Transcript Multisystemic Therapy (MST)

Multisystemic Therapy (MST)
For additional information see
www.mstservices.com
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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 outof-home placements
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MST Research and Dissemination
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Family Services Research Center (FSRC)
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MST Services
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Research Center at the Medical University of South
Carolina (MUSC), Dr. Scott Henggeler, Director
MUSC affiliated organization offering assistance in MST
program development and training through licensing
agreements with the MUSC and the FSRC
MST Institute
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Independent non-profit organization providing quality
control expertise, data, and tools to all interested parties
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MST “Champions” & Advocates
OJJDP - Office of Juvenile Justice and
Delinquency Prevention
 Washington State Institute of Public Policy
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 MST:
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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
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MST Research and Development
 Theoretical
underpinnings
 Research findings on delinquent
behavior
 MST research findings
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MST Theoretical Assumptions
Based on Bronfenbrenner, Haley , and Minuchin
Children and adolescents are embedded in
multiple systems that have direct and
indirect influences on their behavior.
 Influences are reciprocal and bi-directional
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Ecological Models
School
Family
Child
Peers
Neighborhood
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Ecological Models
Treatment Providers
Neighborhood
School
Peers
Family
Child
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Causal Models of Delinquency & Drug Use
Condensed Longitudinal Model
Family
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Low Parental Monitoring
Low Affection
High Conflict
School
Delinquent
Peers
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Delinquent
Behavior
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Low School Involvement
Poor Academic Performance
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Prior Delinquent
Behavior
Elliott, Huizinga & Ageton
(1985)
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Needs of Violent & Chronic Juvenile Offenders
and Their Multiproblem Families
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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
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The Missouri Delinquency Project
Charles M. Borduin, (PI), University of Missouri
Barton J. Mann, University of Illinois - Chicago
Lynn T. Cone, University of Missouri
Scott W. Henggeler, Medical University of South Carolina
Bethany R. Fucci, University of Missouri
David M. Blaske, University of Missouri
Robert A. Williams, University of Missouri
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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
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Service/Treatment Options
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Multisystemic Therapy
 77
completers
 15 dropouts
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Individual Therapy
 63
completers
 21 dropouts
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Usual probation services for refusers
 24
refusers
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Service Delivery vs. Treatment
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Service Delivery
Models
Family Preservation
Inpatient
Outpatient
Residential
Treatment
Foster Care
Treatment Models
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Multisystemic Therapy
Multisystemic
Therapy
Cognitive Therapy
Family Therapy
Psychodynamic
Therapy
Behavior Therapy
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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 broker
of 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
Expectations of Outcome
Responsibility of staff & agency
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Immediate, maximum effort by
family & staff to attain goals
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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
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MST Treatment Principles
 Nine
principles of MST intervention
design and implementation
 Treatment fidelity and adherence is
measured with relation to these nine
principles
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Principles of MST
1. Finding the Fit
The 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.
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Principles of MST
3. Increasing Responsibility
Interventions should be designed to promote
responsibility 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.
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Principles of MST
5. Targeting Sequences
Interventions should target sequences of behavior
within and between multiple systems that
maintain identified problems.
6. Developmentally Appropriate
Interventions should be developmentally
appropriate and fit the developmental needs of
the youth.
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Principles of MST
7. Continuous Effort
Interventions should be designed to require
daily or weekly effort by family members.
8. Evaluation and Accountability
Interventions efficacy is evaluated
continuously from multiple perspectives,
with providers assuming accountability for
overcoming barriers to successful outcomes.
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Principles of MST
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.
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Instrumental Outcomes at Post-treatment
Multisystemic Therapy was significantly
more effective at:
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Increasing family cohesion and adaptability
Increasing family supportiveness
Decreasing family hostility
Decreasing parental symptomatology
Decreasing behavior problems in youth
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Ultimate Outcomes at Four-Year Follow-Up
Multisystemic Therapy was significantly
more effective at:
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Preventing violent offending
Preventing other criminal offending
Preventing drug-related offending
Decreasing seriousness of committed crimes
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Missouri Delinquency Project
Percent of Offenders
Not Re-Arrested
120%
MST
Completers
100%
80%
MST
Dropouts
60%
40%
IT Completers
20%
IT Dropouts
Refusers
0%
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0.6
1.1
1.7
2.2
2.8
3.3
3.9
4.4
5
Years Past Treatment Termination
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The Role of Treatment Fidelity
Standard Training for MST clinical staff
 5-Day
on-site orientation to MST
 Weekly MST consultations:
viewed as the core of the training
program -- true on-the-job training
 Quarterly on-site booster training
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The Role of Treatment Fidelity
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.
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The Role of Treatment Fidelity
MST treatment adherence predicted:
decreased criminal activity
 decreased incarceration
 decreased adolescent emotional distress
 increased parental emotional distress
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The Role of Treatment Fidelity
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
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Bridging the Gap: University to Community
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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
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Community-based Dissemination Efforts
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Program Replications
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California
 Maryland
Connecticut
 Michigan*
Colorado
 Minnesota
Delaware*
 Missouri
Florida
 New York*
Ireland (No.)  Nebraska
Kansas
 North Carolina
Louisiana
 Ohio*
Manchester (UK)
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Oregon
Pennsylvania*
South Carolina*
Tennessee*
Texas*
Washington
Washington D.C.
Ontario, Canada*
Norway*
* Clinical Trials
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Critical Elements of Implementation
Continuous Focus on Outcomes
 Fidelity to the Treatment Model
 Accessibility of Treatment
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 What
influences these critical elements?
 Interagency
collaboration
 Organizational support of the program
 Operational practices and policies
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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:
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Juvenile Justice, Family Court, Mental Health,
Social Welfare, School systems, parent groups
Clearly defined target population,
program goals, and referral process
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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
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 Commitment
to training and supervision
 Policies (e.g. flex-time, transportation)
 Resources (e.g. pay, cellular phones)
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Influences within the Clinical Context/Team
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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
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Why is MST Successful?
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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
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