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8/7/2019 Des Moines 3.30.11 #3 Multi Systemic Family Therapy
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Multisystemic Family TherapyMultisystemic Family Therapy
Theory of Social EcologyTheory of Social Ecology
MultiMulti--determined nature of human behavior determined nature of human behavior
Ecological validityEcological validity
Reciprocal Nature of Human InteractionReciprocal Nature of Human Interaction
((Bonfenbrenner¶sBonfenbrenner¶s 1979)1979)
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MultiMulti--determined nature of determined nature of
human behavior human behavior
FamilyFamily
Peer Peer
SchoolSchool
NeighborhoodNeighborhood
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Broad View of Contextual InfluencesBroad View of Contextual Influences
E.g., mother¶s employer, school boardE.g., mother¶s employer, school board
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Contributors to DelinquencyContributors to Delinquency
Within Systems & BetweenWithin Systems & Between
SystemsSystems Within systemsWithin systems
Lax parental supervisionLax parental supervision
Association with delinquent peers Association with delinquent peers
Between systemsBetween systems
Lack of caregiver knowledge about friendsLack of caregiver knowledge about friends
Conflict between family and schoolConflict between family and school
(Henggeler et al., 2009)(Henggeler et al., 2009)
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Ecological ValidityEcological Validity
Understand youth f unctioning real worldUnderstand youth f unctioning real world
HomeHome
ClassroomClassroomCommunityCommunity
First hand sourcesFirst hand sources
Caregivers, siblings, teachers, coachesCaregivers, siblings, teachers, coaches
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Reciprocal NatureReciprocal Nature
of Human Interactionof Human Interaction Parent asks teen to do choresParent asks teen to do chores
Child complains, argues, does them poorlyChild complains, argues, does them poorly
ParentParent ± ± easier to do him/herself easier to do him/herself
Child learns complaining worksChild learns complaining works
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Main Agent of ChangeMain Agent of Change
CaregiversCaregivers
Example:Example:
Uses family strengths: love of child, socialUses family strengths: love of child, socialsupportsupport
Overcome stressors: parental substanceOvercome stressors: parental substanceabuse, stress, hopelessnessabuse, stress, hopelessness
Increase caregiver effectivenessIncrease caregiver effectiveness
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ExampleExample
Help parents design effective interventionsHelp parents design effective interventions
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Research on MST MechanismsResearch on MST Mechanisms
of Changeof Change
High therapist
adherence
MST
Improved family
Functioning &
Parental monitoring
Decreased
association with
delinquent peers
Decreased
delinquent
behavior
(Henggeler et al., 2009)
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Therapist Attitude to FamiliesTherapist Attitude to Families
Don¶tDon¶t
Blame familiesBlame families
Ignore familiesIgnore families
Label familiesLabel families
Give up on familiesGive up on families
(Henggeler et al., 2009)(Henggeler et al., 2009)
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Home Based ModelHome Based Model
24 hour, 7 day a week availability24 hour, 7 day a week availability
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Training and SupervisionTraining and Supervision
5 day initial orientation5 day initial orientation
Majority of learningMajority of learning ± ± working with familiesworking with families
and supervision by onand supervision by on--site s
upervisor andsite supervisor andoff off--site consultantsite consultant
Weekly meeting with s
upervisor who
uses
Weekly meeting with s
upervisor who
usesa protocol for reviewing casesa protocol for reviewing cases
Weekly disc
ussion with cons
ultant
Weekly disc
ussion with cons
ultant
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Referral
behavior Referral
behavior MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
Fit
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
Fit
Intermediary
Goals
Prioritize
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
Fit
Intermediary
Goals
Prioritize
Intervention
development
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
Fit
Intermediary
Goals
Prioritize
Intervention
development
Intervention
implementation
Do
MST Analytic
Process
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Referral
behavior Referral
behavior
Desired
outcomes of
family
Overarching
goals
Fit
Intermediary
Goals
Prioritize
Intervention
development
Intervention
implementation
Do
Assessment
Measure
Re-evaluate
MST Analytic
Process
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Prime FeaturesPrime Features
Never give up on familiesNever give up on families
Failed interventions are team¶s responsibilityFailed interventions are team¶s responsibility
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AssessmentAssessment
Background Information FormBackground Information Form
GenogramGenogram
Reasons for referral: ProblemsReasons for referral: ProblemsFrequencyFrequency
IntensityIntensity
DurationDurationImpactImpact
Meets with stakeholders: Family,Meets with stakeholders: Family,
teachers, probation officers, etc.teachers, probation officers, etc.
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GenogramGenogram
63
3840 FJose Ricardo
History
of arrest
59
36 M38
201915 13 16 Rick ADHDMia
Father¶s parents live in
Puerto Rico and write but
do not visit
Ricardo & brother Jose
emigrated 5 years ago
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AssessmentAssessment
Strengths & Needs AssessmentStrengths & Needs Assessment
In each system: family, school, etc.In each system: family, school, etc.
Case SummaryCase Summary
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Referral BehaviorsReferral Behaviors
Behavior Frequency Intensity Duration
Marijuana Use 3 ± 4 times a week 1 ± 2 blunts
shared with 2
peers
Approx. 16
months
Tr uancy 2 ± 3 times a week Skips entireday Started lastschool year (12
mos. ago)
Aggression ±
fights with peers
Two incidents Client had
stitches, black
eye
Incidents were 3
and 8 mos. Ago
Father-sonconflict ± both are
verbally
aggressive
1 ± 2 times a week Both scream,youth uses
r ude language;
lasts 1 ± 2
minutes
(Henggler, 2009)
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Desired OutcomesDesired Outcomes
Participant Goal
Rick Get off probation
Get dad to stop nagging
Ricardo (father) Rick go to schoolRick get a job
Rick make him proud
Mia Rick do good
Rick stop getting in trouble
Rick stop fighting
Jose (Uncle) Rick stay away from bad kidsRick stop smoking dope
Probation officer Rick stay in school
Rick stop using dr ugs
Rick stop fighting
(Henggler, 2009)
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System Strengths & WeaknessesSystem Strengths & Weaknesses
Systemic Strengths Systemic Weaknesses
Individual:
Athletic ± likes baseball
Social ± leader
Wants a job
Impulsive
Verbally & physically aggressive
Failing classes
Thinks can¶t stop mariju
anaFamily:
Father committed to son
Sister well-behaved
Uncle supportive
Father authoritarian
Father & son high conflict
Father history of arrest
Mother dr ug use
Mother goneSchool:
Willing to work with teen as long as he
tries to improve
Has a baseball team
PE teacher/coach interested
Negative peers are at school
Low supervision in free time
School negative to family
Teen may not be sports eligible
School not in contact with father
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System Strengths & WeaknessesSystem Strengths & Weaknesses
Systemic Strengths Systemic Weaknesses
Peers:
Positive friends 2 years ago still go to
school
One friend has job
Cousin
Joe may be role model ± has jobHas one prosocial peer he¶d like to spend
time with ± plays baseball
Most peers are not in school or skip
Most friends use marijuana & alcohol
2 friends in fights
Community:
Recreation center in neighborhood
Little sister goes to churchLady next door potential support for father
High crime neighborhood
High unemploymentMany youth on street corner
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Weekly ReviewWeekly Review
1)1) Therapist describes overarching goalsTherapist describes overarching goals
2)2) Therapist lists previous intermediary goals &Therapist lists previous intermediary goals &
whether met in last weekwhether met in last week
3)3) Therapist lists barriers to intermediary goalsTherapist lists barriers to intermediary goalsexperienced in last weekexperienced in last week
4)4) Explains advances on gains in last weekExplains advances on gains in last week
5)5) Revise ³fit´ with new infoRevise ³fit´ with new info
6)6) Therapist states new intermediary goalsTherapist states new intermediary goals
(Henggeler, 2009)(Henggeler, 2009)
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Weekly ReviewWeekly Review
Overarching GoalsOverarching Goals
SchoolSchool -- No unexcused absencesNo unexcused absences
No disr uptive behavior No disr uptive behavior Passing gradesPassing grades
MarijuanaMarijuana ± ± StopStop
No fightingNo fightingFather and sonFather and son ± ± reduced conflictreduced conflict
(Henggeler, 2009)(Henggeler, 2009)
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Previous Intermediary GoalsPrevious Intermediary Goals
Met Partially No
Therapist & father attend IEP meeting
Strategize approaching teachers
Develop school report card for teachers
All teachers agree to complete card
Set another meeting
Met
Met
Met
Met
Partial
Father to collect urine for dr ug screen Partial
Father and teen to try three strategies when conflict arises Partial
Cousin J to take teen to job interview Not
Review peer sheet with father Not
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Barriers to Intermediary GoalsBarriers to Intermediary Goals
English teacher not in IEP conference ± teen failing in her class plus behavioral
problems ± need teacher buy-in on card
Teen left school early 2 days ± came out in conference
Father collected urine but unsure how to read results ± didn¶t call therapist ± gave
teen privileges as if screen were clean
Teen disrespectf ul and didn¶t follow through with conflict plan
Cousin had to work unexpectedly and couldn¶t take teen to job interview
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Advances in TreatmentAdvances in Treatment
Coach attended IEP ± seemed fond of teen ± willing to help
Teachers and father agree on a more vocational track
Teachers seem willing to fill in brief report card each day
Teen set up another time to go with cousin for job interview
Father had neighbor help twice this week ± check to see if teen home
Father rewarded son this week for making curfew
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Teen: Why
should I try?
I¶m going to
fail anyway.
Teen left
school
early 2 x
Unable to
use conflictresolution
plan
Behavior plan for
home/school link
not in place ± no
consequences
Left after PE,
before English
± easy to
escape
Left with 2
peers ± went
to house of
oneunsupervised Father thinking
teen trying to
make him mad ±
felt hopeless
Father¶s anger
makes teen feel
he¶s winning
Father uses
intolerant
tone; teen
disrespectf ul
Reassessment of Fit
between Problems &
Intermediary Goals
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Marijuana Use
Fit Circles
Insufficientstr ucture ±
too much
down time
Poor impulse
control
Mom¶s dr ug
history ± dr ugs
normalized
Dr ug-using
peers
Poor parental
supervision
Family conflict
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New Intermediary GoalsNew Intermediary Goals
Therapist to follow-up with English teacher
Therapist to check with father on daily report card
See if teachers comply with plan
See if father able to follow through with conseq
uences
Father to call coach about teen not skipping out after P.E.
Father to call peer¶s mom and ask not to allow teen there during school
Work on conflict
Ask father/son why not follow through on conflict plan
Shift roles in role playThought replacement when father discouraged
Pizza for family to facilitate engagement
Therapist to collect random urine dr ug screen this week
(Henggeler, 2009)
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Support for TherapistsSupport for Therapists
Initial 5 day orientation trainingInitial 5 day orientation training
Quarterly booster trainingQuarterly booster training
Weekly onWeekly on--site supervisionsite supervision
Weekly consultationWeekly consultation
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Engaging MultiEngaging Multi--problem Familiesproblem Families
EmpathyEmpathy
Spending nonclinical time with familySpending nonclinical time with family
Cognitive assistsCognitive assistsFather as childFather as child
WarmthWarmth
FlexibilityFlexibility ReframingReframing
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ReframingReframing
1) Echo family¶s point of view1) Echo family¶s point of view³I know you think your baby is crying³I know you think your baby is crying
because she knows you had a bad daybecause she knows you had a bad day
and she¶s just trying to upset you.´and she¶s just trying to upset you.´
2) Offer an alternative2) Offer an alternative
³Lots of babies get gas sometimes.³Lots of babies get gas sometimes.
I¶ve heard a lot of moms say their I¶ve heard a lot of moms say their
babies are f ussy right after they eat.´babies are f ussy right after they eat.´
3) Check to see family¶s response.3) Check to see family¶s response.
³Do you think that might be part of ³Do you think that might be part of
what¶s oin on?´what¶s oin on?´
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Nonclinical StrategiesNonclinical Strategies
Family PhotosFamily Photos
FoodFood
Helping with practical needsHelping with practical needs
5 minute sessions5 minute sessions
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Dimensions of Family RelationsDimensions of Family Relations
WarmthWarmth
ControlControl
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Parenting StyleParenting Style
WarmthWarmth ControlControl
Authoritative Authoritative HighHigh HighHigh
Authoritarian Authoritarian LowLow HighHigh
PermissivePermissive HighHigh LowLow
Neglectf ulNeglectf ul LowLow LowLow
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AuthoritativeAuthoritative
Responsive to reasonable needsResponsive to reasonable needs
Maturity demands appropriate to developmentMaturity demands appropriate to development
Clear expectationsClear expectations ± ± school performanceschool performance
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AuthoritarianAuthoritarian
Directive and over Directive and over--controllingcontrolling
Require unquestioning obedienceRequire unquestioning obedience
Severe punishment, sometimes physicalSevere punishment, sometimes physical
Directive teaching styleDirective teaching style
No child participation in decisionsNo child participation in decisions
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PermissivePermissive
Little str ucture and disciplineLittle str ucture and discipline
Few demands for mature behavior Few demands for mature behavior
Tolerate antisocial behavior Tolerate antisocial behavior
Warm and responsive, but not demandingWarm and responsive, but not demanding
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NeglectfulNeglectful
Little discipline or affectionLittle discipline or affection
Little concern or interest in parentingLittle concern or interest in parenting
Are not responsive to child¶s needs Are not responsive to child¶s needs
Do not expect responsible behavior Do not expect responsible behavior
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Outcome StudiesOutcome Studies
Study Population Comparison Follow
-Up
MST Outcomes
Henggeler
et al., 1986
N = 57
Delinquents Diversion
Services
Post-tx Family relations
Behavior problems
Association with delinq. peers
Br unk et al.,1987
N = 33
MaltreatingFamilies
BehavioralParent
Training
Post-tx Parent-child relations
Henggeler
et al., 1991
Serious
juvenile
offenders
Individual
counseling;
community
services
3 yrs Alcohol and dr ug use
Dr ug-related arrests
Henggeler
et al., 1992
N = 84
Violent &
chronic
juvenile
offenders
Community
services
59
weeks
Family relations
Peer relations
Recidivism (43%)
Out of home placement (64%)
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Outcome StudiesOutcome Studies -- RecentRecent
Study Population Comparison Follow-
Up
MST Outcomes
Stambaugh
et al., 2007
N = 267
Serious
emotional
disturbance
Wraparound 18 mo. Symptoms
Out-of-home
placement (54%)
Henggeler
et al., 2006N = 161
Substance
abusingteens in dr ug
court
4 Tx
conditionsincluding
family court
with usual
services
12 mo.
Postentry
Substance abuse
Timmons-
Mitchell etal., (2006)
N = 93
Juvenile
offenders atimminent risk
of placement
Usual
communityservices
18 mo. Youth f unction
Substance useRearrests (37%)
Rowland et
al., 2007
N = 31
Serious
emotional
disturbance
Hawaii¶s
intensive
Continuum
of Care
6 mo.
Post
entry
Symptoms
Minor crimes
Days out of home
(68%)
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Outcome StudiesOutcome Studies-- Sexual OffendersSexual Offenders
Study Population Comparison Follow-
Up
MST Outcomes
Borduin
et al.
1990
N = 16
Adolescent
sex
offenders
Individual
counseling
3 yrs Sexual offending
Other criminal offending
Borduin &
Schaeffer
(2001) N
= 48
Prelim
Adolescent
sex
offenders
Usual
community
services
9 yrs Behavior problems & symptoms
Family relations
Peer relations
Academic performance
Borduin &
Schaeffer,
in press
Full
Caregiver distress
Recidivism for sex crimes (83%)
Recidivism for other crimes
(50%)
Days incarcerated (80%)
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Outcome StudiesOutcome Studies ± ± Sex OffendersSex Offenders
Study Population Comparison Follow-
Up
MST Outcomes
Letournea
u et al., in
press
Juvenile
sex
offenders
Usual sex-
offender
specific tx
12 mos
post-tx
Sexual behavior problems
Delinquency, substance abuse &
externalizing symptoms
Out-of-home placements
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34 Studies of MST34 Studies of MST33 Showed Decreases:33 Showed Decreases:
Factors StudiedFactors Studied
SymptomsSymptoms
RearrestsRearrests
Substance abuseSubstance abuse
OutOut--of of--home placementshome placements
Sexual behavior problemsSexual behavior problems
Externalizing symptomsExternalizing symptoms
Sexual crime recidivismSexual crime recidivism
(Henggeler, 2009)(Henggeler, 2009)
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34 Studies of MST34 Studies of MST
33 Showed Decreases33 Showed Decreases
Factors Studied:Factors Studied:
Inpatient admissionsInpatient admissionsMedical charges & direct care costsMedical charges & direct care costs
Attempted suicide Attempted suicide
Violent crimeViolent crime Association with delinquent peers Association with delinquent peers
SsychiatricSsychiatric symptomatologysymptomatology
(Henggeler, 2009)(Henggeler, 2009)
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34 Studies of MST34 Studies of MST
33 Showed Increases:33 Showed Increases:
Factors Studied:Factors Studied:
Improved family relationsImproved family relationsImproved parentImproved parent--child interactionschild interactions
Improved peer relationsImproved peer relations
Increased school attendanceIncreased school attendanceHigher consumer satisfactionHigher consumer satisfaction
Improved academic performanceImproved academic performance
Increased social competenceIncreased social competence
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34 Studies of MST34 Studies of MST
33 Showed Increases:33 Showed Increases:
Factors Studied:Factors Studied:
Blood glucose testingBlood glucose testing
Metabolic controlMetabolic control
Youth f unctioningYouth f unctioning
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1 Study1 Study
((SundellSundell et al., 2008)et al., 2008)
Compared to child welfare services inCompared to child welfare services in
SwedenSweden
No outcomes favoring either No outcomes favoring either txtx
Low treatment fidelityLow treatment fidelity