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Multisystemic Family Therapy
Theory of Social Ecology

Multi-determined nature of human behavior

Ecological validity

Reciprocal Nature of Human Interaction
(Bonfenbrenner’s 1979)
Multi-determined nature of
human behavior
 Family
 Peer
 School
 Neighborhood
Broad View of Contextual Influences

E.g., mother’s employer, school board
Contributors to Delinquency
Within Systems & Between
Systems

Within systems
Lax parental supervision
Association with delinquent peers

Between systems
Lack of caregiver knowledge about friends
Conflict between family and school
(Henggeler et al., 2009)
Ecological Validity

Understand youth functioning real world
Home
Classroom
Community

First hand sources
Caregivers, siblings, teachers, coaches
Reciprocal Nature
of Human Interaction

Parent asks teen to do chores

Child complains, argues, does them poorly

Parent – easier to do him/herself

Child learns complaining works
Main Agent of Change
Caregivers
Example:
Uses family strengths: love of child, social
support
Overcome stressors: parental substance
abuse, stress, hopelessness
Increase caregiver effectiveness
Example

Help parents design effective interventions

That support prosocial behavior
Effective caregivers
Supportive school
Involved extended family
Support from neighbors
New Generations of Family Therapy
1)
Systemic focus
2)
Not just family: wider systems
3)
Include biological factors: Use of
medication
4)
Emphasis on therapeutic alliance
(Lebow, 2005)
New Generations of Family
Therapy
5)
6)
Shaping interventions to research on
specific issues
Sustaining change – engagement in
sports, prosocial groups
7)
Emphasizing family strengths
8)
Considering client goals
New Generation of Family
Therapy
9)
Tracking outcomes
10)
Attending to culture
Prefer therapists from culture
Research on Causes

Not amenable to interventions
Genetic loadings
Prenatal exposure to toxins
(Henggeler et al., 2009)
Research on Causes

Teen
ADHD, impulsivity
Positive attitudes to delinquency
Lack of guilt
Negative affect
(Henggeler et al., 2009)
Research on Causes

Family
Poor supervision
Parental substance abuse
Parental mental health problems
Inconsistent or lax discipline
Poor affective relations with teen
(Henggeler et al., 2009)
Research on Causes

Peers
Association with drug-using or
delinquent peers
Poor relationship with peers, peer rejection
(Henggeler et al., 2009)
Research on Causes

School level
Academic difficulties, low grades, held back
Behavioral problems – truancy, suspensions
Negative attitudes towards school
Inflexible school: zero-tolerance
(Henggeler et al., 2009)
Research on Causes

Neighborhood
Availability of weapons & drugs
High environmental and psychosocial
stress (e.g., violence)
(Henggeler et al., 2009)
Research on MST Mechanisms
of Change
Improved family
Functioning &
Parental monitoring
High therapist
adherence
MST
Decreased
association with
delinquent peers
Decreased
delinquent
behavior
(Henggeler et al., 2009)
Clinical Implications

Address caregiver functioning

Empower families to address teen problems

Must deal with delinquent peer issue

Improve school or vocational performance

Develop indigenous support system
(Henggeler et al., 2009)
Therapist Attitude to Families
Don’t
 Blame
families
 Ignore
families
 Label
 Give
families
up on families
(Henggeler et al., 2009)
Basic MST Team Structure
2 to 4 therapists
Supervisor
Each therapist: 4 to 6 families
Intensive home-and community-based tx
3 to 5 months: 60 hours
Home Based Model
24 hour, 7 day a week availability
9 Treatment Principles
1) Finding the fit between problems and the
system

Example: therapist developed fit circle
hypothesizing roles played by school,
caregiver, peer, individual & community
factors in development and maintenance
of problem behaviors
(Henggeler, 2009)
Treatment Principles
2) Positive and strength focused

Therapeutic contacts should emphasize
system strengths

Example: Therapist leveraged father’s
commitment to son and son’s desire for
father’s respect to facilitate commitment
to treatment
(Henggeler, 2009)
Treatment Principles
3) Increasing responsibility

Interventions designed to increase
responsible behavior and decrease
irresponsible

Example: Goals were 1) Increase
attendance at school, stop using drugs,
and comply with father’s rules
(Henggeler, 2009)
Treatment Principles
4) Present focused, action oriented and
target well-defined problems

Example: Treatment targets that can be
measured. Attending school measured by
school records. Stopping drugs confirmed
by urine tests. Teen’s anger over mother’s
abandonment not a treatment target.
Treatment Principles
5) Targeting sequences within and between
multiple systems that maintain problems

Examples: Poor home-school link
father/son conflict - ineffective monitoring
father/school conflict - father avoiding
school; school judging father
youth/school conflict – youth insufficiently
supervised at school; youth avoided
school
(Henggeler, 2009)
Treatment Principles
6) Developmentally appropriate

Example: Plan included awards and
consequences appropriate for a teen – access
to music, video games, cell phone use,
transportation, and money
Treatment Principles
7) Continuous effort

Interventions require daily or weekly effort
by family members

Example: home/school daily report card;
home behavioral plans require daily effort
(Henggeler, 2009)
Treatment Principles
8) Evaluation and accountability

Efficacy is evaluated continuously from multiple
perspectives

Example: Monitoring drug use through urine
screens, school attendance through school
records, curfew compliance through father, son,
and probation reports
(Henggeler, 2009)
Treatment Principles
9) Generalization

Interventions designed to promote treatment
generalization and long-term maintenance of
change by empowering family to address
members’ needs across systems

Example: Father learned to communicate with
school, better access social supports, obtain
urine drug screens and develop behavioral
interventions
(Henggeler, 2009)
Training and Supervision

5 day initial orientation

Majority of learning – working with families
and supervision by on-site supervisor and
off-site consultant

Weekly meeting with supervisor who uses
a protocol for reviewing cases

Weekly discussion with consultant
Referral
Referral
behavior
behavior
MST Analytic
Process
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Fit
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Fit
Prioritize
Intermediary
Goals
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Fit
Prioritize
Intermediary
Goals
Intervention
development
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Fit
Prioritize
Intermediary
Goals
Intervention
implementation
Do
Intervention
development
Referral
Referral
behavior
behavior
MST Analytic
Process
Desired
outcomes of
family
Overarching
goals
Fit
Re-evaluate
Prioritize
Intermediary
Goals
Assessment
Measure
Intervention
implementation
Do
Intervention
development
Prime Features

Never give up on families

Failed interventions are team’s responsibility
Assessment


Background Information Form
Genogram
Reasons for referral: Problems
Frequency
Intensity
Duration
Impact
Meets with stakeholders: Family,
teachers, probation officers, etc.
Genogram
Father’s parents live in
Puerto Rico and write but
do not visit
63
59
Ricardo & brother Jose
emigrated 5 years ago
38
15
Jose
19
38
20
40 F
Ricardo
History
of arrest
13
Mia
36 M
16
Rick ADHD
Assessment


Strengths & Needs Assessment
In each system: family, school, etc.
Case Summary
Referral Behaviors
Behavior
Frequency
Intensity
Duration
Marijuana Use
3 – 4 times a week
1 – 2 blunts
shared with 2
peers
Approx. 16
months
Truancy
2 – 3 times a week
Skips entire
day
Started last
school year (12
mos. ago)
Aggression –
fights with peers
Two incidents
Client had
stitches, black
eye
Incidents were 3
and 8 mos. Ago
Father-son
conflict – both are
verbally
aggressive
1 – 2 times a week
Both scream,
youth uses
rude language;
lasts 1 – 2
minutes
(Henggler, 2009)
Desired Outcomes
Participant
Goal
Rick
Get off probation
Get dad to stop nagging
Ricardo (father)
Rick go to school
Rick get a job
Rick make him proud
Mia
Rick do good
Rick stop getting in trouble
Rick stop fighting
Jose (Uncle)
Rick stay away from bad kids
Rick stop smoking dope
Probation officer
Rick stay in school
Rick stop using drugs
Rick stop fighting
(Henggler, 2009)
System Strengths & Weaknesses
Systemic Strengths
Individual:
Athletic – likes baseball
Social – leader
Wants a job
Family:
Father committed to son
Sister well-behaved
Uncle supportive
School:
Willing to work with teen as long as he
tries to improve
Has a baseball team
PE teacher/coach interested
Systemic Weaknesses
Impulsive
Verbally & physically aggressive
Failing classes
Thinks can’t stop marijuana
Father authoritarian
Father & son hyigh conflict
Father history of arrest
Mother drug use
Mother gone
Negative peers are at school
Low supervision in free time
School negative to family
Teen may not be sports eligible
School not in contact with father
System Strengths & Weaknesses
Systemic Strengths
Peers:
Positive friends 2 years ago still go to
school
One friend has job
Cousin Joe may be role model – has job
Has one prosocial peer he’d like to spend
time with – plays baseball
Community:
Recreation center in neighborhood
Little sister goes to church
Lady next door potential support for father
Systemic Weaknesses
Most peers are not in school or skip
Most friends use marijuana & alcohol
2 friends in fights
Father authoritarian
Father & son hyigh conflict
Father history of arrest
Mother drug use
Mother gone
Weekly Review
1)
2)
3)
4)
5)
6)
Therapist describes overarching goals
Therapist lists previous intermediary goals &
whether met in last week
Therapist lists barriers to intermediary goals
experienced in last week
Explains advances on gains in last week
Revise “fit” with new info
Therapist states new intermediary goals
(Henggeler, 2009)
Weekly Review

Overarching Goals
School - No unexcused absences
No disruptive behavior
Passing grades
Marijuana – Stop
No fighting
Father and son – reduced conflict
(Henggeler, 2009)
Previous Intermediary Goals
Met
Therapist & father attend IEP meeting
Strategize approaching teachers
Develop school report card for teachers
All teachers agree to complete card
Set another meeting
Partially
No
Met
Met
Met
Partial
Met
Father to collect urine for drug screen
Partial
Father and teen to try three strategies when conflict arises
Partial
Cousin J to take teen to job interview
Not
Review peer sheet with father
Not
Barriers to Intermediary Goals
English teacher not in IEP conference – teen failing in her class plus behavioral
problems – need teacher buy-in on card
Teen left school early 2 days – came out in conference
Father collected urine but unsure how to read results – didn’t call therapist – gave
teen privileges as if screen were clean
Teen disrespectful and didn’t follow through with conflict plan
Cousin had to work unexpectedly and couldn’t take teen to job interview
Advances in Treatment
Coach attended IEP – seemed fond of teen – willing to help
Teachers and father agree on a more vocational track
Teachers seem willing to fill in brief report card each day
Teen set up another time to go with cousin for job interview
Father had neighbor help twice this week – check to see if teen home
Father rewarded son this week for making curfew
Teen: Why
should I try?
I’m going to
fail anyway.
Left after PE,
before English
– easy to
escape
Behavior plan for
home/school link
not in place – no
consequences
Teen left
school
early 2 x
Left with 2
peers – went
to house of
one
unsupervised
Reassessment of Fit
between Problems &
Intermediary Goals
Father thinking
teen trying to
make him mad –
felt hopeless
Unable to
use conflict
resolution
plan
Father uses
intolerant
tone; teen
disrespectful
Father’s anger
makes teen feel
he’s winning
Fit Circles
Insufficient
structure –
too much
down time
Poor impulse
control
Marijuana Use
Mom’s drug
history – drugs
normalized
Drug-using
peers
Family conflict
Poor
parental
supervision
New Intermediary Goals
Therapist to follow-up with English teacher
Therapist to check with father on daily report card
See if teachers comply with plan
See if father able to follow through with consequences
Father to call coach about teen not skipping out after P.E.
Father to call peer’s mom and ask not to allow teen there during school
Work on conflict
Ask father/son why not follow through on conflict plan
Shift roles in role play
Thought replacement when father discouraged
Pizza for family to facilitate engagement
Therapist to collect random urine drug screen this week
(Henggeler, 2009)
Support for Therapists
 Initial
5 day orientation training
 Quarterly
booster training
 Weekly
on-site supervision
 Weekly
consultation
Engaging Multi-problem Families







Empathy
Spending nonclinical time with family
Cognitive assists
Father as child
Warmth
Flexibility
Reframing
Reframing
1) Echo family’s point of view
“I know you think your baby is crying
because she knows you had a bad day
and she’s just trying to upset you.”
2) Offer an alternative
“Lots of babies get gas sometimes.
I’ve heard a lot of moms say their
babies are fussy right after they eat.”
3) Check to see family’s response.
“Do you think that might be part of
what’s going on?”
Nonclinical Strategies
 Family
Photos
 Food
 Helping
5
with practical needs
minute sessions
Dimensions of Family Relations
 Warmth
 Control
Parenting Style

Authoritative
Warmth
High
Control
High

Authoritarian
Low
High

Permissive
High
Low

Neglectful
Low
Low
Authoritative

Responsive to reasonable needs

Maturity demands appropriate to development

Clear expectations – school performance
Authoritarian
 Directive
 Require
 Severe
unquestioning obedience
punishment, sometimes physical
 Directive
 No
and over-controlling
teaching style
child participation in decisions
Permissive

Little structure and discipline

Few demands for mature behavior

Tolerate antisocial behavior

Warm and responsive, but not demanding
Neglectful

Little discipline or affection

Little concern or interest in parenting

Are not responsive to child’s needs

Do not expect responsible behavior
Outcome Studies
Study
Population
Comparison Follow
-Up
MST Outcomes
Henggeler
et al., 1986
N = 57
Delinquents
Diversion
Services
Post-tx
Family relations
Behavior problems
Association with delinq. peers
Brunk et al.,
1987
N = 33
Maltreating
Families
Behavioral
Parent
Training
Post-tx
Parent-child relations
Henggeler
et al., 1991
Serious
juvenile
offenders
Individual
counseling;
community
services
3 yrs
Alcohol and drug use
Drug-related arrests
Henggeler
et al., 1992
N = 84
Violent &
chronic
juvenile
offenders
Community
services
59
weeks
Family relations
Peer relations
Recidivism (43%)
Out of home placement (64%)
Outcome Studies - Recent
Study
Population
Comparison FollowUp
MST Outcomes
Stambaugh Serious
et al., 2007 emotional
N = 267
disturbance
Wraparound
18 mo.
Symptoms
Out-of-home
placement (54%)
Henggeler
et al., 2006
N = 161
Substance
abusing
teens in drug
court
4 Tx
conditions
including
family court
with usual
services
12 mo.
Post
entry
Substance abuse
TimmonsMitchell et
al., (2006)
N = 93
Juvenile
offenders at
imminent risk
of placement
Usual
community
services
18 mo.
Youth function
Substance use
Rearrests (37%)
Rowland et
al., 2007
N = 31
Serious
emotional
disturbance
Hawaii’s
intensive
Continuum
of Care
6 mo.
Post
entry
Symptoms
Minor crimes
Days out of home
(68%)
Outcome Studies- Sexual Offenders
Study
Population
Comparison FollowUp
Adolescent
sex
offenders
Individual
counseling
3 yrs
Borduin & Adolescent
Schaeffer sex
(2001) N offenders
= 48
Prelim
Usual
community
services
9 yrs
Borduin
et al.
1990
N = 16
Borduin &
Schaeffer,
in press
Full
MST Outcomes
Sexual offending
Other criminal offending
Behavior problems & symptoms
Family relations
Peer relations
Academic performance
Caregiver distress
Recidivism for sex crimes (83%)
Recidivism for other crimes
(50%)
Days incarcerated (80%)
Outcome Studies – Sex Offenders
Study
Letournea
u et al., in
press
Population Comparison FollowUp
Juvenile
sex
offenders
Usual sexoffender
specific tx
12 mos
post-tx
MST Outcomes
Sexual behavior problems
Delinquency, substance abuse &
externalizing symptoms
Out-of-home placements
34 Studies of MST
33 Showed Decreases:
Factors Studied
 Symptoms
 Rearrests
 Substance abuse
 Out-of-home placements
 Sexual behavior problems
 Externalizing symptoms
 Sexual crime recidivism
(Henggeler, 2009)
34 Studies of MST
33 Showed Decreases
Factors Studied:
 Inpatient admissions
 Medical charges & direct care costs
 Attempted suicide
 Violent crime
 Association with delinquent peers
 Ssychiatric symptomatology
(Henggeler, 2009)
34 Studies of MST
33 Showed Increases:
Factors Studied:
 Improved
family relations
 Improved parent-child interactions
 Improved peer relations
 Increased school attendance
 Higher consumer satisfaction
 Improved academic performance
 Increased social competence
34 Studies of MST
33 Showed Increases:
Factors Studied:
 Blood
glucose testing
 Metabolic control
 Youth functioning
1 Study
(Sundell et al., 2008)
Compared to child welfare services in
Sweden
No outcomes favoring either tx
Low treatment fidelity