1. Multisystemic Therapy 04/00 Multisystemic Therapy (MST) For additional information see www.mstservices.com

2. Multisystemic Therapy 04/00 Primary Goals of MST n Reduce youth criminal activity n Reduce other types of antisocial behavior such as drug abuse and sexual offending n Achieve these outcomes at cost savings by decreasing rates of incarceration and out- of-home placements

3. Multisystemic Therapy 04/00 MST Research and Dissemination n Family Services Research Center (FSRC) ä Research Center at the Medical University of South Carolina (MUSC), Dr. Scott Henggeler, Director n MST Services ä MUSC affiliated organization offering assistance in MST program development and training through licensing agreements with the MUSC and the FSRC n MST Institute ä Independent non-profit organization providing quality control expertise, data, and tools to all interested parties

4. Multisystemic Therapy 04/00 MST “Champions” & Advocates n OJJDP - Office of Juvenile Justice and Delinquency Prevention n Washington State Institute of Public Policy ä MST: most cost effective approach to reducing crime n “Blueprints for Violence Prevention” ä MST selected as one of the 10 “Blueprint” programs by Delbert Elliott, Center for the Study and Prevention of Violence, University of Colorado

5. Multisystemic Therapy 04/00 MST Research and Development n Theoretical underpinnings n Research findings on delinquent behavior n MST research findings

6. Multisystemic Therapy 04/00 MST Theoretical Assumptions n Children and adolescents are embedded in multiple systems that have direct and indirect influences on their behavior. n Influences are reciprocal and bi-directional Based on Bronfenbrenner, Haley, and Minuchin

7. Multisystemic Therapy 04/00 Ecological Models Child Neighborhood FamilyPeers School

8. Multisystemic Therapy 04/00 Ecological Models Child Family Peers School Neighborhood Treatment Providers

9. Multisystemic Therapy 04/00 Causal Models of Delinquency & Drug Use Condensed Longitudinal Model Family School Delinquent Peers Delinquent Behavior Prior Delinquent Behavior Low Parental Monitoring Low Affection High Conflict Low School Involvement Poor Academic Performance Elliott, Huizinga & Ageton (1985) - - + +

10. Multisystemic Therapy 04/00 Needs of Violent & Chronic Juvenile Offenders and Their Multiproblem Families n Improve parental discipline practices n Increase family affection n Decrease association with deviant peers n Increase association with prosocial peers n Improve school/vocational performance n Engage in positive recreational activities n Improve family-community relations n Empower family to solve future difficulties

11. Multisystemic Therapy 04/00 The Missouri Delinquency Project Charles M. Borduin, (PI), University of Missouri Barton J. Mann, University of Illinois - Chicago Lynn T. Cone, University of Missouri Scott W. Henggeler, Medical University of South Carolina Bethany R. Fucci, University of Missouri David M. Blaske, University of Missouri Robert A. Williams, University of Missouri

12. Multisystemic Therapy 04/00 Participants: 200 Offenders and Their Families n Averaged 4.2 previous arrests n 64% had been incarcerated previously for at least 4 weeks n Average age = 14.8 years n 67% male, 33% female n 30% African-American, 70% Caucasian n 47% lived with only one parental figure

13. Multisystemic Therapy 04/00 Service/Treatment Options n Multisystemic Therapy ä 77 completers ä 15 dropouts n Individual Therapy ä 63 completers ä 21 dropouts n Usual probation services for refusers ä 24 refusers

14. Multisystemic Therapy 04/00 Service Delivery vs. Treatment Service Delivery Models n Family Preservation n Inpatient n Outpatient n Residential Treatment n Foster Care Treatment Models n Multisystemic Therapy n Cognitive Therapy n Family Therapy n Psychodynamic Therapy n Behavior Therapy

15. Multisystemic Therapy 04/00 Delivery of Multisystemic Therapy

16. Multisystemic Therapy 04/00 MST Case Example n 15 year old minority youth n Referral to MST for truancy, aggressive behavior at home and school, multiple shopliftings, and drug abuse n Lives with mother, stepfather, and three younger siblings

17. Multisystemic Therapy 04/00 MST Treatment Principles n Nine principles of MST intervention design and implementation n Treatment fidelity and adherence is measured with relation to these nine principles

18. Multisystemic Therapy 04/00 Principles of MST 1.Finding the Fit The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context. 2.Positive & Strength Focused Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.

19. Multisystemic Therapy 04/00 Principles of MST 3.Increasing Responsibility Interventions should be designed to promote responsibility and decrease irresponsible behavior among family members. 4.Present-focused, Action-oriented & Well-defined Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.

20. Multisystemic Therapy 04/00 Principles of MST 5.Targeting Sequences Interventions should target sequences of behavior within and between multiple systems that maintain identified problems. 6.Developmentally Appropriate Interventions should be developmentally appropriate and fit the developmental needs of the youth.

21. Multisystemic Therapy 04/00 Principles of MST 7.Continuous Effort Interventions should be designed to require daily or weekly effort by family members. 8.Evaluation and Accountability Interventions efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.

22. Multisystemic Therapy 04/00 Principles of MST 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.

23. Multisystemic Therapy 04/00 Instrumental Outcomes at Post-treatment n Increasing family cohesion and adaptability n Increasing family supportiveness n Decreasing family hostility n Decreasing parental symptomatology n Decreasing behavior problems in youth Multisystemic Therapy was significantly more effective at:

24. Multisystemic Therapy 04/00 Ultimate Outcomes at Four-Year Follow-Up n Preventing violent offending n Preventing other criminal offending n Preventing drug-related offending n Decreasing seriousness of committed crimes Multisystemic Therapy was significantly more effective at:

25. Multisystemic Therapy 04/00 Missouri Delinquency Project

26. Multisystemic Therapy 04/00 The Role of Treatment Fidelity Standard Training for MST clinical staff ä 5-Day on-site orientation to MST ä Weekly MST consultations: viewed as the core of the training program -- true on-the-job training ä Quarterly on-site booster training

27. Multisystemic Therapy 04/00 The Role of Treatment Fidelity n Examined the effects of MST in the absence of ongoing weekly MST consultation. n Adherence measure: 26 item questionnaire completed by the youth’s caregiver/parent. n Results: adherence to the MST treatment model varied greatly without weekly MST consultation. n Client outcomes: where treatment adherence was high, outcomes were substantially better.

28. Multisystemic Therapy 04/00 The Role of Treatment Fidelity MST treatment adherence predicted: n decreased criminal activity n decreased incarceration n decreased adolescent emotional distress n increased parental emotional distress

29. Multisystemic Therapy 04/00 The Role of Treatment Fidelity Implications of research: n High adherence is essential for obtaining outcomes with difficult clinical populations n Traditional training and supervisory protocols are not sufficient for obtaining high adherence n To obtain the strongest possible outcomes, MST programs should “institutionalize” adherence monitoring and on-going training for staff

30. Multisystemic Therapy 04/00 Bridging the Gap: University to Community n University-based research projects often show promising results which can not be replicated by community-based programs n MST has successfully made this transition ä Positive university-based research ä Positive community-based research ä Focusing on the implementation of effective community-based MST programs

31. Multisystemic Therapy 04/00 Community-based Dissemination Efforts n Program Replications ä California ä Connecticut ä Colorado ä Delaware* ä Florida ä Ireland (No.) ä Kansas ä Louisiana ä Manchester (UK) ä Maryland ä Michigan* ä Minnesota ä Missouri ä New York* ä Nebraska ä North Carolina ä Ohio* * Clinical Trials ä Oregon ä Pennsylvania* ä South Carolina* ä Tennessee* ä Texas* ä Washington ä Washington D.C. ä Ontario, Canada* ä Norway*

32. Multisystemic Therapy 04/00 Critical Elements of Implementation n Continuous Focus on Outcomes n Fidelity to the Treatment Model n Accessibility of Treatment F What influences these critical elements? ä Interagency collaboration ä Organizational support of the program ä Operational practices and policies

33. Multisystemic Therapy 04/00 Influences of Other System Stakeholders n Funding structure in place n Ability of MST therapist to take the “lead” in clinical decision making n Key stakeholders usually include: ä Juvenile Justice, Family Court, Mental Health, Social Welfare, School systems, parent groups n Clearly defined target population, program goals, and referral process

34. Multisystemic Therapy 04/00 Influences within the Provider Organization n Clear understanding of MST at all levels n Commitment to implement MST fully n Target MST compatible populations n Willingness to modify policies and dedicate resources to achieve outcomes ä Commitment to training and supervision ä Policies (e.g. flex-time, transportation) ä Resources (e.g. pay, cellular phones)

35. Multisystemic Therapy 04/00 Influences within the Clinical Context/Team n Clinical supervisor: committed, credible authority n Distinct and dedicated MST staff n Low caseloads (4-6 families per clinician) n Weekly group supervision per MST protocol n Weekly MST consultation for clinical team n Adequate on-call coverage system n MST training for all staff who can influence treatment n Outcome-based discharge criteria n Therapists: strengths and barriers

36. Multisystemic Therapy 04/00 Why is MST Successful? n Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factors n Treatment is family driven and occurs in the youths’ natural environment n Providers are accountable for outcomes n Therapists are well trained and supported n Significant energies are devoted to developing positive interagency relations