Site Dev Highlighted article or topic – Transport Findings Update and Summary _____________________________________ Website: Pre Sonja Schoenwald, Ph.D. January 14, 2009 FSRC Update & Publications

MST Transport & Implementation Research Thanks to: Office of Juvenile Justice and Delinquency Prevention National Institute of Mental Health National Institute of Drug Abuse Family Services Research Center Charles Glisson Don Hedeker David Mackinnon Service systems, organizations, clinicians, and families

Transporting New Treatments: MST as Test Case Funded by National Institute of Mental Health MH – 2004 National Institute of Drug Abuse DA – 2007 Schoenwald, PI

MST Transportability Study Aims To Examine Relations Between :  MST therapist adherence and outcomes  Organizational climate and structure, adherence, & outcomes  Supervision, adherence, & outcomes  Impact of clinician training & experience on adherence  A mediation model of transport

Social Ecological Model of Treatment Transportability Extra-Organizational Context (Referral, Reimbursement, Disposition) Organization Clinician Child ( Structure,Climate, ) Adherence Outcomes MST Supervision(Behavior, functioning, criminal activity) Clinician Variables Professional Training & Experience

Design  Prospective, uncontrolled study  Children nested within therapists nested within organizations within service systems  Repeated measures  Youth: Pre, post, 6 & 12 months post-treatment; lifetime pre through 1-year post criminal charges  Clinicians: TAM monthly; SAM bimonthly  Organizations: biannually  Service system: biannually, & per case

Participants  45 MST programs in 12 states and Canada  452 therapists: 73% female, 73% Caucasian, 15% African American, 6% Asian/PI, 2% Hispanic  64% masters (social work, counseling, psychology)  1979 youths and their caregivers  Youths were: 15.5 years old, 65% male, 58% Caucasian, 19% African American, 6% Asian, 4% Hispanic, 13% Biracial

MST Transportability Study Published Findings Redux

Predictors of Post-Treatment Change  Therapist Adherence (Schoenwald, Sheidow, Letourneau, & Liao, 2003; FSRC Pub. # 235)  Select Organizational Climate & Structure Scales (Schoenwald et al., 2003; same as above)  Consultant Adherence (Schoenwald, Sheidow, & Letourneau, 2004; FSRC Pub. # 242)

Organizational Factors Assessed Climate  Psychological impact of work environment  Validated measure, OCQ, has 10 scales Structure  Formal features of organization  Hierarchy of Authority  Procedural & Rule Specification  Participation in Decision-making  “Fit” of work with structure is more important than structure per se

Organizational Predictors  Select climate and structure factors predicted short-term outcomes, some in unexpected directions.  Climate & structure did not predict adherence.  Adherence moderated relations between climate and structure and outcomes.

Findings at Long-Term Follow-Up

Youth Change Over Time  Significant reductions in behavior and functioning problems through 1-year post- treatment  Significant reductions in criminal charges through 4-year post-treatment

Did Adherence Predict Longer- Term Post-Treatment Change?  Reductions in behavior problems one-year post- treatment differed significantly as function of therapist adherence ratings Schoenwald, S. K., Carter, R. E., Chapman, J. E., & Sheidow, A. J. (2008). Therapist adherence and organizational effects on change in youth behavior problems one year after Multisystemic Therapy. Administration and Policy in Mental Health and Mental Health Services Research, 35, ; FSRC Pub #326)

Adherence – Criminal Outcomes  At the highest level of adherence, the annualized rate of post-treatment charges for youth was 47% lower than at the lowest level of adherence.  When therapist adherence scores were one SD above the mean, annualized rate of post-treatment charges was 29% lower than when therapist adherence scores were one SD below the mean. Schoenwald, S.K., Chapman, J.E., Sheidow, A.J., & Carter, R.E. (in press). Long- term youth criminal outcomes in MST transport: The impact of therapist adherence and organizational climate and structure. Journal of Clinical Child and Adolescent Psychology.

Structure & Climate Findings Higher Therapist Adherence Was Predicted By  Greater organizational average levels of Growth & Advancement  Therapist perception of greater Growth & Advancement and Job Satisfaction Lower Therapist Adherence Predicted By  Therapist perception of greater Emotional Exhaustion

Greater reductions in youth Externalizing behavior were predicted by:  Higher organizational average levels of Growth & Advancement  Lower organizational average levels of Hierarchy of Authority  Therapist perceptions of greater Participatory Decision making Structure & Climate Findings (2)

However,  When therapist adherence was added to the statistical models, the effects of these organizational climate and structure factors on youth outcomes weakened. Structure & Climate Findings (3)

Structure & Climate Findings (4) Youth Criminal Charges (on average 4 years post-treatment) Were Predicted By  Therapist perceptions of greater Job Satisfaction, Growth & Advancement  Higher organizational average Participatory Decision making But, These effects washed out when therapist adherence was included in the model

What Does This Mean For Your Work?  When adherence is good, but youth long-term outcomes are not, it may be that select aspects of organizational climate or structure are affecting the outcomes.  BUT: Depending on the outcome in question, those organizational effects are either weak or wash out compared to the effects of adherence  SO: Keep focusing on adherence

Supervisor Adherence  Supervisor Adherence Measure (SAM)  Subscales  Supervision structure & process (SP)  Promotion of MST principles (AP)  Promotion of MST analytic process (ANP)  Supervisor development of clinician’s skills and competencies (CD ) *

Supervisor Adherence Findings  Greater supervisor average focus on Adherence to Principles predicted therapist adherence.  Greater supervisor adherence to the Structure and Process (SP) of supervision during a youth’s treatment episode predicted greater reductions in youth behavior and functioning problems.  Greater average focus on Clinician Development predicted a lesser decrease in youth functioning problems. Schoenwald, S.K., Sheidow, A.J., & Chapman, J.E. (in press). Clinical supervision in treatment transport: Effects on adherence and outcomes. Journal of Consulting and Clinical Psychology.

Empirically – Supported Fidelity Links Consultant SupervisorTherapistOutcomes CAM Therapist Report SAM Therapist Report TAM Parent Report Behaviors Function Criminal Activity* Organization*