Multisystemic therapy

Photo by: Lisa F. Young

Definition

Multisystemic therapy (MST) is an intensive family- and community-based treatment program designed to make positive changes in the various social systems (home, school, community, peer relations) that contribute to the serious antisocial behaviors of children and adolescents who are at risk for out-of-home placement. These out-of-home placements might include foster care, group homes , residential care, correctional facilities, or hospitalization .

Purpose

MST is licensed by MST Services, Inc., through the Medical University of South Carolina and operates with the fundamental assumption that parents (defined as guardians), or those who have primary caregiving responsibilities to children, have the most important influence in changing problem behaviors in children and adolescents.

The primary goals of MST are to:

develop in parents or caregivers the capacity to manage future difficulties
reduce juvenile criminal activity
reduce other types of antisocial behaviors, such as drug abuse
achieve these outcomes at a cost savings by decreasing rates of incarceration and other out-of-home placements

MST was created approximately 25 years ago as an intensive family- and community-based treatment program to focus on juvenile offenders presenting with serious antisocial behaviors and who were at-risk for out-of-home placement. The program has been shown to be effective with targeted populations that include inner-city delinquents, violent and chronic juvenile offenders, juvenile offenders who abuse or are dependent on substances and also have psychiatric disorders, adolescent sex offenders, and abusive and neglectful parents. A more recent focus (1994–1999) of MST has been to treat youths with psychiatric emergencies such as suicidal ideation, homicidal ideation, psychosis , or threat of harm to self or others due to mental illness. The results are promising and indicate that MST is an effective alternative to psychiatric hospitalization. Some treatment conditions and interventions were modified to take care of this population, including developing a crisis plan during the initial family assessment and adding child and adolescent psychiatrists, psychiatric residents, and crisis caseworkers to the MST treatment team. Supervision of the treatment team was initially increased from weekly to daily meetings. Caseloads of MST therapists were reduced from five to three families, increasing the intensity of the intervention . When some adolescents were hospitalized for safety, the MST staff maintained clinical responsibility for the adolescent who was insulated from the usual activities due to inpatient care.

Description

MST programs are usually housed in community-based mental health organizations considered to have a culture more rehabilitative than punitive. The program staff creates strong working relationships with referral sources such as juvenile justice and the family court. They work closely with deputy juvenile officers, social welfare workers, teachers, and guidance counselors, for example, to obtain the perspectives of multiple systems or "stake-holders" who have the common goal of improving children, adolescent and family treatment goals. Each youth referred to the program is assigned to an MST therapist who designs individualized interventions in accordance with the nine MST treatment principles, thereby addressing specific needs of the youth and his or her specific environment.

MST is a time-limited (four to six months) intensive therapeutic program that provides services in the family's home, at other locations (school, neighborhoods), or wherever the family feels most comfortable. After the initial sessions, family members who attend family sessions with the therapist will vary depending on the nature of the particular problem being discussed. For example, children are not included in sessions addressing intimate marital issues between parents or dealing with poor parental discipline, so as not to undermine parental authority.

Characteristics of the MST model—such as availability of the MST staff (24 hours a day, seven days per week), flexible scheduling, and delivery of services in the home—all provide safety for the family, prevent violence, develop a joint working relationship between therapist and family, provide the family with easier access to needed services, increase the likelihood that the family will stay in treatment, and help the family maintain changes in behaviors. The MST staff are full-time practitioners, wear pagers, carry cellular telephones, and work in teams of three. They can provide intensive services because of small caseloads and have multiple contacts with the family during the week (sometimes daily). They stay as long as required and at times most convenient to the family, including weekends, evenings, and holidays. Services provided by staff at unusual times (10 P.M.to 8 A.M.) are discouraged, except in emergencies. The development of an informal support system in which the family can call on a friend or family member at crucial times is part of the treatment goals. Families have less contact with the therapist as they get closer to being discharged from treatment.

MST is designed to be a flexible intervention to provide highly individualized treatment to families. Specific treatment techniques or therapies are used as a part of MST interventions. These include behavior parent training, structural family therapy , and strategic family and cognitive-behavioral therapy . In addition, some biological influences such as depression and depressive disorders may be identified, and psychotropic medications are integrated into treatment. This model does not support one method for obtaining successful changes in behaviors; however, there are nine guiding principles of treatment:

The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic context. At the initial visit with the family, the staff begins to assess the family's strengths; capabilities; needs; problems; environmental support systems; and transactions with social systems such as peers, extended family, friends, teachers, parental workplace, referral resources, and neighbors. The therapist and family work together to identify and prioritize problems to be targeted for change, determine interventions, and develop a treatment plan. The assessment is conducted in a manner that empowers family members by encouraging them to define their problems, needs, strengths, and—except in matters of imminent safety— set their priorities. The assessment is gradually updated until the family has reached its goals and is functioning independently.
Therapeutic contacts emphasize the positive and should use systemic strengths as levers for change. MST is a strength-based treatment program and adherence to this principle decreases negativity among family members, builds positive expectations and hope, identifies strengths, and decreases therapist and family frustrations by emphasizing problem-solving. It also builds the care-giver's confidence. The therapist develops and maintains the focus on the strength of families and positive thinking through the use of positive language, teaching, and the technique of reframing negative thoughts and beliefs; the liberal use of positive rewards for appropriate behaviors; using a problem-solving stance rather than one of failure and seeing barriers as challenges; and identifying and using what the family does well.
Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members. The therapist assists parents and youths in behaving in a responsible manner across a variety of domains. Parental responsibilities include providing support, guidance, and discipline; expressing love and nurturance; protection; advocacy; and meeting basic physical needs. The child and adolescent's primary responsibilities include complying with family and societal rules, attending school and putting forth reasonable effort, helping around the house, and not harming self or others. Therapists will spend a great deal of time throughout the treatment process enhancing, developing, and maintaining the responsible behaviors of parents through praise and support. Other family members who become engaged in the treatment process are also encouraged by the therapist to reinforce responsible parental behaviors that will help maintain these behaviors when treatment ends. It has been noted that when parents increase their responsibilities, there is almost always improvement in the child's behavior. Parental abdication of responsibilities may be caused by factors such as mental illness or the lack of necessary parenting skills. Interventions would be designed to address these influences. For children and adolescents, positive reinforcement and discipline are used to increase responsible behaviors and decrease irresponsible behaviors. Parents are encouraged to spell out clearly expectations and punishment for compliance and noncompliance before putting them into action. For example, the child should know ahead of time that missing curfew will result in being grounded for a week. Parents are also taught to praise often for compliant behaviors.
Interventions are focused on the present and are action oriented, targeting specific and well-defined problems. Due to time limitations of the MST model, family members are required to work intensely to solve often long-standing problems. Once information has been gathered and assessed, therapist and family jointly formalize problem and goals into a treatment plan. The plan specifies which changes in what behavior or skill will be achieved by whom, by what method or action, and in what period of time within the limits of the program. The treatment plan contains the family's overarching goals or ultimate aims that are to be accomplished by the end of the treatment period, and intermediate goals or incremental steps needed to reach the overarching goal. These intermediate goals are measurable and time limited and the interventions chosen are those that have been determined to have the most immediate and powerful impact on the problem behavior. The therapist assists families in meeting their specific goals by helping them focus their time, energy, and resources on their assignments. Also, the expected outcome of each intervention is described in observable and measurable terms before the treatment plan is put into action. This aids the MST staff and the family to determine whether the interventions are effective or if alternatives are needed.
Interventions should target sequences of behavior within and between multiple systems that maintain the identified problem. As an example, an ineffective parenting style (permissive, authoritarian, neglectful) may be identified as a factor in influencing the problem behavior and is, therefore, targeted for an intervention. However, the parents are having marital difficulties that lead to disagreements in child rearing practices; these difficulties are maintaining the poor parenting style and will be the focus of an intervention as well. In addition, the family may have some practical or concrete needs (housing, heat, transportation) that are, in turn, having an impact on parental discipline and require interventions across the family—community support system that is also a factor in maintaining the identified problem.
Interventions are developmentally appropriate and fit the developmental needs of the youth. The nature of the intervention should take into account the age and maturity of the child or adolescent and the caregiver. It is noted that, for children and young adolescents, interventions aimed at increasing parental control are the most appropriate. Such interventions might include introducing systematic monitoring, reward, and discipline systems. For an older adolescent, interventions would most likely focus on preparing the youth for entry into the adult world, such as increasing his or her social maturity. Other interventions may be needed to overcome obstacles to independent living, such as having the teenager participate in GED classes or enter a vocational training school. The developmental stage of the care-giver is also important to consider. For example, grandparents may not have the physical or emotional health to become primary caregivers but may be able to assist parents in other ways, such as helping with homework or sitting with the youth after school for a few hours.
Interventions are designed to require daily or weekly effort by family members. This leads to a more rapid decrease in the problem behavior, and current and continuous evaluation of whether the intervention is working and producing the expected results. For example, if a parent sits near the child while he or she is doing homework, progress toward the anticipated goal of better school performance is gauged. This design also allows family members to experience immediate success and obtain positive feedback.
Intervention effectiveness is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes. To assess the impact of an intervention, before intervention is implemented the therapist is required to document anticipated outcomes for each intervention by describing the observable and measurable outcome that he or she is aiming for. This information is used to assess the successes made or barriers encountered during treatment. The MST staff may also be in daily contact with teachers and administrators, deputy juvenile officers, and welfare professionals who provide feedback regarding whether the interventions across systems are successful in changing behaviors.
Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members' needs across multiple systemic contexts. The MST therapist, the MST team, and the provider agency are responsible for engaging the family in treatment, making services for the family easier to obtain, and achieving positive outcomes for the child or adolescent and the family in every case. The program's achievement of successful goals and maintenance of behavior change is due to staff adherence to the treatment model. Research has demonstrated that strong adherence correlates to strong case outcomes. The key to the success of the model is intensive and ongoing staff training. Clinical staff training includes five days of orientation training, weekly supervision with an MST expert, and quarterly booster training. On-site supervisors are also intensively trained to ensure that the MST staff adhere to the MST model.

Normal results

At the end of MST treatment, parents have been provided with the resources needed to parent effectively and maintain better family structure and cohesion. Specifically, parents:

are able to monitor their child(ren) or adolescent's behaviors systematically
have learned to use appropriate reward and discipline measures to maintain new behavioral changes
can communicate more effectively with each other and their children
can advocate for their children and themselves across social systems (school, social services)
can problem-solve daily conflicts
can maintain positive relations with natural social supports such as extended family, friends, and church members
are able to maintain a positive working relationship with school personnel
have learned strategies to monitor and promote the child's or adolescent's school performance and/or vocational functioning

Other outcomes to be expected have to do with the youth's relationships with peers and his or her performance in school. Specifically, it is expected that the child or adolescent has decreased his or her association with delinquent and/or drug-using peers; has increased his or her relationships with positive peers and engages in positive activities through after-school activities, organized athletics, or volunteer or paid activities; has better school performance; and has had no, or has decreased, days requiring out-of-home placement.

Resources

BOOKS

Brown, Tamara L., and others. "Treating Juvenile Offenders in Community Settings." In Treating Adult and Juvenile Offenders With Special Needs, edited by J. B. Ashford and others. Washington, DC: American Psychological Association, 2001.

Henggeler, Scott W., and others. Multisystemic Treatment of Antisocial Behavior in children and Adolescents. New York: The Guilford Press, 1998.

ORGANIZATIONS

National Institute of Mental Health. 6001 Executive Bloulevard, RM.8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. Fax: (301) 443-4279. TTY: (301) 443-8431. <http://www.nimh.nih.gov> .

Office of Juvenile Justice and Delinquency Prevention. 810 Seventh Street NW, Washington, D.C. 20531. (202) 307-5911. Fax: (202) 307-2093. <http://www.ojjdp.ncjrs.org> .

OTHER

Scott W. Henggeler, Ph.D., Director, Department of Psychiatry and Behavioral Sciences, Family Services Research Center, Medical University of South Carolina, 67 President Street, Suite CPP, Charleston, SC 29425, Box 250861. (843) 876-1800.

Janice VanBuren, Ph.D.