MultisystemicTherapy: Who we Are, What We Do, and Real...

Multisystemic Therapy: Who we Are, What We Do, and Real World

Applications

Multisystemic Therapy (MST) Overview

1

What is “MST”?

• Community-based, family-driven treatment for antisocial/delinquent behavior in youth

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

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

• Highly structured clinical supervision and quality assurance processes

2Multisystemic Therapy (MST) Overview

Social Ecological Model

3

CommunityProvider Agency

School

NeighborhoodPeers

Extended Family

Siblings

CHILDCaregiver Caregiver

Standard MST Referral Criteria (ages 12-17)

Inclusionary Criteria• Youth at risk for placement

due to anti-social or delinquent behaviors, including substance abuse

• Youth involved with the juvenile justice system

• Youth who have committed sexual offenses in conjunction with other antisocial behavior

Exclusionary Criteria• Youth living independently• Sex offending in the absence of other

anti social behavior• Youth with moderate to severe autism

(difficulties with social communication, social interaction, and repetitive behaviors)

• Actively homicidal, suicidal or psychotic• Youths whose psychiatric problems are

the primary reason leading to referral, or who have severe and serious psychiatric problems


How is MST Implemented?

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

- Structural Family Therapy- Strategic Family Therapy

• Pharmacological interventions (e.g., for ADHD)


How is MST Implemented?(Cont.)

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

• Team of 2 to 4 therapists plus a supervisor

• 24 hr/ 7 day/ week team availability: on call system

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

• Work is done in the community, home, school, neighborhood: removes barriers to service access


How is MST Implemented? (Cont.)

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

• Never-ending focus on engagement and alignment with primary caregiver and other key stakeholders (e.g. probation, courts, children and family services, etc.)

• MST has strong track record of client retention and satisfaction with MST

• MST staff must be able to have a “lead” clinical role, ensuring services are individualized to strengths and needs of each youth/family


Core Elements of MST

Key Points:

• MST Treatment Principles

• MST Analytic Process

• MST Quality Assurance System


MST Treatment Principles

• Nine principles of MST intervention design and implementation

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


1. Finding the Fit: The primary purpose of assessment is to understand

the “fit” between the identified problems and their broader systemic context

Kim’s Substance

Abuse

Drug using Peers Access to

marijuana

Kim can buy drugs with cash given to her by

relatives

Uses after conflicts with

mother

Lack of consequences

for use

Boredom, doesn’t have other things

to do

Modeling of use in community (peers

and adults)

Low monitoring by mother

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Principles of MST (Cont.)

2. Positive & Strength Focused

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



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.


5. Targeting Sequences: Interventions should target sequences of behavior within and between multiple systems that maintain identified problems (cont.)

Mom asks youth to do

homework and clean room

Youth says he’ll do it in a minute

Mom makes a second

request; youth ignores

Step-father intervenes:

“listen to your mom”

Youth states “get out of my face, you’re not my dad”

Step father starts shouting: “you live in my

house, do it now”

Mom gets in the middle to stop

verbal argument and gets pushed

Mom hits her head, step-

father is furious

Youth runs to room, and locks

door

Step-father calls police

Youth arrested for assault

charge


6. Developmentally Appropriate

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



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

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



9. Generalization

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.


Environment of Alignment and Engagementof Family and Key Participants

Measure

Re-evaluate Prioritize

Do

IntermediaryGoals

InterventionDevelopment

MST Conceptualizationof “Fit”

Assessment ofAdvances & Barriers to

Intervention Effectiveness

InterventionImplementation

MSTAnalyticalProcess

ReferralBehavior

OverarchingGoals

Desired Outcomesof Family and Other

Key Participants

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Causal Models of Delinquency and Drug Use: Common Findings of 50+ Years of

Research

Family

School

DelinquentPeers

DelinquentBehavior

Prior DelinquentBehavior

Neighborhood/ CommunityContext

18

Research on Delinquency and Drug Use

Family Level

• Poor parental supervision

• Inconsistent or lax discipline

• Poor affective relations between youth, caregivers, and siblings

• Parental substance abuse and mental health problems


Research on Delinquency and Drug Use (Cont.)

Peer Level

• Association with drug-using and/or delinquent peers

• Poor relationship with peers, peer rejection

• Association with antisocial peers is the most powerful direct predictor of delinquent behavior!



School Level

• Academic difficulties, low grades, having been retained

• Behavioral problems at school, truancy, suspensions

• Negative attitude toward school

• Attending a school that does not flex to youth needs



Community Level

• Availability of weapons and drugs

• High environmental and psychosocial stress (violence)

• Neighborhood transience – neighbors move in and out


Research on Delinquencyand Drug Use (Cont.)

Youth Level

• ADHD, impulsivity

• Positive attitude toward delinquency and substance use

• Lack of guilt for transgressions

• Negative affect


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MST Theory of Change


MSTImproved

Family Functioning

Peers

School

Reduced Antisocial

Behavior and Improved

Functioning

Community


25

Evona Referral Behaviors

Substance Use: Marijuana, Methamphetamines (daily)

Runaway Behavior: Several times over the past year for as long as two months

Truancy: Missed all of the first half of the school year in 2017 - 2018


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Evona Overarching Goals1. The youth will maintain a clean and sober lifestyle as evidenced by at

least four clean U.A. tests and reliable collateral reports from family and community members

2. The youth will follow curfew and home guidelines established by Dad and appointed Guardians as evidenced by no reports or arrests for runaway or

AWOL behavior during MST

3. The youth will attend school at least 80% of the time and receive passing grades as evidenced by reliable school, parent, and community reports


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EvonaSA

Fit Factor: Negative Peer Association (Evonawas spending time with SA peers while on

runaway)Evidence: AEB – reliable collateral reports

Fit Factor: Parent SeparationEvidence: Evona started using when

his mom left to live in Tonga

Fit Factor: history of Substance use in extended Family

Evidence: Family ReportFit Factor: Access and opportunity in community

Fit Factor: Low MonitoringEvidence: Parent Absent or busy

working

Fit Factor: Coping with Loss, sadness and frustration

Fit Factor: Idle, Unsupervised time

Evidence: truant and not in prosocial activities

Evona Fit Circle


28

John Paul Referral Behaviors

Disruptive in Class: Comes in late; talks loudly; throws pencils/objects; ordered a pizza during class. Started in 8th grade but has increased in

frequency and intensity in the last 2 months

Theft: Youth and younger brother broke into an amazon package in a driveway where they suspected fidgets were delivered; took fathers credit card without permission and ordered vaping products online to be delivered. Increased in

frequency resulting in arrest and charges pending (May/June)


29

Illegal Activities on Campus: Youth and younger brother sold powdered lemonade on campus under guise of drugs to students; current investigation of

being in possession of e-cigarette/vape on campus

Verbal Aggression: Mimics teacher; swears; uses abusive language; makes threatening comments/gestures to teachers and to mom. Escalating behaviors

since mid 8th grade

John Paul Referral Behaviors Continued


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John Paul Overarching Goals

1. John Paul will be able to re-direct himself from being disruptive in class after one prompting on 4 out of 5 days per parent-teacher report

2. John Paul will have no arrests in the community during MST treatment per parent/police report

3. John Paul will not engage in illegal activities on campus during MST treatment per parent/administration/police report


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4. John Paul will express himself to caregivers without being verbally aggressive (no swearing, yelling, cursing) with one prompting on 4 out of 5 days per parent report

5.John Paul will diminish his use of e-cigarettes/vapors during MST treatment per parent report

John Paul Overarching Goals Cont…


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John Paul Fit Circle

Illegal behaviors

on Campus

Fit Factor: Negative Peer InfluenceEvidence: School report, psych eval

Fit Factor: Low monitoring and supervision

Evidence: had unsupervised free time at school

Fit Factor: Youth Impulsivity

Fit Factor: Ineffective rules, rewards and contingencies at school

Evidence: school uses suspension which is reinforcing for youth

Fit Factor: ineffective home contingencyEvidence: Family was not connecting

home contingency/rewards to outcomes; believed in natural consequences

Fit Factor: ineffective home-school linkEvidence: Family believed that if they did not hear anything it was fine

Fit Factor: Ineffective co-parentingEvidence: Dad report that parents are

not always on the same pageFit Factor: Access to itemsEvidence: Parents did not know how to prevent youth from bringing items to school

How MST AddressesYouth Substance AbuseCausal Models of Delinquency and Drug Use: Common Findings of 50+ Years of Research

Family

School

Delinquent/ Substance-Using Peers

Delinquent/ Substance-Using

Behavior

Prior Delinquent/Substance-Using

Behavior

Neighborhood/ CommunityContext


How MST Addresses Substance Abuse


• Strong Engagement of Caregivers and Youth, and their ongoing involvement in working to address the youth’s substance abuse problems is key to addressing youth’s substance abuse problems.

• MST Keeps Kids in Treatment!



• Assessment of Youth Drug & Alcohol Use– Finding the Fit – Assessment is informed by

multiple sources to understand the way the youth’s use of drugs and/or alcohol fits within the context of the youth and family system, and other elements of the youth’s ecology


• Intervention Strategies:– Redirecting the young person away from substance-using peers– Monitoring the youth’s whereabouts closely– Detecting use with objective mechanisms

(e.g. UA or breathalyzer)– Reducing family conflict– Establishing powerful incentives to stay clean– Helping the youth to develop refusal and coping skills to

promote abstinence




• Quality Assurance and Implementation with Fidelity– Therapist adherence to the nine treatment

principles has been linked with decreased drug use in youth who receive MST (Henggeler, Pickrel, & Brondino, 1999)

Incorporating Contingency Management in MST

Contingency Management is one of the most extensively researched and best validated interventions in the field of substance abuse treatment

Henggeler et al., 2006


Integration of CM into

MST

Improved outcomes in juvenile drug

court via substance use reduction

Accelerated decrease in

substance use



• CM is a substance abuse treatment approach based in behavioral and cognitive-behavioral therapy that includes

– Tailored ABC Assessments of use/non-use conducted with the youth and caregivers

– Family Drug-Management Planning, including Drug-Refusal Skills Training

– Point and Level Reward System

– Drug Testing Protocol used primarily by caregivers

– Strong focus on engagement and sustainability

CM has strong treatment compatibility with MST

• Areas of Focus


Improved Family Functioning

• increased monitoring of use by parents via drug testing

• increased parental consistency, including use of powerful incentives

• decreased family conflict

Decreased Contact with Negative Peers

• positive replacement activities

• family plans for risk-avoidance

• improved school attendance• youth drug refusal skills

Measurable Outcomes

• reduced substance use• generalization of treatment

gains• sustained improvements


Substance Abuse Results in MST

Randomized Trial with Substance Abusing / Dependent Offenders (N=118); MST vs. Community Treatment

Henggeler, Pickrel, & Brondino, 1999


Enga

gem

ent

& R

eten

tion

• 98% of MST families completed treatment Su

bsta

nce

Use

• Greater post-treatment reductions for MST Sc

hool

Att

enda

nce

• Significant increase in regular school settings


Henggeler, Clingempeel, Brondino, & Pickrel (2002).


0%

10%

20%

30%

40%

50%

60%

Marijuana Abstinence at 4-Year Follow-up

Youth in MST

Youth in Usual Services


4-Year Follow up

Henggeler, et al 2002


0

0.2

0.4

0.6

MST youth Control Group

Arrests per Year for Violent Crimes

Arrests for ViolentCrimes


Schaeffer & Borduin (2005)


0

0.2

0.4

0.6

MST

Treatment as

usual

Decreased drug-related arrests at 14 years

Consistent Outcomes for MST

In Comparison with Control Groups, MST:• Led to higher consumer satisfaction• Decreased long-term rates of re-arrest 25% to 70%• 47% to 64% decreases in long-term rates of days in out-of-home

placements • Improved family relations and functioning• Increased mainstream school attendance and performance • Decreased adolescent psychiatric symptoms• Decreased adolescent substance use

But, none of this happens without adherence to MST


14 years post treatment(n= 165, 94% tracking success)• 54% fewer arrests• 59% fewer violent arrests• 64% fewer drug-related arrests• 57%fewer days in adult

confinement• 43% fewer days on adult

probation

22 years post treatment

(n= 148, 84% tracking success)• 36% fewer felony arrests• 75% fewer violent felony arrests• 33% fewer days in adult confinement• 38% fewer issues with family instability

(divorce, paternity, child support suits)• 3% fewer financial problems

(credit, contract, rent suits)


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14-year and 22-year post-treatment outcomes (MST compared to Individual Treatment: individuals treated 1983-1986)

Long-term Outcomes for MST

MST Assumptions• Children’s behavior is strongly influenced by their

families, friends and communities (and vice versa)

• Families and communities are central and essential partners and collaborators in MST treatment

• Caregivers/parents want the best for their children and want them to grow to become productive adults


MST Assumptions (Cont.)

• Families can live successfully without formal, mandated services

• Change can occur quickly

• Professional treatment providers should be accountable for achieving outcomes

• Science/research provides valuable guidance


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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 each youth’s natural environment

• Significant energies are devoted to developing positive interagency relations

• MST personnel are well trained and supported• Providers are accountable for outcomes

• Continuous quality improvement occurs at all levels


MultisystemicTherapy: Who we Are, What We Do, and Real...

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