Transcript MST Substance-Related Outcomes

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
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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
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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 MST
1. Finding the Fit
2. Positive & Strength Focused
3. Increasing Responsibility
4. Present-focused, Action-oriented & Welldefined
5. Targeting Sequences
6. Developmentally Appropriate
7. Continuous Effort
8. Evaluation and Accountability
9. Generalization
Referral
Behavior
Desired Outcomes
of Family and Other
Key Participants
MST
Analytical
Process
Overarching
Goals
Environment of Alignment and Engagement
of Family and Key Participants
MST Conceptualization
of “Fit”
Re-evaluate
Prioritize
Assessment of
Advances & Barriers to
Intervention Effectiveness
Intermediary
Goals
Measure
Intervention
Implementation
Do
Intervention
Development
PUBLISHED MST OUTCOMES
10 Randomized Trials and 1 Quasi-Experimental
Trial Published (>1000 families participating)
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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
$64,000/youth
15.
Bootcamps
($ 7,910)/youth
Percentage of Offenders
Not Re-Arrested
Simpsonville, SC Project
110%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MST
Usual
Services
0
0.4
0.8
1.2
1.5
Years Post Treatment
2
2.4
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%
0
0.6
1.1
1.7
2.2
2.8
3.3
3.9
Years Past Treatment Termination
4.4
5
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
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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
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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 MST
QUALITY 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
MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Supervisor
Youth/
Family
Therapist
Supervisory
Adherence
Measure
Therapist
Adherence
Measure
Manualized
Manualized
MST
Consultants/
MST Institute
Internet communication
Person to Person communication
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)
MST QUALITY ASSURANCE SYSTEM
Organizational Context
Manualized
Manualized
Supervisor
Youth/
Family
Therapist
Supervisory
Adherence
Measure
Therapist
Adherence
Measure
Manualized
Manualized
MST
Consultants/
MST Institute
Internet communication
Person to Person communication
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 CommunityBased 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
<[email protected]>
• Publication Requests: <musc.edu/fsrc>
• Dissemination/Site Development:
Marshall Swenson, 843 856-8226
<[email protected]>