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Multisystemic Therapy
Multisystemic Therapy M R McCart, S W Henggeler, and S Hales, Medical University of South Carolina, Charleston, SC, USA ã 2011 Elsevier Inc. All rights reserved.
Glossary Controlled clinical trial: A type of scientific experiment that involves assignment of research participants to intervention and control groups. Efficacy trial: A controlled clinical trial that is designed to test whether an intervention is effective under ideal circumstances. Effectiveness trial: A controlled clinical trial that measures whether an intervention is effective in ‘real world’ clinical settings.
Introduction Multisystemic therapy (MST) is a family- and community-based treatment for youth with serious delinquent behavior (e.g., violent offending, sexual offending, chronic offending) who are at risk for being placed out of the home (e.g., in detention, jail, or a residential treatment setting). The model has also been adapted for youth and families presenting other serious clinical problems (e.g., serious emotional disturbance, maltreatment, chronic health care conditions). Numerous published clinical trials have shown that MST is an effective treatment for juvenile delinquents and for youth with other serious problems. With MST programs for juvenile offenders transported to more than 30 states and 11 nations, treating 17 000 youth and families annually, MST is one of the most widely transported evidence-based treatments that have been developed. The purpose of this article is to provide a brief overview of the MST approach. Specifically, this article discusses the theoretical basis of MST and provides a description of the MST treatment model. A case example is presented and research supporting the effectiveness of MST is summarized.
Characteristics of the MST Model Theoretical and Research Foundations Social ecological theory, as developed by Urie Bronfenbrenner, serves as the conceptual foundation of MST. The theory of social ecology proposes that human behavior is influenced by characteristics of the multiple systems in which individuals are embedded (e.g., family, peer, school, neighborhood) as well as their reciprocal relations with persons within those systems. Consistent with this view, decades of research have shown that the primary risk factors for delinquency pertain to various aspects of the youth’s environment, such as the family, peer network, school, and neighborhood. For example, at the family level, certain caregiver difficulties (e.g., high stress, mental health problems, substance abuse) and ineffective parenting practices (e.g., low supervision, inconsistent discipline, poor affective relations) predict elevated levels of delinquent
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Pharmacotherapy: The treatment of a clinical problem through the administration of medication. Recidivism: The repetition of criminal or delinquent behavior. Stakeholder: An individual who has an interest in and is affected by the outcome of a process. Transportability trial: Research that examines the movement of effective interventions to usual care settings.
behavior among youth. Regarding the peer network, research shows that youth are more likely to participate in delinquent acts if they associate with negative peers who are frequently in trouble. Indeed, association with deviant peers is the most powerful and consistent predictor of antisocial behavior in adolescents. At the school level, youth with academic and behavior problems often perform poorly in their classes and are more likely to drop out of school early, which, in turn, is associated with higher rates of antisocial behavior. Further, youth who reside in neighborhoods characterized by high levels of poverty, social disorganization, and criminal activity are more likely to engage in delinquent behavior. The social ecological model and literature on the determinants of delinquency have clear implications for the design of interventions. If youth antisocial behavior is multidetermined from risk factors pertaining to youth and the key social systems in which they are embedded, then, interventions must be capable of addressing a broad array of risk factors to optimize the probability of changing the behavior. Thus, MST works to address risk factors within each aspect of the youth’s environment (e.g., the family, peer, school) and between social systems that influence behavior (e.g., caregiver interactions with school). Further, to support behavior change in real-world contexts, consistent with Urie Bronfenbrenner’s concept of ecological validity, MST emphasizes the importance of considering delinquent behavior in its natural setting. Therefore, MST uses a home-based model of service delivery and strives for real-world validity in the assessment of behavior and delivery of interventions. Assessments are considered ecologically valid when they obtain information from multiple sources (e.g., caregivers, siblings, extended family, teachers) and consider the youth’s behavior in multiple areas (e.g., at home, in school, during neighborhood activities). Similarly, MST interventions are provided where problems occur (homes, schools, community locations).
MST Theory of Change A primary assumption of MST is that caregivers play a vital role in achieving and maintaining positive changes in their youth’s
Encyclopedia of Adolescence, Volume 3
doi:10.1016/B978-0-12-373915-5.00121-2
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behavior. Therefore, helping caregivers to develop the necessary skills to effectively parent their youth is a central focus of MST. As caregivers strengthen their parenting skills, the therapist assists the caregiver in targeting other areas that might be contributing to youth problem behavior, such as poor school performance and contact with negative peers. For example, a therapist might assist the caregiver with developing positive relationships with school personnel and encourage the caregiver to provide rewards to their youth (e.g., special meals) for improved grades. The therapist might also help the caregiver develop a system for encouraging the youth for spending time with positive peers (e.g., travel and resources for sports or club events) and for providing negative consequences (e.g., reduced curfew) when the youth associates with negative peers. MST interventions also strive to help caregivers develop a network of indigenous supports including family, friends, and community members in order to maintain the positive changes gained during treatment. In sum, a main goal of the MST theory of change is to create an environment where positive youth behavior is supported and problematic behavior is discouraged. Importantly, the MST theory of change has been supported in several rigorous research studies. Numerous outcome studies have shown that MST improved family relations, peer relations, and school attendance concurrent with decreases in youth criminal behavior and substance use. Studies with chronic offenders, juvenile offenders, and substance-abusing offenders, however, have also used sophisticated statistical techniques to examine the MST mechanisms of change. These studies showed that the capacity of MST to decrease adolescent antisocial behavior was directly attributable to MST effects on family relations and peer associations. That is, decreased antisocial behavior seems to be a product of the capacity of MST to empower caregivers and decrease youth association with antisocial peers.
Characteristics of MST Clinical Implementation Treatment Delivery Multisystemic therapy is delivered by a team of professionals that typically includes two to four full-time Master’s level therapists and an advanced Master’s level or doctoral level supervisor. MST teams are usually employed by private-sector (not-for-profit or for-profit) provider agencies and are contracted to work through juvenile justice, child welfare, mental health, and other health (e.g., Medicaid) authorities. MST therapists each carry a caseload of about four to six families. They, or another member of the team (an on-call schedule is used) are available to families 24 h day 1, 7 days a week so that sessions can be scheduled at times convenient to the family and so therapists can respond to crises whenever they occur. MST is intensive and usually consists of over 60 h of therapist contact with the family and other members of the youth’s environment. Treatment intensity, however, is matched to family need. For example, the therapist might work 6–10 h week 1 early in treatment as behavior change efforts are being first implemented. Later, assuming favorable changes have been made, therapeutic efforts focus on enhancing the sustainability of change. The duration of treatment,
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however, is fairly short and typically lasts from 3 to 5 months. As noted previously, there is a strong emphasis on the delivery of MST services in home- and community-based settings at times convenient to the family, which helps overcome barriers to service access (e.g., transportation) and facilitates family engagement in the treatment process.
Clinical Procedures Within MST, interventions are considered most effective when they are individualized to meet each family’s unique strengths and needs. Thus, MST does not follow a manualized treatment protocol. Instead, nine treatment principles provide the framework for problem conceptualization and treatment planning (see Table 1). Particular emphasis is placed on the provision of strength-based services (see Principle 2) – youth and systemic strengths are identified and used as levers of change throughout treatment. Thus, therapists communicate an optimistic perspective to the family and other members of the youth’s ecology throughout the assessment and treatment process. In close collaboration with the family and other stakeholders (e.g., juvenile justice authorities), the nine MST treatment principles help guide the development of each family’s treatment plan. Goals are created to include all aspects of the youth’s ecology, including the individual, family, peer, and community network. In the beginning stages of treatment, key members of the youth’s ecology (e.g., caregivers, teachers, juvenile justice authorities) define which youth behaviors to target in treatment. Next, the MST team identifies the primary environmental factors, or ‘drivers,’ that seem to be influencing each problem behavior and then organize them into a coherent conceptual framework. For example, a youth’s current drug use might be most closely associated with lack of supervision by caregivers and friendships with drug using peers. Next, MST therapists, along with other team members (i.e., other therapists on the team, the MST supervisor, and the MST expert consultant) create specific intervention strategies to target the most proximal factors that seem to be influencing the targeted Table 1
MST treatment principles
1. The primary purpose of assessment is to understand the ‘fit’ between the identified problems and their broader systemic context 2. Therapeutic contacts should emphasize the positive and use systemic strengths as levers for change 3. Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members 4. Interventions should be present-focused and action-oriented, targeting specific and well-defined problems 5. Interventions should target sequences of behavior within and between multiple systems 6. Interventions should be developmentally appropriate and fit the developmental needs of the youth 7. Interventions should be designed to require daily or weekly effort by family members 8. Intervention efficacy should be evaluated continuously from multiple perspectives 9. Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change Reproduced from Henggeler et al. (2009).
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behavior. Intervention strategies are developed using scientifically proven approaches such as behavioral parent training, cognitive behavior interventions, pragmatic family therapy, and motivational interviewing. Interventions that address specific environmental causes of behavior problems are incorporated into the treatment plan, such as helping a caregiver advocate for more school services or working with other parents in the neighborhood to provide after-school supervision for teens. Similarly, if it becomes apparent that a youth needs medication in conjunction with treatment to meet his or her needs, then evidence-based pharmacotherapy (e.g., for ADHD) is incorporated into the treatment plan. Intervention effectiveness is monitored continuously throughout MST. If interventions are not achieving the desired aims, the team uses the information gained from the failure to reconceptualize the drivers of the identified problems. Based on this reconceptualization, new interventions are designed and implemented in a recursive process until there is positive change in the target behavior. This process ensures that families are not blamed if an intervention strategy is not successful in changing youth behavior. Furthermore, MST requires therapists to ‘do whatever it takes’ to assist families in reaching treatment goals. A central assumption is that when the MST team develops accurate hypotheses about what drives youth behavior and then delivers appropriate interventions to target the specified drivers, families tend to meet their treatment goals.
Case Example Justin is a 16-year old African American male who was referred to MST by the juvenile court after receiving a charge for assault and battery. The charge stemmed from an incident in Justin’s neighborhood. According to Justin, an older boy ridiculed Justin’s clothes as he was walking a few blocks from his house. Justin became verbally aggressive and began punching and kicking the boy. Neighbors called the police and Justin was arrested. Table 2
Justin lives with his biological mother (Ms Wilson) and maternal grandmother in his grandmother’s home, which is in a low-income neighborhood. Justin’s father (Mr Smith) died of a heart attack when Justin was very young. According to Ms Wilson, Justin’s father was heavily involved in a local street gang known for drug dealing and violence. Ms Wilson reports that she and Justin have had no contact with Mr Smith’s side of the family during the past several years. Ms Wilson has been unemployed for the past 6 months. She devotes most of her time to looking for employment and frequently spends the night at her boyfriend’s house. When Ms Wilson is away from the home, Justin is cared for by his grandmother. However, Justin’s grandmother is on several medications for chronic health problems that cause significant drowsiness. As a result, she sleeps often, leaving Justin unsupervised for large portions of the day and evening. Conversations with Ms Wilson also revealed that she rarely disciplines Justin for his misbehavior. At school, Justin is reported to be well-liked by teachers, but his attendance is sporadic (2–3 days week 1) and he is two grades behind (in ninth grade instead of eleventh). Justin’s probation officer and family report that Justin spends most of his time with a group of same-aged peers who frequently skip school and fight with youth from a neighboring community. The initial MST assessment focused on identifying key strengths in Justin’s ecology, the desired outcomes of all stakeholders (e.g., family members, probation), and the fit between identified problems and their broader systemic context (Principle 1). Through conversations with Justin, his mother, his grandmother, and a teacher at Justin’s school, the MST therapist was able to identify several strengths and needs across Justin’s key ecological systems (see Table 2). Key systemic strengths include Justin’s prosocial interests, positive relationships with teachers, and his large maternal family social network. Some key ecological needs include low family monitoring/discipline, Justin’s academic difficulties, and limited opportunities for prosocial activities in the
Strengths and needs: Justin’s ecology
System
Strengths
Needs
Youth
• • •
Athletic Polite to adults Prosocial interests: basketball
Family
• • •
Strong mother–son bond Strong work ethic (mother, mother’s boyfriend) Large extended network on mother’s side, all positive – mother has two sisters; Justin has several same-age cousins Mother’s boyfriend cares, has positive relationship with mother and Justin Likeable, pleasant Several prosocial cousins close in age Mostly good relationships with teachers, who want Justin to do well
• • • • • • •
Low communication skills Gets angry quickly when provoked Positive view of aggressive retaliation Poor organizational and study skills Poor monitoring (mother gone most nights, grandmother too frail) Few consequences for misbehavior Paternal grandmother declining health/extensive medical needs
• • • • • • • •
Older and bigger than classmates Neighborhood peers mostly gang involved Two or more grade levels behind Struggles to understand material Poor work habits (e.g., no structure for homework) No recreational facilities/places for adolescents to hang out Alcohol and drugs easily available Gang presence
• School
• • •
Community
•
Peer
Church within walking distance; grandmother active there
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neighborhood. Justin’s desired outcomes were to ‘play basketball at the local community center’ and ‘meet members of his father’s family.’ Ms Wilson’s desired outcomes were for Justin to ‘stay out of trouble in the neighborhood’ and ‘complete high school.’ Justin’s grandmother desired for Justin to ‘stay away from drugs’ and ‘not get into any more trouble with the police.’ Justin’s probation officer requested for him to ‘complete an anger management group,’ and ‘attend school every day.’ Using these strengths, needs, and desired outcomes as a starting point, the MST therapist worked with the stakeholders to develop overarching treatment goals, including (a) no new criminal charges for Justin and compliance with probation officer requests, (b) compliance with all house rules, (c) demonstration of success in school (i.e., no unexcused absences or suspensions/expulsions, completion of assignments), and (d) increased contact with prosocial peers. Consistent with MST Principles, overarching goals used strength-based language (Principle 2) and set forth explicit criteria for judging when goals had been met (Principle 8). Within MST, efforts are often taken to prevent youths’ exposure to other court-involved youth in group settings. This stems from research showing that when delinquent youth spend time together, they tend to reinforce one another’s delinquent behavior. Therefore, the MST therapist requested that he be allowed to provide anger management skills training to Justin individually, rather than have him attend a court-sponsored anger management group, and the probation officer agreed. This treatment component was accomplished through individual sessions with Justin and occasional involvement from Ms Wilson using a structured, empirically supported anger management protocol.
The MST therapist also combined information across sources and identified the most likely drivers for Justin’s assault incident and poor school performance. As illustrated in Figure 1, the drivers of many problems were shared. For example, low caregiver supervision was a critical factor in Justin being out on the streets late at night and of his sporadic school attendance. Also, Justin’s embarrassment about being in a class with younger peers was supporting his tendency to skip school and associate with other truant peers. Drivers were then prioritized and targeted during treatment sessions occurring several times every week. Initially, the therapist addressed a few straightforward drivers that would give the family some early success, such as having Ms Wilson enroll Justin in an after school tutoring and homework club to help facilitate his understanding of classroom material and homework completion. Two identified drivers of Justin’s behavior problems were Ms Wilson’s low monitoring and the fact that Justin had few prosocial friends or activities. In addressing these drivers, the therapist began by challenging some of Ms Wilson’s misconceptions about parenting an adolescent, such as her belief that the grandmother’s mere presence in the home was sufficient to monitor Justin’s whereabouts, or that contact with peers only during the school day was enough to meet Justin’s developmental need for friendships and peer support. Consistent with the MST belief that intervention generalizability and maintenance of positive changes is enhanced when multiple ecology members are involved (Principle 9), the therapist included Ms Wilson’s boyfriend in some sessions. This boyfriend (who also had two boys of his own from a previous relationship) was instrumental in convincing Ms Wilson that Justin needed more
Mother not at home in evenings Mother won’t let Justin see paternal family
Grandmother poor health/frail
Conflict between Justin and Mother
Justin’s ineffective communication skills
Low parental monitoring and little discipline
Behind in school and poor attendance Difficulty understanding work
Assault on neighborhood peers
Out late at night in dangerous areas
Not completing homework
Embarrassed to be in classes with younger students
Figure 1 Drivers of Justin’s presenting problems.
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Association w/negative peers
Few prosocial peers or activities in neighborhood
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supervision and positive peer connections. Ms Wilson ultimately agreed to spend more nights at home so that she could supervise Justin and ensure that he went to school in the morning. With the help of the MST therapist, Ms Wilson also implemented a behavior plan in the home that involved rewards (allowance, time playing videogames) and consequences (taking his cell phone away) for school attendance, homework completion, and staying away from delinquent peers in the neighborhood. These interventions encouraged more responsible behavior from both Justin and Ms Wilson (Principle 3) and required consistent daily effort (Principle 7). As Ms Wilson implemented Justin’s behavior plan over several weeks, it became apparent that new, more varied rewards were needed to sustain Justin’s motivation to comply. One of Justin’s desired outcomes was to play basketball at a community center located about five miles from his house. The therapist accompanied Ms. Wilson to verify that the community center was an appropriate place for Justin to be with minimal supervision. A plan was then set up for Ms Wilson to take Justin to the community center for a few hours every Saturday, contingent upon his adherence to the behavior plan during the week. Justin’s behavior improved greatly with this extra incentive, and he began developing positive relationships with prosocial friends at the community center, thereby helping to meet Justin’s developmental need for appropriate peer contacts (Principle 6). As treatment progressed, Justin reiterated his strong desire to meet members of his paternal family. Ms Wilson initially objected to this idea, which angered Justin and led to some arguments in the home. To address this conflict, the therapist held dyadic sessions with Ms Wilson and Justin to help them with their communication and problem-solving skills (Principle 5). Over a series of sessions, Justin learned to calmly communicate his reasons for wanting to see his paternal family, and Ms Wilson discussed the reasons for her hesitation (i.e., her fear that they might expose Justin to gang activities). Using a problem-solving approach, Justin and his mother identified a paternal family member who had no gang involvement (paternal aunt) and who Ms Wilson felt more comfortable allowing Justin to see and set rules for their contact (e.g., Ms Wilson would be present for initial visits). As a result of this work, Justin was able to spend time visiting with his aunt and learn more about his father, which he greatly appreciated. Throughout treatment, the MST therapist solicited opinions from all stakeholders regarding whether interventions were helping the family meet their overarching goals (Principle 8) and made adjustments accordingly. By the end of treatment, both Ms Wilson and Justin reported fewer arguments in the home, an appraisal supported by Justin’s grandmother. School teachers confirmed that Justin’s attendance had increased and that his academic skills had improved. To facilitate the maintenance of Justin’s school improvements (Principle 9), Ms Wilson advocated that the school promote Justin to tenth grade and place him in an accelerated dropout prevention curriculum that would provide him with smaller classes, a supportive community of peers and teachers, and the possibility of graduating with his agemates. Justin had no additional arrests and began spending larger parts of his time playing basketball with new prosocial friends at the community center.
As with drivers for problem behaviors, MST therapists also identify drivers for improved behaviors. Hypothesized drivers for Justin’s improved behaviors included (a) increased and consistent supervision by his mother, (b) strictly enforced rules by Ms Wilson regarding school and whereabouts, (c) improved communication and decreased conflict between Justin and his mother, and (d) Justin’s involvement in prosocial age-appropriate activities with nondeviant peers.
Training, Supervision, and Quality Assurance Multisystemic therapy includes an intensive quality assurance and improvement system aimed at supporting treatment fidelity and youth outcomes. Several approaches are taken to provide training and supervision in MST. Therapists first participate in a 5-day orientation training. During this training, therapists learn about the theoretical and research foundations of MST, and they participate in role-play exercises to develop specific clinical skills (e.g., family engagement techniques, assessment and intervention strategies). Following this training, therapists gain experience delivering MST to families under the guidance of the Master’s or doctoral level MST-trained clinical supervisor. Supervisors meet weekly with therapists to review cases, help problem-solve barriers to family engagement, and ensure that the interventions follow the nine core treatment principles. In addition, each team is assigned an expert MST consultant who helps facilitate adherence to the MST model through quarterly booster trainings and weekly review of cases. This consultant is employed by MST Services Inc. (which is licensed by the Medical University of South Carolina for the transport of MST technology and intellectual property) or one of its network partners (i.e., organizations that have been trained to provide all aspects of MST program development and support). MST is implemented in the context of a comprehensive quality assurance and improvement system. Considerable effort is devoted to this system because, as noted subsequently, considerable research supports a strong relationship between therapist adherence to the MST model and positive youth/family outcomes (e.g., reduced delinquent behavior, improved caregiver–child relations). In addition to the initial and ongoing training, supervision, and consultation protocols, important components of the quality assurance and improvement system include validated surveys that measure implementation adherence by therapists, supervisors, and consultants, and a web-based tracking system that provides teams with ongoing feedback about adherence and youth outcomes. In addition to providing weekly consultation to the clinical team, MST expert consultants provide support to provider agencies who are interested in developing new MST programs. Specifically, consultants (a) conduct community assessments to determine whether the needs that prompted interest in MST are likely to be met by an MST program, (b) determine whether the agency has the practical resources needed to fund an MST team, and (c) explore whether the key leaders and decision-makers in the agency will be committed to the success of the program. Once an MST program has been implemented in a community, MST expert consultants provide continued support by conducting semiannual program reviews and by helping to problem-solve any organizational barriers to program implementation.
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Empirical Support for MST To date, MST has been evaluated in approximately 20 controlled clinical trials. On the basis of this research, several groups, including independent researchers, federal agencies (e.g., National Institute on Drug Abuse, US Surgeon General), and consumer advocates (National Alliance on Mental Illness), have concluded that MST is an effective intervention for youth exhibiting serious behavior problems and their families. The following sections provide a brief overview of MST outcome research – from efficacy trials to large multisite evaluations.
Efficacy Studies Efficacy trials are intended to provide a test of a developing treatment that optimizes the probability that favorable outcomes will be observed, if, in fact, the treatment is effective. Thus, MST efficacy trials included close direct supervision by key MST developers (i.e., Scott Henggeler in Memphis and, later, Chuck Borduin in Columbia, Missouri), and therapists were graduate students in clinical psychology. The studies were conducted through university clinics (though the MST homebased model of service delivery was used), which minimized the many organizational factors (e.g., paperwork and billing requirements, comp time, conflicting administrative demands) that can impede the success of MST programs. The first efficacy trial of MST was published in 1986 and evaluated MST with inner-city juvenile offenders. Subsequent efficacy trials were conducted with maltreating families, juvenile sexual offenders, and chronic juvenile offenders. Across these studies, findings consistently supported the efficacy of the MST model in comparison with control conditions. As per the aims of MST, affective and instrumental aspects of family relations were improved and youth showed decreased association with deviant peers. Importantly, juvenile offenders evidenced significant decreases in behavior problems, rearrests, and incarceration. One study, for example, followed research participants for 14 years and showed that MST produced a greater than 50% decrease in rearrest for violent crimes, drug-related crimes, and nonviolent crimes. Moreover, days incarcerated were reduced by 57% in that study, which has important implications for the cost-effectiveness of MST (i.e., savings through reduced out-of-home placements of youth).
Effectiveness Studies A primary aim of effectiveness research is to determine whether a treatment that has shown promise in ideal settings (e.g., university with close treatment developer oversight) can be implemented effectively, with similar results, in real-world clinical practice. Building off the favorable findings in the aforementioned efficacy trials, effectiveness studies of MST were conducted in collaboration with community mental health centers in South Carolina using real-world practitioners. In one study, Scott Henggeler served in the role of off-site MST expert consultant, with direct clinical supervision provided by a supervisor at the community mental health center. Participants were serious juvenile offenders at imminent risk of incarceration. Largely replicating the efficacy findings, results showed that MST was more effective than the comparison
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condition at improving family and peer relations as well as decreasing recidivism and out-of-home placement. A second effectiveness study examined whether favorable outcomes could still be attained if an off-site MST expert no longer provided weekly case support. If favorable outcomes still could be achieved, such would greatly ease the burden of quality assurance in the larger scale transport of MST programs (i.e., continuous training of therapists might not be needed). Participants were serious juvenile offenders at imminent risk of incarceration across two communities, and therapists and their supervisors were mental health center employees. Although MST was more effective than the comparison condition at decreasing youth psychiatric symptoms and rates of incarceration, significant treatment effects were not observed for family relations or rearrest. Importantly, in anticipation of less than ideal outcomes, a measure of therapist treatment fidelity had been developed and was administered to caregivers and youth (i.e., the measure assessed therapist adherence to MST treatment principles). Analyses showed that treatment fidelity was associated significantly with youth recidivism – when therapists adhered to MST treatment principles, rates of rearrest were significantly lower than when treatment adherence was poor. This finding supported the MST quality assurance system and clearly demonstrated the importance of treatment fidelity in achieving desired clinical outcomes. More recently, a third effectiveness study was conducted in Chicago with Chuck Borduin serving in the role of expert consultant. Participants were juvenile sexual offenders, and services were provided through an MST team working with a local provider organization. Results showed that MST was more effective than usual sex offender-specific treatment (e.g., cognitive-behavioral group therapy) at decreasing sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements. Together, this body of effectiveness research demonstrated the capacity of MST to be transported effectively to community-based settings.
Hybrid Efficacy-Effectiveness Studies The success of MST with serious juvenile offenders led to a series of studies examining MST with other types of severe clinical problems through the Family Services Research Center, Medical University of South Carolina (MUSC). In these studies, second-generation MST experts (i.e., individuals trained by Scott Henggeler) provided either direct clinical supervision or served in the role of off-site MST expert. The clinical samples in these studies included youth presenting psychiatric emergencies (i.e., suicidal, homicidal, psychotic), Hawaiian youth with serious emotional disturbance, substance-abusing juvenile offenders, and physically abused adolescents and their families. Some of the studies were conducted through community mental health centers, and in others, therapists were employed by the university. Except for the Hawaiian study, all were conducted in Charleston, South Carolina. Results tended to be comparable across these studies and favored youth and families in the MST condition. Youth evidenced decreased emotional and behavioral problems as well as decreased substance use. Families tended to show improved functioning, and youth spent more time in regular school settings. Importantly, with the exception of one study in
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which MST was integrated into juvenile drug court, MST was highly effective at decreasing days in restrictive out-of-home placements (e.g., incarceration, psychiatric hospitalization). Together, these studies demonstrated the capacity of MST to achieve favorable outcomes with no involvement of an MST treatment developer and with youth and families presenting significant problems other than serious criminal offending.
Independent Transportability Trials Several rigorous evaluations of MST have been published by independent investigators – researchers not affiliated with the treatment developers. Such studies provide ultimate tests of the transportability of a promising treatment. If a treatment model can prove effective in distal real-world clinical settings when training is provided by third-generation MST experts, a major step in closing the science to service gap can be accomplished. In the case of these studies, quality assurance was overseen by MST Services (the MUSC-licensed organization noted previously), and treatment was provided by community-based practitioners. Terje Ogden conducted a multisite trial of MST in Norway that focused on youth with serious antisocial behavior (Norway does not have a juvenile justice system). Results showed that MST was effective in decreasing youth externalizing and internalizing symptoms and at increasing youth social competence. Importantly, large decreases in out-of-home placement were observed, and these were sustained through a 2-year follow-up. Also, outcomes were linked with treatment fidelity – in particular, one of the four sites in this study evidenced poor fidelity to the MST program, and this site did not have positive outcomes. In further research, Terje Ogden has shown that favorable MST practices and outcomes were sustained past the completion of the outcome study. However, a recent multisite clinical trial conducted in neighboring Sweden failed to replicate favorable MST treatment effects. In attempting to understand this failure to replicate, the investigators noted that treatment fidelity was very low across the research sites. The first independent MST trial in the United States was conducted by Jane Timmons-Mitchell and her colleagues with juvenile felons at imminent risk of out-of-home placement. Findings showed that MST was more effective than usual services at improving youth functioning, decreasing substance use problems, and reducing rearrests. Subsequently, another clinical trial was conducted by Leyla Stambaugh and colleagues on youth with serious emotional disturbance and at risk for out-of-home placement. MST was compared with Wraparound, which is a widely used intensive intervention in system-of-care sites in the United States. MST was more effective than Wraparound at decreasing youth symptoms, improving youth functioning, and reducing out-of-home placements. In summary, the effectiveness of MST has been replicated by independent investigators in community-based settings, with third-generation MST experts providing ongoing quality assurance – such as currently being provided for MST programs worldwide. A critical caveat, however, pertains to the importance of treatment fidelity in achieving favorable outcomes, which also applies to other evidence-based treatments transported to real-world contexts.
Adaptations to the Basic MST Model The basic MST model includes several key components that can be applied effectively for treating youth with complex clinical problems other than antisocial behavior. These critical features of MST include addressing the multidetermined nature of serious clinical problems, viewing the family as key to effective behavior change, using a home-based model of service delivery to overcome barriers to service access, integrating evidencebased intervention techniques, and using a comprehensive quality assurance and improvement system to support therapist fidelity and youth outcomes. Hence, as indicated previously, MST adaptations have been developed and validated for treating serious emotional disturbance in adolescents, juvenile sexual offenders, and adolescent substance abuse. In addition, investigators are examining MST adaptations for addressing a range of other complex problems – with the greatest advances accomplished for chronic pediatric health care conditions. Deborah Ellis and Sylvie Naar-King have led the way in developing and validating MST adaptations for serious health care problems experienced by youth. Two clinical trials with inner-city adolescents with poorly controlled Type 1 diabetes were conducted. In comparison with counterparts who received standard diabetes care, youth in the MST condition showed improved adherence to their diabetes care regimen and metabolic control as well as decreased diabetes stress and inpatient admissions – the latter of which resulted in decreased medical charges and direct care costs. In another clinical trial, these investigators examined an MST adaptation for treating obesity in African-American adolescents. MST was more effective than a family group weight management program at decreasing percent overweight, body fat, and body mass index. Moreover, Deborah Ellis and Sylvie Naar-King have obtained promising results in uncontrolled (i.e., no comparison condition) MST studies for youth with asthma and HIV infections.
Conclusions In conclusion, MST is a family- and community-based intervention with demonstrated empirical support for reducing delinquent behavior and out-of-home placements among youth presenting serious clinical problems. Favorable findings from early efficacy studies were generally replicated by later effectiveness studies, and these have been supported by independent evaluations conducted in distal community-based sites. This research, however, has also demonstrated the critical importance of treatment fidelity in the success of MST. Hence, all MST programs worldwide participate in an intensive quality assurance and improvement system to sustain program fidelity and facilitate youth outcomes. In addition to work with serious juvenile offenders, several research groups have developed and validated adaptations of MST for treating other types of complex and serious clinical problems. Such adaptations are made possible by the defining features of MST, which are not necessarily specific to juvenile offending. First, MST is designed to address known risk factors for serious clinical problems comprehensively, with caregivers viewed as critical to achieving sustainable outcomes. Second,
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services are provided in homes and other community-based settings to overcome barriers to service access. Third, treatment integrates evidence-based interventions validated for particular clinical issues (e.g., depression, ADHD), which leverages clinical advances made by other developers of evidence-based treatments. Fourth, MST involves use of a comprehensive quality assurance/quality improvement protocol to support fidelity to the treatment model and client outcomes.
See also: Addictions in Adolescence; Cognitive-Behavioral Therapy for Adolescents; Disruptive Behaviors and Aggression; Modes of Intervention.
Further Reading Bronfenbrenner U (1979) The Ecology of Human Development: Experiments by Design and Nature. Cambridge, MA: Harvard University Press. Henggeler SW, Melton GB, Brondino MJ, et al. (1997) Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology 65: 821–833. Henggeler SW, Melton GB, and Smith LA (1992) Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology 60: 953–961. Henggeler SW, Rowland MR, Randall J, et al. (1999) Home-based multisystemic therapy as an alternative to the hospitalization of youth in psychiatric crisis: Clinical outcomes. Journal of the American Academy of Child & Adolescent Psychiatry 38: 1331–1339. Henggeler SW and Schaeffer C (2010) Treating serious antisocial behavior using multisystemic therapy. In: Weisz JR and Kazdin AE (eds.) Evidence-Based Psychotherapies for Children and Adolescents, 2nd edn., pp. 259–276. New York: Guilford Press. Henggeler SW, Schoenwald SK, Borduin CM, et al. (2009) Multisystemic Therapy for Antisocial Behavior in Children and Adolescents, 2nd edn. New York: Guilford.
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Henggeler SW, Schoenwald SK, Rowland MD, and Cunningham PB (2002) Serious Emotional Disturbance in Children and Adolescents: Multisystemic Therapy. New York: Guilford Press. Letourneau EJ, Henggeler SW, Borduin CM, et al. (2009) Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology 23: 89–102. Ogden T and Hagen KA (2006) Multisystemic therapy of serious behaviour problems in youth: Sustainability of therapy effectiveness two years after intake. Journal of Child and Adolescent Mental Health 11: 142–149. Schaeffer CM and Borduin CM (2005) Long-term follow-up to a randomized clinical trial of multisystemic therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology 73: 445–453. Schoenwald SK and Henggeler SW (2002) Mental health services research and family based treatment: Bridging the gap. In: Liddle H, Santisteban DA, Levant RF, and Bray JH (eds.) Family Psychology: Science-Based Interventions, pp. 259–282. Washington DC: American Psychological Association. Schoenwald SK and Henggeler SW (eds.) (2003) Current strategies for moving evidence-based interventions into clinical practice. Special Series, Cognitive and Behavioral Practice 10: 275–323. Sheidow AJ and Henggeler SW (2008) Multisystemic therapy with substance using adolescents: A synthesis of research. In: Stevens A (ed.) Crossing Frontiers: International Developments in the Treatment of Drug Dependence, pp. 11–33. Brighton, England: Pavilion Publishing. Stambaugh LF, Mustillo SA, Burns BJ, et al. (2007) Outcomes from wraparound and multisystemic therapy in a center for mental health services system-of-care demonstration site. Journal of Emotional and Behavioral Disorders 15: 143–155. Timmons-Mitchell J, Bender MB, Kishna MA, and Mitchell CC (2006) An independent effectiveness trial of multisystemic therapy with juvenile justice youth. Journal of Clinical Child and Adolescent Psychology 35: 227–236.
Relevant Websites www.musc.edu/psychiatry/research/fsrc/abt_fsrc.htm – Family Services Research Center at the Medical University of South Carolina. www.mstservices.com – Multisystemic Therapy. www.promisingpractices.net – The Promising Practices Network. www.nrepp.samhsa.gov – SAMHSA’s National Registry of Evidence-based Programs and Practices. www.ncmhjj.com – The National Center for Mental Health and Juvenile Justice. www.aecf.org – The Annie E. Casey Foundation.
Glossary Controlled clinical trial: A type of scientific experiment that involves assignment of research participants to intervention and control groups. Efficacy trial: A controlled clinical trial that is designed to test whether an intervention is effective under ideal circumstances. Effectiveness trial: A controlled clinical trial that measures whether an intervention is effective in ‘real world’ clinical settings.
Introduction Multisystemic therapy (MST) is a family- and community-based treatment for youth with serious delinquent behavior (e.g., violent offending, sexual offending, chronic offending) who are at risk for being placed out of the home (e.g., in detention, jail, or a residential treatment setting). The model has also been adapted for youth and families presenting other serious clinical problems (e.g., serious emotional disturbance, maltreatment, chronic health care conditions). Numerous published clinical trials have shown that MST is an effective treatment for juvenile delinquents and for youth with other serious problems. With MST programs for juvenile offenders transported to more than 30 states and 11 nations, treating 17 000 youth and families annually, MST is one of the most widely transported evidence-based treatments that have been developed. The purpose of this article is to provide a brief overview of the MST approach. Specifically, this article discusses the theoretical basis of MST and provides a description of the MST treatment model. A case example is presented and research supporting the effectiveness of MST is summarized.
Characteristics of the MST Model Theoretical and Research Foundations Social ecological theory, as developed by Urie Bronfenbrenner, serves as the conceptual foundation of MST. The theory of social ecology proposes that human behavior is influenced by characteristics of the multiple systems in which individuals are embedded (e.g., family, peer, school, neighborhood) as well as their reciprocal relations with persons within those systems. Consistent with this view, decades of research have shown that the primary risk factors for delinquency pertain to various aspects of the youth’s environment, such as the family, peer network, school, and neighborhood. For example, at the family level, certain caregiver difficulties (e.g., high stress, mental health problems, substance abuse) and ineffective parenting practices (e.g., low supervision, inconsistent discipline, poor affective relations) predict elevated levels of delinquent
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Pharmacotherapy: The treatment of a clinical problem through the administration of medication. Recidivism: The repetition of criminal or delinquent behavior. Stakeholder: An individual who has an interest in and is affected by the outcome of a process. Transportability trial: Research that examines the movement of effective interventions to usual care settings.
behavior among youth. Regarding the peer network, research shows that youth are more likely to participate in delinquent acts if they associate with negative peers who are frequently in trouble. Indeed, association with deviant peers is the most powerful and consistent predictor of antisocial behavior in adolescents. At the school level, youth with academic and behavior problems often perform poorly in their classes and are more likely to drop out of school early, which, in turn, is associated with higher rates of antisocial behavior. Further, youth who reside in neighborhoods characterized by high levels of poverty, social disorganization, and criminal activity are more likely to engage in delinquent behavior. The social ecological model and literature on the determinants of delinquency have clear implications for the design of interventions. If youth antisocial behavior is multidetermined from risk factors pertaining to youth and the key social systems in which they are embedded, then, interventions must be capable of addressing a broad array of risk factors to optimize the probability of changing the behavior. Thus, MST works to address risk factors within each aspect of the youth’s environment (e.g., the family, peer, school) and between social systems that influence behavior (e.g., caregiver interactions with school). Further, to support behavior change in real-world contexts, consistent with Urie Bronfenbrenner’s concept of ecological validity, MST emphasizes the importance of considering delinquent behavior in its natural setting. Therefore, MST uses a home-based model of service delivery and strives for real-world validity in the assessment of behavior and delivery of interventions. Assessments are considered ecologically valid when they obtain information from multiple sources (e.g., caregivers, siblings, extended family, teachers) and consider the youth’s behavior in multiple areas (e.g., at home, in school, during neighborhood activities). Similarly, MST interventions are provided where problems occur (homes, schools, community locations).
MST Theory of Change A primary assumption of MST is that caregivers play a vital role in achieving and maintaining positive changes in their youth’s
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behavior. Therefore, helping caregivers to develop the necessary skills to effectively parent their youth is a central focus of MST. As caregivers strengthen their parenting skills, the therapist assists the caregiver in targeting other areas that might be contributing to youth problem behavior, such as poor school performance and contact with negative peers. For example, a therapist might assist the caregiver with developing positive relationships with school personnel and encourage the caregiver to provide rewards to their youth (e.g., special meals) for improved grades. The therapist might also help the caregiver develop a system for encouraging the youth for spending time with positive peers (e.g., travel and resources for sports or club events) and for providing negative consequences (e.g., reduced curfew) when the youth associates with negative peers. MST interventions also strive to help caregivers develop a network of indigenous supports including family, friends, and community members in order to maintain the positive changes gained during treatment. In sum, a main goal of the MST theory of change is to create an environment where positive youth behavior is supported and problematic behavior is discouraged. Importantly, the MST theory of change has been supported in several rigorous research studies. Numerous outcome studies have shown that MST improved family relations, peer relations, and school attendance concurrent with decreases in youth criminal behavior and substance use. Studies with chronic offenders, juvenile offenders, and substance-abusing offenders, however, have also used sophisticated statistical techniques to examine the MST mechanisms of change. These studies showed that the capacity of MST to decrease adolescent antisocial behavior was directly attributable to MST effects on family relations and peer associations. That is, decreased antisocial behavior seems to be a product of the capacity of MST to empower caregivers and decrease youth association with antisocial peers.
Characteristics of MST Clinical Implementation Treatment Delivery Multisystemic therapy is delivered by a team of professionals that typically includes two to four full-time Master’s level therapists and an advanced Master’s level or doctoral level supervisor. MST teams are usually employed by private-sector (not-for-profit or for-profit) provider agencies and are contracted to work through juvenile justice, child welfare, mental health, and other health (e.g., Medicaid) authorities. MST therapists each carry a caseload of about four to six families. They, or another member of the team (an on-call schedule is used) are available to families 24 h day 1, 7 days a week so that sessions can be scheduled at times convenient to the family and so therapists can respond to crises whenever they occur. MST is intensive and usually consists of over 60 h of therapist contact with the family and other members of the youth’s environment. Treatment intensity, however, is matched to family need. For example, the therapist might work 6–10 h week 1 early in treatment as behavior change efforts are being first implemented. Later, assuming favorable changes have been made, therapeutic efforts focus on enhancing the sustainability of change. The duration of treatment,
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however, is fairly short and typically lasts from 3 to 5 months. As noted previously, there is a strong emphasis on the delivery of MST services in home- and community-based settings at times convenient to the family, which helps overcome barriers to service access (e.g., transportation) and facilitates family engagement in the treatment process.
Clinical Procedures Within MST, interventions are considered most effective when they are individualized to meet each family’s unique strengths and needs. Thus, MST does not follow a manualized treatment protocol. Instead, nine treatment principles provide the framework for problem conceptualization and treatment planning (see Table 1). Particular emphasis is placed on the provision of strength-based services (see Principle 2) – youth and systemic strengths are identified and used as levers of change throughout treatment. Thus, therapists communicate an optimistic perspective to the family and other members of the youth’s ecology throughout the assessment and treatment process. In close collaboration with the family and other stakeholders (e.g., juvenile justice authorities), the nine MST treatment principles help guide the development of each family’s treatment plan. Goals are created to include all aspects of the youth’s ecology, including the individual, family, peer, and community network. In the beginning stages of treatment, key members of the youth’s ecology (e.g., caregivers, teachers, juvenile justice authorities) define which youth behaviors to target in treatment. Next, the MST team identifies the primary environmental factors, or ‘drivers,’ that seem to be influencing each problem behavior and then organize them into a coherent conceptual framework. For example, a youth’s current drug use might be most closely associated with lack of supervision by caregivers and friendships with drug using peers. Next, MST therapists, along with other team members (i.e., other therapists on the team, the MST supervisor, and the MST expert consultant) create specific intervention strategies to target the most proximal factors that seem to be influencing the targeted Table 1
MST treatment principles
1. The primary purpose of assessment is to understand the ‘fit’ between the identified problems and their broader systemic context 2. Therapeutic contacts should emphasize the positive and use systemic strengths as levers for change 3. Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members 4. Interventions should be present-focused and action-oriented, targeting specific and well-defined problems 5. Interventions should target sequences of behavior within and between multiple systems 6. Interventions should be developmentally appropriate and fit the developmental needs of the youth 7. Interventions should be designed to require daily or weekly effort by family members 8. Intervention efficacy should be evaluated continuously from multiple perspectives 9. Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change Reproduced from Henggeler et al. (2009).
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behavior. Intervention strategies are developed using scientifically proven approaches such as behavioral parent training, cognitive behavior interventions, pragmatic family therapy, and motivational interviewing. Interventions that address specific environmental causes of behavior problems are incorporated into the treatment plan, such as helping a caregiver advocate for more school services or working with other parents in the neighborhood to provide after-school supervision for teens. Similarly, if it becomes apparent that a youth needs medication in conjunction with treatment to meet his or her needs, then evidence-based pharmacotherapy (e.g., for ADHD) is incorporated into the treatment plan. Intervention effectiveness is monitored continuously throughout MST. If interventions are not achieving the desired aims, the team uses the information gained from the failure to reconceptualize the drivers of the identified problems. Based on this reconceptualization, new interventions are designed and implemented in a recursive process until there is positive change in the target behavior. This process ensures that families are not blamed if an intervention strategy is not successful in changing youth behavior. Furthermore, MST requires therapists to ‘do whatever it takes’ to assist families in reaching treatment goals. A central assumption is that when the MST team develops accurate hypotheses about what drives youth behavior and then delivers appropriate interventions to target the specified drivers, families tend to meet their treatment goals.
Case Example Justin is a 16-year old African American male who was referred to MST by the juvenile court after receiving a charge for assault and battery. The charge stemmed from an incident in Justin’s neighborhood. According to Justin, an older boy ridiculed Justin’s clothes as he was walking a few blocks from his house. Justin became verbally aggressive and began punching and kicking the boy. Neighbors called the police and Justin was arrested. Table 2
Justin lives with his biological mother (Ms Wilson) and maternal grandmother in his grandmother’s home, which is in a low-income neighborhood. Justin’s father (Mr Smith) died of a heart attack when Justin was very young. According to Ms Wilson, Justin’s father was heavily involved in a local street gang known for drug dealing and violence. Ms Wilson reports that she and Justin have had no contact with Mr Smith’s side of the family during the past several years. Ms Wilson has been unemployed for the past 6 months. She devotes most of her time to looking for employment and frequently spends the night at her boyfriend’s house. When Ms Wilson is away from the home, Justin is cared for by his grandmother. However, Justin’s grandmother is on several medications for chronic health problems that cause significant drowsiness. As a result, she sleeps often, leaving Justin unsupervised for large portions of the day and evening. Conversations with Ms Wilson also revealed that she rarely disciplines Justin for his misbehavior. At school, Justin is reported to be well-liked by teachers, but his attendance is sporadic (2–3 days week 1) and he is two grades behind (in ninth grade instead of eleventh). Justin’s probation officer and family report that Justin spends most of his time with a group of same-aged peers who frequently skip school and fight with youth from a neighboring community. The initial MST assessment focused on identifying key strengths in Justin’s ecology, the desired outcomes of all stakeholders (e.g., family members, probation), and the fit between identified problems and their broader systemic context (Principle 1). Through conversations with Justin, his mother, his grandmother, and a teacher at Justin’s school, the MST therapist was able to identify several strengths and needs across Justin’s key ecological systems (see Table 2). Key systemic strengths include Justin’s prosocial interests, positive relationships with teachers, and his large maternal family social network. Some key ecological needs include low family monitoring/discipline, Justin’s academic difficulties, and limited opportunities for prosocial activities in the
Strengths and needs: Justin’s ecology
System
Strengths
Needs
Youth
• • •
Athletic Polite to adults Prosocial interests: basketball
Family
• • •
Strong mother–son bond Strong work ethic (mother, mother’s boyfriend) Large extended network on mother’s side, all positive – mother has two sisters; Justin has several same-age cousins Mother’s boyfriend cares, has positive relationship with mother and Justin Likeable, pleasant Several prosocial cousins close in age Mostly good relationships with teachers, who want Justin to do well
• • • • • • •
Low communication skills Gets angry quickly when provoked Positive view of aggressive retaliation Poor organizational and study skills Poor monitoring (mother gone most nights, grandmother too frail) Few consequences for misbehavior Paternal grandmother declining health/extensive medical needs
• • • • • • • •
Older and bigger than classmates Neighborhood peers mostly gang involved Two or more grade levels behind Struggles to understand material Poor work habits (e.g., no structure for homework) No recreational facilities/places for adolescents to hang out Alcohol and drugs easily available Gang presence
• School
• • •
Community
•
Peer
Church within walking distance; grandmother active there
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neighborhood. Justin’s desired outcomes were to ‘play basketball at the local community center’ and ‘meet members of his father’s family.’ Ms Wilson’s desired outcomes were for Justin to ‘stay out of trouble in the neighborhood’ and ‘complete high school.’ Justin’s grandmother desired for Justin to ‘stay away from drugs’ and ‘not get into any more trouble with the police.’ Justin’s probation officer requested for him to ‘complete an anger management group,’ and ‘attend school every day.’ Using these strengths, needs, and desired outcomes as a starting point, the MST therapist worked with the stakeholders to develop overarching treatment goals, including (a) no new criminal charges for Justin and compliance with probation officer requests, (b) compliance with all house rules, (c) demonstration of success in school (i.e., no unexcused absences or suspensions/expulsions, completion of assignments), and (d) increased contact with prosocial peers. Consistent with MST Principles, overarching goals used strength-based language (Principle 2) and set forth explicit criteria for judging when goals had been met (Principle 8). Within MST, efforts are often taken to prevent youths’ exposure to other court-involved youth in group settings. This stems from research showing that when delinquent youth spend time together, they tend to reinforce one another’s delinquent behavior. Therefore, the MST therapist requested that he be allowed to provide anger management skills training to Justin individually, rather than have him attend a court-sponsored anger management group, and the probation officer agreed. This treatment component was accomplished through individual sessions with Justin and occasional involvement from Ms Wilson using a structured, empirically supported anger management protocol.
The MST therapist also combined information across sources and identified the most likely drivers for Justin’s assault incident and poor school performance. As illustrated in Figure 1, the drivers of many problems were shared. For example, low caregiver supervision was a critical factor in Justin being out on the streets late at night and of his sporadic school attendance. Also, Justin’s embarrassment about being in a class with younger peers was supporting his tendency to skip school and associate with other truant peers. Drivers were then prioritized and targeted during treatment sessions occurring several times every week. Initially, the therapist addressed a few straightforward drivers that would give the family some early success, such as having Ms Wilson enroll Justin in an after school tutoring and homework club to help facilitate his understanding of classroom material and homework completion. Two identified drivers of Justin’s behavior problems were Ms Wilson’s low monitoring and the fact that Justin had few prosocial friends or activities. In addressing these drivers, the therapist began by challenging some of Ms Wilson’s misconceptions about parenting an adolescent, such as her belief that the grandmother’s mere presence in the home was sufficient to monitor Justin’s whereabouts, or that contact with peers only during the school day was enough to meet Justin’s developmental need for friendships and peer support. Consistent with the MST belief that intervention generalizability and maintenance of positive changes is enhanced when multiple ecology members are involved (Principle 9), the therapist included Ms Wilson’s boyfriend in some sessions. This boyfriend (who also had two boys of his own from a previous relationship) was instrumental in convincing Ms Wilson that Justin needed more
Mother not at home in evenings Mother won’t let Justin see paternal family
Grandmother poor health/frail
Conflict between Justin and Mother
Justin’s ineffective communication skills
Low parental monitoring and little discipline
Behind in school and poor attendance Difficulty understanding work
Assault on neighborhood peers
Out late at night in dangerous areas
Not completing homework
Embarrassed to be in classes with younger students
Figure 1 Drivers of Justin’s presenting problems.
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Association w/negative peers
Few prosocial peers or activities in neighborhood
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supervision and positive peer connections. Ms Wilson ultimately agreed to spend more nights at home so that she could supervise Justin and ensure that he went to school in the morning. With the help of the MST therapist, Ms Wilson also implemented a behavior plan in the home that involved rewards (allowance, time playing videogames) and consequences (taking his cell phone away) for school attendance, homework completion, and staying away from delinquent peers in the neighborhood. These interventions encouraged more responsible behavior from both Justin and Ms Wilson (Principle 3) and required consistent daily effort (Principle 7). As Ms Wilson implemented Justin’s behavior plan over several weeks, it became apparent that new, more varied rewards were needed to sustain Justin’s motivation to comply. One of Justin’s desired outcomes was to play basketball at a community center located about five miles from his house. The therapist accompanied Ms. Wilson to verify that the community center was an appropriate place for Justin to be with minimal supervision. A plan was then set up for Ms Wilson to take Justin to the community center for a few hours every Saturday, contingent upon his adherence to the behavior plan during the week. Justin’s behavior improved greatly with this extra incentive, and he began developing positive relationships with prosocial friends at the community center, thereby helping to meet Justin’s developmental need for appropriate peer contacts (Principle 6). As treatment progressed, Justin reiterated his strong desire to meet members of his paternal family. Ms Wilson initially objected to this idea, which angered Justin and led to some arguments in the home. To address this conflict, the therapist held dyadic sessions with Ms Wilson and Justin to help them with their communication and problem-solving skills (Principle 5). Over a series of sessions, Justin learned to calmly communicate his reasons for wanting to see his paternal family, and Ms Wilson discussed the reasons for her hesitation (i.e., her fear that they might expose Justin to gang activities). Using a problem-solving approach, Justin and his mother identified a paternal family member who had no gang involvement (paternal aunt) and who Ms Wilson felt more comfortable allowing Justin to see and set rules for their contact (e.g., Ms Wilson would be present for initial visits). As a result of this work, Justin was able to spend time visiting with his aunt and learn more about his father, which he greatly appreciated. Throughout treatment, the MST therapist solicited opinions from all stakeholders regarding whether interventions were helping the family meet their overarching goals (Principle 8) and made adjustments accordingly. By the end of treatment, both Ms Wilson and Justin reported fewer arguments in the home, an appraisal supported by Justin’s grandmother. School teachers confirmed that Justin’s attendance had increased and that his academic skills had improved. To facilitate the maintenance of Justin’s school improvements (Principle 9), Ms Wilson advocated that the school promote Justin to tenth grade and place him in an accelerated dropout prevention curriculum that would provide him with smaller classes, a supportive community of peers and teachers, and the possibility of graduating with his agemates. Justin had no additional arrests and began spending larger parts of his time playing basketball with new prosocial friends at the community center.
As with drivers for problem behaviors, MST therapists also identify drivers for improved behaviors. Hypothesized drivers for Justin’s improved behaviors included (a) increased and consistent supervision by his mother, (b) strictly enforced rules by Ms Wilson regarding school and whereabouts, (c) improved communication and decreased conflict between Justin and his mother, and (d) Justin’s involvement in prosocial age-appropriate activities with nondeviant peers.
Training, Supervision, and Quality Assurance Multisystemic therapy includes an intensive quality assurance and improvement system aimed at supporting treatment fidelity and youth outcomes. Several approaches are taken to provide training and supervision in MST. Therapists first participate in a 5-day orientation training. During this training, therapists learn about the theoretical and research foundations of MST, and they participate in role-play exercises to develop specific clinical skills (e.g., family engagement techniques, assessment and intervention strategies). Following this training, therapists gain experience delivering MST to families under the guidance of the Master’s or doctoral level MST-trained clinical supervisor. Supervisors meet weekly with therapists to review cases, help problem-solve barriers to family engagement, and ensure that the interventions follow the nine core treatment principles. In addition, each team is assigned an expert MST consultant who helps facilitate adherence to the MST model through quarterly booster trainings and weekly review of cases. This consultant is employed by MST Services Inc. (which is licensed by the Medical University of South Carolina for the transport of MST technology and intellectual property) or one of its network partners (i.e., organizations that have been trained to provide all aspects of MST program development and support). MST is implemented in the context of a comprehensive quality assurance and improvement system. Considerable effort is devoted to this system because, as noted subsequently, considerable research supports a strong relationship between therapist adherence to the MST model and positive youth/family outcomes (e.g., reduced delinquent behavior, improved caregiver–child relations). In addition to the initial and ongoing training, supervision, and consultation protocols, important components of the quality assurance and improvement system include validated surveys that measure implementation adherence by therapists, supervisors, and consultants, and a web-based tracking system that provides teams with ongoing feedback about adherence and youth outcomes. In addition to providing weekly consultation to the clinical team, MST expert consultants provide support to provider agencies who are interested in developing new MST programs. Specifically, consultants (a) conduct community assessments to determine whether the needs that prompted interest in MST are likely to be met by an MST program, (b) determine whether the agency has the practical resources needed to fund an MST team, and (c) explore whether the key leaders and decision-makers in the agency will be committed to the success of the program. Once an MST program has been implemented in a community, MST expert consultants provide continued support by conducting semiannual program reviews and by helping to problem-solve any organizational barriers to program implementation.
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Empirical Support for MST To date, MST has been evaluated in approximately 20 controlled clinical trials. On the basis of this research, several groups, including independent researchers, federal agencies (e.g., National Institute on Drug Abuse, US Surgeon General), and consumer advocates (National Alliance on Mental Illness), have concluded that MST is an effective intervention for youth exhibiting serious behavior problems and their families. The following sections provide a brief overview of MST outcome research – from efficacy trials to large multisite evaluations.
Efficacy Studies Efficacy trials are intended to provide a test of a developing treatment that optimizes the probability that favorable outcomes will be observed, if, in fact, the treatment is effective. Thus, MST efficacy trials included close direct supervision by key MST developers (i.e., Scott Henggeler in Memphis and, later, Chuck Borduin in Columbia, Missouri), and therapists were graduate students in clinical psychology. The studies were conducted through university clinics (though the MST homebased model of service delivery was used), which minimized the many organizational factors (e.g., paperwork and billing requirements, comp time, conflicting administrative demands) that can impede the success of MST programs. The first efficacy trial of MST was published in 1986 and evaluated MST with inner-city juvenile offenders. Subsequent efficacy trials were conducted with maltreating families, juvenile sexual offenders, and chronic juvenile offenders. Across these studies, findings consistently supported the efficacy of the MST model in comparison with control conditions. As per the aims of MST, affective and instrumental aspects of family relations were improved and youth showed decreased association with deviant peers. Importantly, juvenile offenders evidenced significant decreases in behavior problems, rearrests, and incarceration. One study, for example, followed research participants for 14 years and showed that MST produced a greater than 50% decrease in rearrest for violent crimes, drug-related crimes, and nonviolent crimes. Moreover, days incarcerated were reduced by 57% in that study, which has important implications for the cost-effectiveness of MST (i.e., savings through reduced out-of-home placements of youth).
Effectiveness Studies A primary aim of effectiveness research is to determine whether a treatment that has shown promise in ideal settings (e.g., university with close treatment developer oversight) can be implemented effectively, with similar results, in real-world clinical practice. Building off the favorable findings in the aforementioned efficacy trials, effectiveness studies of MST were conducted in collaboration with community mental health centers in South Carolina using real-world practitioners. In one study, Scott Henggeler served in the role of off-site MST expert consultant, with direct clinical supervision provided by a supervisor at the community mental health center. Participants were serious juvenile offenders at imminent risk of incarceration. Largely replicating the efficacy findings, results showed that MST was more effective than the comparison
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condition at improving family and peer relations as well as decreasing recidivism and out-of-home placement. A second effectiveness study examined whether favorable outcomes could still be attained if an off-site MST expert no longer provided weekly case support. If favorable outcomes still could be achieved, such would greatly ease the burden of quality assurance in the larger scale transport of MST programs (i.e., continuous training of therapists might not be needed). Participants were serious juvenile offenders at imminent risk of incarceration across two communities, and therapists and their supervisors were mental health center employees. Although MST was more effective than the comparison condition at decreasing youth psychiatric symptoms and rates of incarceration, significant treatment effects were not observed for family relations or rearrest. Importantly, in anticipation of less than ideal outcomes, a measure of therapist treatment fidelity had been developed and was administered to caregivers and youth (i.e., the measure assessed therapist adherence to MST treatment principles). Analyses showed that treatment fidelity was associated significantly with youth recidivism – when therapists adhered to MST treatment principles, rates of rearrest were significantly lower than when treatment adherence was poor. This finding supported the MST quality assurance system and clearly demonstrated the importance of treatment fidelity in achieving desired clinical outcomes. More recently, a third effectiveness study was conducted in Chicago with Chuck Borduin serving in the role of expert consultant. Participants were juvenile sexual offenders, and services were provided through an MST team working with a local provider organization. Results showed that MST was more effective than usual sex offender-specific treatment (e.g., cognitive-behavioral group therapy) at decreasing sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements. Together, this body of effectiveness research demonstrated the capacity of MST to be transported effectively to community-based settings.
Hybrid Efficacy-Effectiveness Studies The success of MST with serious juvenile offenders led to a series of studies examining MST with other types of severe clinical problems through the Family Services Research Center, Medical University of South Carolina (MUSC). In these studies, second-generation MST experts (i.e., individuals trained by Scott Henggeler) provided either direct clinical supervision or served in the role of off-site MST expert. The clinical samples in these studies included youth presenting psychiatric emergencies (i.e., suicidal, homicidal, psychotic), Hawaiian youth with serious emotional disturbance, substance-abusing juvenile offenders, and physically abused adolescents and their families. Some of the studies were conducted through community mental health centers, and in others, therapists were employed by the university. Except for the Hawaiian study, all were conducted in Charleston, South Carolina. Results tended to be comparable across these studies and favored youth and families in the MST condition. Youth evidenced decreased emotional and behavioral problems as well as decreased substance use. Families tended to show improved functioning, and youth spent more time in regular school settings. Importantly, with the exception of one study in
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which MST was integrated into juvenile drug court, MST was highly effective at decreasing days in restrictive out-of-home placements (e.g., incarceration, psychiatric hospitalization). Together, these studies demonstrated the capacity of MST to achieve favorable outcomes with no involvement of an MST treatment developer and with youth and families presenting significant problems other than serious criminal offending.
Independent Transportability Trials Several rigorous evaluations of MST have been published by independent investigators – researchers not affiliated with the treatment developers. Such studies provide ultimate tests of the transportability of a promising treatment. If a treatment model can prove effective in distal real-world clinical settings when training is provided by third-generation MST experts, a major step in closing the science to service gap can be accomplished. In the case of these studies, quality assurance was overseen by MST Services (the MUSC-licensed organization noted previously), and treatment was provided by community-based practitioners. Terje Ogden conducted a multisite trial of MST in Norway that focused on youth with serious antisocial behavior (Norway does not have a juvenile justice system). Results showed that MST was effective in decreasing youth externalizing and internalizing symptoms and at increasing youth social competence. Importantly, large decreases in out-of-home placement were observed, and these were sustained through a 2-year follow-up. Also, outcomes were linked with treatment fidelity – in particular, one of the four sites in this study evidenced poor fidelity to the MST program, and this site did not have positive outcomes. In further research, Terje Ogden has shown that favorable MST practices and outcomes were sustained past the completion of the outcome study. However, a recent multisite clinical trial conducted in neighboring Sweden failed to replicate favorable MST treatment effects. In attempting to understand this failure to replicate, the investigators noted that treatment fidelity was very low across the research sites. The first independent MST trial in the United States was conducted by Jane Timmons-Mitchell and her colleagues with juvenile felons at imminent risk of out-of-home placement. Findings showed that MST was more effective than usual services at improving youth functioning, decreasing substance use problems, and reducing rearrests. Subsequently, another clinical trial was conducted by Leyla Stambaugh and colleagues on youth with serious emotional disturbance and at risk for out-of-home placement. MST was compared with Wraparound, which is a widely used intensive intervention in system-of-care sites in the United States. MST was more effective than Wraparound at decreasing youth symptoms, improving youth functioning, and reducing out-of-home placements. In summary, the effectiveness of MST has been replicated by independent investigators in community-based settings, with third-generation MST experts providing ongoing quality assurance – such as currently being provided for MST programs worldwide. A critical caveat, however, pertains to the importance of treatment fidelity in achieving favorable outcomes, which also applies to other evidence-based treatments transported to real-world contexts.
Adaptations to the Basic MST Model The basic MST model includes several key components that can be applied effectively for treating youth with complex clinical problems other than antisocial behavior. These critical features of MST include addressing the multidetermined nature of serious clinical problems, viewing the family as key to effective behavior change, using a home-based model of service delivery to overcome barriers to service access, integrating evidencebased intervention techniques, and using a comprehensive quality assurance and improvement system to support therapist fidelity and youth outcomes. Hence, as indicated previously, MST adaptations have been developed and validated for treating serious emotional disturbance in adolescents, juvenile sexual offenders, and adolescent substance abuse. In addition, investigators are examining MST adaptations for addressing a range of other complex problems – with the greatest advances accomplished for chronic pediatric health care conditions. Deborah Ellis and Sylvie Naar-King have led the way in developing and validating MST adaptations for serious health care problems experienced by youth. Two clinical trials with inner-city adolescents with poorly controlled Type 1 diabetes were conducted. In comparison with counterparts who received standard diabetes care, youth in the MST condition showed improved adherence to their diabetes care regimen and metabolic control as well as decreased diabetes stress and inpatient admissions – the latter of which resulted in decreased medical charges and direct care costs. In another clinical trial, these investigators examined an MST adaptation for treating obesity in African-American adolescents. MST was more effective than a family group weight management program at decreasing percent overweight, body fat, and body mass index. Moreover, Deborah Ellis and Sylvie Naar-King have obtained promising results in uncontrolled (i.e., no comparison condition) MST studies for youth with asthma and HIV infections.
Conclusions In conclusion, MST is a family- and community-based intervention with demonstrated empirical support for reducing delinquent behavior and out-of-home placements among youth presenting serious clinical problems. Favorable findings from early efficacy studies were generally replicated by later effectiveness studies, and these have been supported by independent evaluations conducted in distal community-based sites. This research, however, has also demonstrated the critical importance of treatment fidelity in the success of MST. Hence, all MST programs worldwide participate in an intensive quality assurance and improvement system to sustain program fidelity and facilitate youth outcomes. In addition to work with serious juvenile offenders, several research groups have developed and validated adaptations of MST for treating other types of complex and serious clinical problems. Such adaptations are made possible by the defining features of MST, which are not necessarily specific to juvenile offending. First, MST is designed to address known risk factors for serious clinical problems comprehensively, with caregivers viewed as critical to achieving sustainable outcomes. Second,
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services are provided in homes and other community-based settings to overcome barriers to service access. Third, treatment integrates evidence-based interventions validated for particular clinical issues (e.g., depression, ADHD), which leverages clinical advances made by other developers of evidence-based treatments. Fourth, MST involves use of a comprehensive quality assurance/quality improvement protocol to support fidelity to the treatment model and client outcomes.
See also: Addictions in Adolescence; Cognitive-Behavioral Therapy for Adolescents; Disruptive Behaviors and Aggression; Modes of Intervention.
Further Reading Bronfenbrenner U (1979) The Ecology of Human Development: Experiments by Design and Nature. Cambridge, MA: Harvard University Press. Henggeler SW, Melton GB, Brondino MJ, et al. (1997) Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology 65: 821–833. Henggeler SW, Melton GB, and Smith LA (1992) Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology 60: 953–961. Henggeler SW, Rowland MR, Randall J, et al. (1999) Home-based multisystemic therapy as an alternative to the hospitalization of youth in psychiatric crisis: Clinical outcomes. Journal of the American Academy of Child & Adolescent Psychiatry 38: 1331–1339. Henggeler SW and Schaeffer C (2010) Treating serious antisocial behavior using multisystemic therapy. In: Weisz JR and Kazdin AE (eds.) Evidence-Based Psychotherapies for Children and Adolescents, 2nd edn., pp. 259–276. New York: Guilford Press. Henggeler SW, Schoenwald SK, Borduin CM, et al. (2009) Multisystemic Therapy for Antisocial Behavior in Children and Adolescents, 2nd edn. New York: Guilford.
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Henggeler SW, Schoenwald SK, Rowland MD, and Cunningham PB (2002) Serious Emotional Disturbance in Children and Adolescents: Multisystemic Therapy. New York: Guilford Press. Letourneau EJ, Henggeler SW, Borduin CM, et al. (2009) Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology 23: 89–102. Ogden T and Hagen KA (2006) Multisystemic therapy of serious behaviour problems in youth: Sustainability of therapy effectiveness two years after intake. Journal of Child and Adolescent Mental Health 11: 142–149. Schaeffer CM and Borduin CM (2005) Long-term follow-up to a randomized clinical trial of multisystemic therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology 73: 445–453. Schoenwald SK and Henggeler SW (2002) Mental health services research and family based treatment: Bridging the gap. In: Liddle H, Santisteban DA, Levant RF, and Bray JH (eds.) Family Psychology: Science-Based Interventions, pp. 259–282. Washington DC: American Psychological Association. Schoenwald SK and Henggeler SW (eds.) (2003) Current strategies for moving evidence-based interventions into clinical practice. Special Series, Cognitive and Behavioral Practice 10: 275–323. Sheidow AJ and Henggeler SW (2008) Multisystemic therapy with substance using adolescents: A synthesis of research. In: Stevens A (ed.) Crossing Frontiers: International Developments in the Treatment of Drug Dependence, pp. 11–33. Brighton, England: Pavilion Publishing. Stambaugh LF, Mustillo SA, Burns BJ, et al. (2007) Outcomes from wraparound and multisystemic therapy in a center for mental health services system-of-care demonstration site. Journal of Emotional and Behavioral Disorders 15: 143–155. Timmons-Mitchell J, Bender MB, Kishna MA, and Mitchell CC (2006) An independent effectiveness trial of multisystemic therapy with juvenile justice youth. Journal of Clinical Child and Adolescent Psychology 35: 227–236.
Relevant Websites www.musc.edu/psychiatry/research/fsrc/abt_fsrc.htm – Family Services Research Center at the Medical University of South Carolina. www.mstservices.com – Multisystemic Therapy. www.promisingpractices.net – The Promising Practices Network. www.nrepp.samhsa.gov – SAMHSA’s National Registry of Evidence-based Programs and Practices. www.ncmhjj.com – The National Center for Mental Health and Juvenile Justice. www.aecf.org – The Annie E. Casey Foundation.