Multisystemic Therapy: Who we Are, What We Do, and Real World
Applications
Multisystemic Therapy (MST) Overview
1
What is “MST”?
• Community-based, family-driven treatment for antisocial/delinquent behavior in youth
• Focus is on empowering caregivers (parents) to solve current and future problems
• MST “client” is the entire ecology of the youth - family, peers, school, neighborhood
• Highly structured clinical supervision and quality assurance processes
2Multisystemic Therapy (MST) Overview
Social Ecological Model
3
CommunityProvider Agency
School
NeighborhoodPeers
Extended Family
Siblings
CHILDCaregiver Caregiver
Standard MST Referral Criteria (ages 12-17)
Inclusionary Criteria• Youth at risk for placement
due to anti-social or delinquent behaviors, including substance abuse
• Youth involved with the juvenile justice system
• Youth who have committed sexual offenses in conjunction with other anti- social behavior
Exclusionary Criteria• Youth living independently• Sex offending in the absence of other
anti social behavior• Youth with moderate to severe autism
(difficulties with social communication, social interaction, and repetitive behaviors)
• Actively homicidal, suicidal or psychotic• Youths whose psychiatric problems are
the primary reason leading to referral, or who have severe and serious psychiatric problems
4Multisystemic Therapy (MST) Overview
How is MST Implemented?
Intervention strategies: MST draws from research-based treatment techniques• Behavior therapy• Parent management training • Cognitive behavior therapy• Pragmatic family therapies
- Structural Family Therapy- Strategic Family Therapy
• Pharmacological interventions (e.g., for ADHD)
5Multisystemic Therapy (MST) Overview
How is MST Implemented?(Cont.)
• Single therapist working intensively with 4 to 6 families at a time
• Team of 2 to 4 therapists plus a supervisor
• 24 hr/ 7 day/ week team availability: on call system
• 3 to 5 months is the typical treatment time (4 months on average across cases)
• Work is done in the community, home, school, neighborhood: removes barriers to service access
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How is MST Implemented? (Cont.)
• MST staff deliver all treatment – typically no or few services are brokered/referred outside the MST team
• Never-ending focus on engagement and alignment with primary caregiver and other key stakeholders (e.g. probation, courts, children and family services, etc.)
• MST has strong track record of client retention and satisfaction with MST
• MST staff must be able to have a “lead” clinical role, ensuring services are individualized to strengths and needs of each youth/family
7Multisystemic Therapy (MST) Overview
Core Elements of MST
Key Points:
• MST Treatment Principles
• MST Analytic Process
• MST Quality Assurance System
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MST Treatment Principles
• Nine principles of MST intervention design and implementation
• Treatment fidelity and adherence is measured with relation to these nine principles
9Multisystemic Therapy (MST) Overview
1. Finding the Fit: The primary purpose of assessment is to understand
the “fit” between the identified problems and their broader systemic context
Kim’s Substance
Abuse
Drug using Peers Access to
marijuana
Kim can buy drugs with cash given to her by
relatives
Uses after conflicts with
mother
Lack of consequences
for use
Boredom, doesn’t have other things
to do
Modeling of use in community (peers
and adults)
Low monitoring by mother
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Principles of MST (Cont.)
2. Positive & Strength Focused
Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.
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Principles of MST (Cont.)
3.Increasing ResponsibilityInterventions should be designed to promote responsibility and decrease irresponsible behavior among family members.
4.Present-focused, Action-oriented & Well-definedInterventions should be present-focused and action-oriented, targeting specific and well-defined problems.
12Multisystemic Therapy (MST) Overview
5. Targeting Sequences: Interventions should target sequences of behavior within and between multiple systems that maintain identified problems (cont.)
Mom asks youth to do
homework and clean room
Youth says he’ll do it in a minute
Mom makes a second
request; youth ignores
Step-father intervenes:
“listen to your mom”
Youth states “get out of my face, you’re not my dad”
Step father starts shouting: “you live in my
house, do it now”
Mom gets in the middle to stop
verbal argument and gets pushed
Mom hits her head, step-
father is furious
Youth runs to room, and locks
door
Step-father calls police
Youth arrested for assault
charge
Principles of MST (Cont.)
6. Developmentally Appropriate
Interventions should be developmentally appropriate and fit the developmental needs of the youth.
14Multisystemic Therapy (MST) Overview
Principles of MST (Cont.)
7. Continuous EffortInterventions should be designed to require daily or weekly effort by family members.
8. Evaluation and AccountabilityIntervention efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.
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Principles of MST (Cont.)
9. Generalization
Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.
16Multisystemic Therapy (MST) Overview
Environment of Alignment and Engagementof Family and Key Participants
Measure
Re-evaluate Prioritize
Do
IntermediaryGoals
InterventionDevelopment
MST Conceptualizationof “Fit”
Assessment ofAdvances & Barriers to
Intervention Effectiveness
InterventionImplementation
MSTAnalyticalProcess
ReferralBehavior
OverarchingGoals
Desired Outcomesof Family and Other
Key Participants
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Causal Models of Delinquency and Drug Use: Common Findings of 50+ Years of
Research
Family
School
DelinquentPeers
DelinquentBehavior
Prior DelinquentBehavior
Neighborhood/ CommunityContext
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Research on Delinquency and Drug Use
Family Level
• Poor parental supervision
• Inconsistent or lax discipline
• Poor affective relations between youth, caregivers, and siblings
• Parental substance abuse and mental health problems
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Research on Delinquency and Drug Use (Cont.)
Peer Level
• Association with drug-using and/or delinquent peers
• Poor relationship with peers, peer rejection
• Association with antisocial peers is the most powerful direct predictor of delinquent behavior!
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Research on Delinquency and Drug Use (Cont.)
School Level
• Academic difficulties, low grades, having been retained
• Behavioral problems at school, truancy, suspensions
• Negative attitude toward school
• Attending a school that does not flex to youth needs
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Research on Delinquency and Drug Use (Cont.)
Community Level
• Availability of weapons and drugs
• High environmental and psychosocial stress (violence)
• Neighborhood transience – neighbors move in and out
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Research on Delinquencyand Drug Use (Cont.)
Youth Level
• ADHD, impulsivity
• Positive attitude toward delinquency and substance use
• Lack of guilt for transgressions
• Negative affect
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MST Theory of Change
Multisystemic Therapy (MST) Overview
MSTImproved
Family Functioning
Peers
School
Reduced Antisocial
Behavior and Improved
Functioning
Community
Multisystemic Therapy (MST) Overview
25
Evona Referral Behaviors
Substance Use: Marijuana, Methamphetamines (daily)
Runaway Behavior: Several times over the past year for as long as two months
Truancy: Missed all of the first half of the school year in 2017 - 2018
Multisystemic Therapy (MST) Overview
26
Evona Overarching Goals1. The youth will maintain a clean and sober lifestyle as evidenced by at
least four clean U.A. tests and reliable collateral reports from family and community members
2. The youth will follow curfew and home guidelines established by Dad and appointed Guardians as evidenced by no reports or arrests for runaway or
AWOL behavior during MST
3. The youth will attend school at least 80% of the time and receive passing grades as evidenced by reliable school, parent, and community reports
Multisystemic Therapy (MST) Overview
27
EvonaSA
Fit Factor: Negative Peer Association (Evonawas spending time with SA peers while on
runaway)Evidence: AEB – reliable collateral reports
Fit Factor: Parent SeparationEvidence: Evona started using when
his mom left to live in Tonga
Fit Factor: history of Substance use in extended Family
Evidence: Family ReportFit Factor: Access and opportunity in community
Fit Factor: Low MonitoringEvidence: Parent Absent or busy
working
Fit Factor: Coping with Loss, sadness and frustration
Fit Factor: Idle, Unsupervised time
Evidence: truant and not in prosocial activities
Evona Fit Circle
Multisystemic Therapy (MST) Overview
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John Paul Referral Behaviors
Disruptive in Class: Comes in late; talks loudly; throws pencils/objects; ordered a pizza during class. Started in 8th grade but has increased in
frequency and intensity in the last 2 months
Theft: Youth and younger brother broke into an amazon package in a driveway where they suspected fidgets were delivered; took fathers credit card without permission and ordered vaping products online to be delivered. Increased in
frequency resulting in arrest and charges pending (May/June)
Multisystemic Therapy (MST) Overview
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Illegal Activities on Campus: Youth and younger brother sold powdered lemonade on campus under guise of drugs to students; current investigation of
being in possession of e-cigarette/vape on campus
Verbal Aggression: Mimics teacher; swears; uses abusive language; makes threatening comments/gestures to teachers and to mom. Escalating behaviors
since mid 8th grade
John Paul Referral Behaviors Continued
Multisystemic Therapy (MST) Overview
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John Paul Overarching Goals
1. John Paul will be able to re-direct himself from being disruptive in class after one prompting on 4 out of 5 days per parent-teacher report
2. John Paul will have no arrests in the community during MST treatment per parent/police report
3. John Paul will not engage in illegal activities on campus during MST treatment per parent/administration/police report
Multisystemic Therapy (MST) Overview
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4. John Paul will express himself to caregivers without being verbally aggressive (no swearing, yelling, cursing) with one prompting on 4 out of 5 days per parent report
5.John Paul will diminish his use of e-cigarettes/vapors during MST treatment per parent report
John Paul Overarching Goals Cont…
Multisystemic Therapy (MST) Overview
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John Paul Fit Circle
Illegal behaviors
on Campus
Fit Factor: Negative Peer InfluenceEvidence: School report, psych eval
Fit Factor: Low monitoring and supervision
Evidence: had unsupervised free time at school
Fit Factor: Youth Impulsivity
Fit Factor: Ineffective rules, rewards and contingencies at school
Evidence: school uses suspension which is reinforcing for youth
Fit Factor: ineffective home contingencyEvidence: Family was not connecting
home contingency/rewards to outcomes; believed in natural consequences
Fit Factor: ineffective home-school linkEvidence: Family believed that if they did not hear anything it was fine
Fit Factor: Ineffective co-parentingEvidence: Dad report that parents are
not always on the same pageFit Factor: Access to itemsEvidence: Parents did not know how to prevent youth from bringing items to school
How MST AddressesYouth Substance AbuseCausal Models of Delinquency and Drug Use: Common Findings of 50+ Years of Research
Family
School
Delinquent/ Substance-Using Peers
Delinquent/ Substance-Using
Behavior
Prior Delinquent/Substance-Using
Behavior
Neighborhood/ CommunityContext
Multisystemic Therapy (MST) Overview
How MST Addresses Substance Abuse
Multisystemic Therapy (MST) Overview
• Strong Engagement of Caregivers and Youth, and their ongoing involvement in working to address the youth’s substance abuse problems is key to addressing youth’s substance abuse problems.
• MST Keeps Kids in Treatment!
How MST Addresses Substance Abuse
Multisystemic Therapy (MST) Overview
• Assessment of Youth Drug & Alcohol Use– Finding the Fit – Assessment is informed by
multiple sources to understand the way the youth’s use of drugs and/or alcohol fits within the context of the youth and family system, and other elements of the youth’s ecology
How MST Addresses Substance Abuse
• Intervention Strategies:– Redirecting the young person away from substance-using peers– Monitoring the youth’s whereabouts closely– Detecting use with objective mechanisms
(e.g. UA or breathalyzer)– Reducing family conflict– Establishing powerful incentives to stay clean– Helping the youth to develop refusal and coping skills to
promote abstinence
Multisystemic Therapy (MST) Overview
How MST Addresses Substance Abuse
Multisystemic Therapy (MST) Overview
• Quality Assurance and Implementation with Fidelity– Therapist adherence to the nine treatment
principles has been linked with decreased drug use in youth who receive MST (Henggeler, Pickrel, & Brondino, 1999)
Incorporating Contingency Management in MST
Contingency Management is one of the most extensively researched and best validated interventions in the field of substance abuse treatment
Henggeler et al., 2006
Multisystemic Therapy (MST) Overview
Integration of CM into
MST
Improved outcomes in juvenile drug
court via substance use reduction
Accelerated decrease in
substance use
Multisystemic Therapy (MST) Overview
Incorporating Contingency Management in MST
• CM is a substance abuse treatment approach based in behavioral and cognitive-behavioral therapy that includes
– Tailored ABC Assessments of use/non-use conducted with the youth and caregivers
– Family Drug-Management Planning, including Drug-Refusal Skills Training
– Point and Level Reward System
– Drug Testing Protocol used primarily by caregivers
– Strong focus on engagement and sustainability
CM has strong treatment compatibility with MST
• Areas of Focus
Multisystemic Therapy (MST) Overview
Improved Family Functioning
• increased monitoring of use by parents via drug testing
• increased parental consistency, including use of powerful incentives
• decreased family conflict
Decreased Contact with Negative Peers
• positive replacement activities
• family plans for risk-avoidance
• improved school attendance• youth drug refusal skills
Measurable Outcomes
• reduced substance use• generalization of treatment
gains• sustained improvements
Incorporating Contingency Management in MST
Substance Abuse Results in MST
Randomized Trial with Substance Abusing / Dependent Offenders (N=118); MST vs. Community Treatment
Henggeler, Pickrel, & Brondino, 1999
Multisystemic Therapy (MST) Overview
Enga
gem
ent
& R
eten
tion
• 98% of MST families completed treatment Su
bsta
nce
Use
• Greater post-treatment reductions for MST Sc
hool
Att
enda
nce
• Significant increase in regular school settings
Substance Abuse Results in MST
Henggeler, Clingempeel, Brondino, & Pickrel (2002).
Multisystemic Therapy (MST) Overview
0%
10%
20%
30%
40%
50%
60%
Marijuana Abstinence at 4-Year Follow-up
Youth in MST
Youth in Usual Services
Substance Abuse Results in MST
4-Year Follow up
Henggeler, et al 2002
Multisystemic Therapy (MST) Overview
0
0.2
0.4
0.6
MST youth Control Group
Arrests per Year for Violent Crimes
Arrests for ViolentCrimes
Substance Abuse Results in MST
Schaeffer & Borduin (2005)
Multisystemic Therapy (MST) Overview
0
0.2
0.4
0.6
MST
Treatment as
usual
Decreased drug-related arrests at 14 years
Consistent Outcomes for MST
In Comparison with Control Groups, MST:• Led to higher consumer satisfaction• Decreased long-term rates of re-arrest 25% to 70%• 47% to 64% decreases in long-term rates of days in out-of-home
placements • Improved family relations and functioning• Increased mainstream school attendance and performance • Decreased adolescent psychiatric symptoms• Decreased adolescent substance use
But, none of this happens without adherence to MST
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14 years post treatment(n= 165, 94% tracking success)• 54% fewer arrests• 59% fewer violent arrests• 64% fewer drug-related arrests• 57%fewer days in adult
confinement• 43% fewer days on adult
probation
22 years post treatment
(n= 148, 84% tracking success)• 36% fewer felony arrests• 75% fewer violent felony arrests• 33% fewer days in adult confinement• 38% fewer issues with family instability
(divorce, paternity, child support suits)• 3% fewer financial problems
(credit, contract, rent suits)
Multisystemic Therapy (MST) Overview
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14-year and 22-year post-treatment outcomes (MST compared to Individual Treatment: individuals treated 1983-1986)
Long-term Outcomes for MST
MST Assumptions• Children’s behavior is strongly influenced by their
families, friends and communities (and vice versa)
• Families and communities are central and essential partners and collaborators in MST treatment
• Caregivers/parents want the best for their children and want them to grow to become productive adults
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MST Assumptions (Cont.)
• Families can live successfully without formal, mandated services
• Change can occur quickly
• Professional treatment providers should be accountable for achieving outcomes
• Science/research provides valuable guidance
Multisystemic Therapy (MST) Overview
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Why is MST Successful?• Treatment targets known causes of delinquency: family
relations, peer relations, school performance, community factors
• Treatment is family-driven and occurs in each youth’s natural environment
• Significant energies are devoted to developing positive interagency relations
• MST personnel are well trained and supported• Providers are accountable for outcomes
• Continuous quality improvement occurs at all levels
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