment with primary caregiver and other key stakeholders (e.g. education, social work, police)

• MST staff must be able to have a “lead” role, ensuring

services are individualized to strengths and needs of each youth/family

• Continuous focus on outcomes and fidelity to the model

Page 17: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Core Elements of MST

Key Points:

• MST Quality Assurance System

• MST Treatment Principles

• MST Analytic Process

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MST Expert/Consultant

TAMTherapistAdherenceMeasure

CAMConsultantAdherenceMeasure

PIRProgram

Implementation Review and other reports

SAM SupervisorAdherenceMeasure

MST Coach

Input/feedback via internet-based data collection Training/support, including MST manuals/materials

MST QA/QI Overview

Output to – MST Coach

Output to – MST Expert

Output to – MST Supervisor and MST Expert

Output to – Organization, Program Stakeholders and MST Coach

MST Supervisor

MST Therapist

Youth/Family

Organizational Context

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9 Principles of MST Intervention Design and Implementation

1. Finding the Fit2. Positive and Strength Focused3. Increasing Responsibility4. Present-focused, Action-Oriented & Well-Defined5. Targeting Sequences6. Developmentally Appropriate7. Continuous Effort8. Evaluation & Accountability9. Generalisation

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Environment of Alignment and Engagementof Family and Key Participants

Measure

Re-evaluate Prioritise

Do

IntermediaryGoals

IntermediaryGoals

InterventionDevelopment

InterventionDevelopment

MST Conceptualisationof “Fit”

MST Conceptualisationof “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

Page 21: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

MST in Fife

Team 1 established in September 2009

Team 2 established August 2011

2 x MST Supervisors (one also the Programme Manager)

1 MST Business Support Officer (collecting quality assurance data, performance data and admin)

Page 22: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Goals for MST in Fife

• Reduce rates of offending;• Increase time in education & employment;

and• Keep young people out of care.

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MST Referral Criteria in Fife

• 11-17 year olds with serious behaviour problems occurring at home, school and/or in the community

• Who have a caregiver willing to support them at home;

AND• They are at risk of being accommodated as a

result of these behaviours.

Page 24: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Fife Performance Data

• Total number of cases served to date: 201• 49% Female 51% Male• Overall Average Adherence score (TAM): 0.73

(threshold= 0.61)• 77% of young people had TAM above threshold

• Average length of involvement: 138 days

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Risk of Becoming Accommodated at Referral

(n=201)

This amounts to 86% of cases rated as at least a ‘high risk’ of becoming accommodated.

2%12%

50%

25%

11%

Low risk Medium risk High risk Will definitely become accommodated if MST not involved Currently accommodated

Page 26: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Fife MST Caseload at Referral(n=201)

70% At Home17% Returned Home with MST Support9% With New Caregivers4% Adopted Children Only 21% In Education* / Employment

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Fife Instrumental Outcomes Closed Cases

84% with parenting skills necessary to handle future problems

85% with improved family relations82% Percent with improved network of supports85% with success in educational/vocational setting75% of youth involved with prosocial peers/activities 79% where changes have been sustained

Page 28: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Percentage of Young People Remaining at Home and in Education at Case Closure and Follow Up

At HomeIn

Education*/Employment

Case Closuren=172

91% 73%

6 Month Follow Upn=139

89% 71%

12 Month Follow Upn=102

85% 71%

18 Month Follow Upn=54

87% 70%

Page 29: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Offending Rates – Clients Closed for at Least 6 Months

(n=140)

1.9

1.5

1.1

0.0

0.5

1.0

1.5

2.0

Average Charges 6Months Pre MST

Average ChargesDuring MST

Average Charges 6Months Post MST

42.1% decrease in the average monthly rate of offending when comparing pre MST to post MST.

Page 30: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Offending Data

• There was a 47.3% reduction in total number of charges when comparing the 6 month periods pre and post MST (from 281 to 148, n=140)

Page 31: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

Outcomes according to whether young people at home versus brought home/moved to new caregiver at point of referral

 Young People at

Home at Referral

Young PeopleBrought Home /

NewCaregiver at

Referral

At Home at Case Closure

94.4%(n=126)

1 Homeless

80.4%(n=46)

1 Homeless

At Home at 6 Month Follow Up

92.5%(n=106)

1 Homeless

78.8%(n=33)

3 Homeless

At Home at 12 MonthFollow Up

86.7%(n=83)

1 Homeless

72.2%(n=18)

2 Homeless

At Home at 18 MonthFollow Up

93.2%(n=44)

60.0%(n=10)

Page 32: Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager,

What have we learned?

• It is possible to replicate and implement evidence based treatment programmes from other countries. It requires wide stakeholder support, one “Champion” is essential but not enough

• We can offer children, young people and families with serious behavioural problems more effective treatment in their communities.

• Quality assurance is an essential component for successful implementation of evidence based practice

• Resist the pressure to stretch the model and apply it to groups that it’s not been developed for/or that you don’t have the adaptation for.

• MST is an effective intervention process for a specific client group not a magic bullet to solve purchased placement overspends, it can be used as part of an overall strategy that addresses the complexity of need in the Looked After population.

• Can MST contribute to the development of systemic practice within mainstream services? A sign of successful integration?

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Further Learning PointsFurther Learning Points

Organisational change: MST requires very different ways of working: • for the team around the child, • seeing the carer as the key agent of change, • a 24/7 on call service - clarity about roles and responsibilities • the importance of model fidelity for achieving the outcomes -staff need to understand

how evidence-based interventions work differently to standard practiceUnderstanding local needs:

• the profile of the looked after children population and those on the edge of care needs to be analysed in terms of current and future requirements, costs, current services (social work, youth justice, education, health).

• thinking about who should receive a specific intervention and ensuring a sufficient flow of referrals to sustain a programme.

The cost implications must be calculated realistically: frame as cost-avoidance rather than cost-savings: • Must understand costs and benefits across all services, over short, medium and longer

term