multisystemic therapy (mst): bases of success in treating serious clinical problems in children and...
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MULTISYSTEMIC THERAPY (MST):
BASES OF SUCCESS IN TREATING SERIOUS CLINICAL PROBLEMS
IN CHILDREN AND ADOLESCENTS
Scott W. Henggeler, Ph.D., Director
Family Services Research Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston
FAMILY SERVICES RESEARCH CENTER
– Scott W. Henggeler, Ph.D., Director– Cynthia Cupit Swenson, Ph.D., Associate Director– Sonja K. Schoenwald, Ph.D.– Phillippe B. Cunningham, Ph.D.– Colleen Halliday-Boykins, Ph.D.– Elizabeth Letourneau, Ph.D.– Jeff Randall, Ph.D.– Melisa D. Rowland, M.D.– Lisa Saldana, Ph.D.– Ashli Sheidow, Ph.D.– Jason Chapman, Ph.D.
FSRC MISSION:
To develop, validate, and study the dissemination of clinically effective and cost effective mental health and substance abuse services for youths presenting serious clinical problems and their families
OTHER MST-RELATED ORGANIZATIONS
• MST SERVICES (has license with Medical University of South Carolina for transport of MST technology and intellectual property)
Mission: Assists organizations in development of MST programs and builds (or provides) internal capacity of organization to maintain quality assurance system
• MST INSTITUTE
Mission: To facilitate the dissemination of evidence-based practices with high treatment fidelity
• NETWORK PARTNERS in Ohio, Hawaii, Colorado, Tennessee, Pennsylvania, Connecticut, and Norway
Disclosure Statement
• Presenter is stockholder in MST Services Inc., which has the exclusive licensing agreement through the Medical University of South Carolina for the transport of MST technology and intellectual property.
STRUCTURE OF MST
Treatment targets serious juvenile offenders at high risk for out-of-home placement and their families
MST team includes 3-4 master’s level therapists and a 50% time supervisor
Therapists provide services 24/7 Therapists carry caseloads of 4-6 families each for an
average of 4 months Services are provided in homes and other community
settings MST team is supported by intensive quality assurance
system to optimize youth outcomes
CRITICAL COMPONENTS OF MST
1. Addresses the known causes of antisocial behavior comprehensively -- at youth, family, peer, school, and community levels
2. Provides intensive treatment where problems occur – in homes, schools, and neighborhoods
3. Views caregivers as central to achieving favorable youth outcomes – family-based
4. Intensive quality assurance system supports MST program fidelity and youth outcomes
5. MST provider organizations are accountable for family engagement and youth outcomes
Principles of MST1. Finding the Fit2. Positive & Strength Focused3. Increasing Responsibility4. Present-focused, Action-oriented & Well-
defined5. Targeting Sequences6. Developmentally Appropriate7. Continuous Effort8. Evaluation and Accountability9. Generalization
Environment of Alignment and Engagementof Family and Key Participants
Measure
Re-evaluatePrioritize
Do
IntermediaryGoals
IntermediaryGoals
InterventionDevelopment
InterventionDevelopment
MST Conceptualizationof “Fit”
MST Conceptualizationof “Fit”
Assessment ofAdvances & Barriers to
Intervention Effectiveness
Assessment ofAdvances & Barriers to
Intervention Effectiveness
InterventionImplementation
InterventionImplementation
MSTAnalyticalProcess
ReferralBehavior
ReferralBehavior
OverarchingGoals
OverarchingGoals
Desired Outcomesof Family and Other
Key Participants
Desired Outcomesof Family and Other
Key Participants
PUBLISHED MST OUTCOMES
10 Randomized Trials and 1 Quasi-Experimental Trial Published (>1000 families participating)
3 with violent and chronic juvenile offenders 1 with substance abusing or dependent juvenile offenders 2 with juvenile offenders 1 with juvenile sexual offenders 2 with youths presenting serious emotional disturbance 1 with maltreating families 1 with adolescents with poorly controlled diabetes
Approximately 10 additional randomized trials are in progress
OVERVIEW OF MST OUTCOMES ASSOCIATED WITH:
Criminal Behavior & Violence
Adolescent Substance Abuse
Adolescent Sexual Offending
Mental Health
Child Maltreatment
PUBLISHED OUTCOMES FOR CRIMINAL BEHAVIOR
4 Randomized and 1 quasi-experimental trials with serious juvenile offenders
• Decreased recidivism (25% to 70%) for as long as 13 years post treatment
• Decreased self-reported criminal offending• Decreased out-of-home placement (47% to 64% reductions)• Decreased behavior problems• Improved family relations Considerable cost savings (Washington State Institute on Public
Policy)1. MST $64,000/youth15. Bootcamps ($ 7,910)/youth
Simpsonville, SC Project
MST
UsualServices
0%10%20%30%40%50%60%70%80%90%
100%110%
0 0.4 0.8 1.2 1.5 2 2.4Years Post Treatment
Per
cent
age
of O
ffen
ders
N
ot R
e-A
rres
ted
Missouri Delinquency Project
MSTCompleters
MSTDropouts
IT Completers
IT Dropouts
Refusers0%
20%
40%
60%
80%
100%
120%
0 0.6 1.1 1.7 2.2 2.8 3.3 3.9 4.4 5
Years Past Treatment Termination
Per
cent
of O
ffen
ders
Not
Re-
Arr
este
d
MST Substance-Related Clinical Outcomes
• Serious juvenile offenders: two trials – decreased self-reported substance use– fewer drug-related arrests at 13-year follow-up
• Diagnosed substance abusing/dependent juvenile offenders– decreased self-reported substance use– increased attendance in regular school settings– 98% (57 of 58 families) treatment completion (– Incremental costs of MST offset by savings incurred
from reductions in days of out-of-home placement at 12 months
Long-Term Outcomes for Substance Abusers
• 4-year treatment effects for violent criminal behavior (.15 versus .57 arrests per year)
• higher rates of marijuana abstinence for MST participants at 4-years post treatment (55% versus 28%)
MST 12-MONTH OUTCOMES FROM JUVENILE DRUG COURT
RANDOMIZED TRIAL (N=161)
Compared with regular drug court, MST had:
• fewer positive screens 20% versus 60% (2,000 screens)
• less self-reported alcohol and polydrug use
• marginally decreased mental health symptoms (CBCL)
MST OUTCOMES ASSOCIATED WITH ADOLESCENT SEXUAL
OFFENDING• Study with N=16:
3 year rearrest data for sexual offending favoring MST (12.5% versus 75%)
• Replication study with N=48:8-year rearrest data for sexual offending favoring MST (12.5% versus 41.7%)
• 66% decrease in days incarcerated• Effectiveness study underway in Chicago
MST MENTAL HEALTH OUTCOMES-Alternative to
Psychiatric Hospitalization Study• Decreased youth externalizing • Improved family functioning• Increased school attendance• At 4 months post referral MST youth had a 72%
reduction in days hospitalized and a 49% reduction in days in other out-of-home placements
• Higher consumer satisfaction• Positive effects dissipated by 1.5 years
• Similar findings in (N=36) replication study in Hawaii
MST OUTCOMES ASSOCIATED WITH CHILD MALTREATMENT
• Improved parent-child interactions
Current Trial with Child Physical Abuse
• Effectiveness Trial (MST versus Group Behavioral Parent Training) with 160 families with an indicated case of physical abuse
BASES OF MST SUCCESS
1. Addresses multidetermined nature of serious clinical problems
2. High ecological validity of intensive services
3. Intensive quality assurance (improvement) system
4. Integration of evidence-based intervention models
5. Caregiver viewed as key to long term outcomes
6. Program accountability for family engagement and outcomes
1. MST ADDRESSES MULTIDETERMINED NATURE OF SERIOUS CLINICAL PROBLEMS
Decades of Rigorous Research Show Serious Adolescent Problems Linked with:
Individual adolescent characteristics Family functioning Caregiver functioning Association with deviant peers School performance Indigenous family support network Neighborhood characteristics
MST:
Addresses risk factors across the social ecology (comprehensive services)
Builds protective factors across the social ecology
Accomplishes such on an individualized basis
2. MST SERVICES HAVE HIGH ECOLOGICAL VALIDITY AND ARE
INTENSIVE
Home-Based Model of Service Delivery: Services provided in home, school, and
community settings (where problems occur) Overcomes most barriers to service access Increases validity of assessment data Increases validity of outcome data Helps engage family in treatment Enhances treatment generalization
INTENSIVE SERVICES:
Low therapist caseloads (4-6 families) 24 hour/7 day availability of therapist 60 to 100 hours of direct therapist-family
contact over 4 months Therapists work in teams with significant
clinical support
3. OVERVIEW OF MSTQUALITY ASSURANCE
SYSTEM
• System is predicated on linkage between therapist fidelity to MST treatment protocols and child/family outcomes
• Such a linkage is supported by 6 published studies
MST QUALITY ASSURANCE SYSTEM
To Promote Treatment Fidelity, Achieve Outcomes, and Address Barriers to Outcomes
• Specified treatment protocol ( Henggeler et al., 1998, Guilford Press)
• Specified supervisory protocol (Henggeler & Schoenwald, 1998)
• Specified consultation protocol (Schoenwald, 1998)
• Ongoing consultation to address organizational barriers to program success
Supervisor TherapistYouth/Family
MSTConsultants/
MST Institute
Manualized
SupervisoryAdherenceMeasure
TherapistAdherenceMeasure
Organizational Context
Manualized
Manualized
Internet communicationPerson to Person communication
MST QUALITY ASSURANCE SYSTEM
Manualized
MST QUALITY ASSURANCE SYSTEM
• On site 5-day orientation training• Quarterly booster training• Clinicians work within MST teams for peer support• On site clinical supervision from MST-trained
supervisor• Weekly consultation with MST expert via
conference call• Standardized adherence ratings from caregiver via
internet system <www.mstinstitute.org>• Expert coding of audiotaped treatment sessions for
adherence (research studies only)
Supervisor TherapistYouth/Family
MSTConsultants/
MST Institute
Manualized
SupervisoryAdherenceMeasure
TherapistAdherenceMeasure
Organizational Context
Manualized
Manualized
Internet communicationPerson to Person communication
MST QUALITY ASSURANCE SYSTEM
Manualized
4. INTERVENTION STRATEGIES USED WITHIN MST
MST Programs Rely on Evidence-Based Interventions:
Behavior therapy Cognitive behavior therapy Pragmatic family therapies Pharmacological interventions (e.g., ADHD) Community Reinforcement Approach (Budney
& Higgins)
BUT, Evidence-Based Interventions Are Used Within:
Social ecological conceptual model Program commitment to remove barriers to
service access Intensive quality assurance View that caregivers are key to long-term
outcomes Program philosophy that emphasizes provider
accountability for outcomes
5. CAREGIVERS ARE VIEWED AS THE KEY TO LONG-TERM OUTCOMES
Hence: Most clinical resources devoted to developing
capacity of caregiver to achieve goals Significant clinician attention devoted to
delineating and overcoming barriers to effective parenting (e.g., caregiver mental health problems, substance abuse, stress)
Focus on family versus youth
6. MST PROGRAMS ARE ACCOUNTABLE FOR ENGAGEMENT
AND OUTCOMES
High Accountability Requires Access to Resources: High salaries Low caseloads Strong clinical support Strong organizational support Sharing in program success (i.e., reducing
placements) Opportunity to enhance competencies when success
rates are low
SCIENCE TO PRACTICE: TRANSPORT OF MST TO COMMUNITY SETTINGS
MST Services – licensed through the Medical University of South Carolina – supports MST program development and provides or supports ongoing training and quality assurance worldwide
301 licensed MST programs in 30 states and 8 nations
Statewide initiatives in Connecticut, Hawaii, Ohio, and South Carolina. Nationwide initiatives in Norway and Denmark
MST programs serve 10,000 serious juvenile offenders annually, 3% of the eligible population
MAJOR CHALLENGES TO DISSEMINATION
Funding structures often favor incarceration and residential treatment over community-based services
Clinical services differ significantly from the status quo (e.g., home- and family-based; 24/7 availability of therapists)
Training and quality assurance standards emphasize treatment fidelity and provider accountability, which contrast with existing practices and are often not desired
Perhaps the key research and implementation issue is determining what promotes the effectiveness of dissemination sites, which have varying outcomes
POLICY IMPLICATIONS
1. Shift Funding from Ineffective Institution-Based Services to Intensive and Effective Community-Based Services
70% of current service dollars spent on out-of-home placements
Savings can fund:
higher salaries for effective clinicians
prevention programs
early intervention programs
Policy Implications - continued
2. Change training and clinical practice
Currently: Minimal outcome accountability “Train and hope” approach to technology transfer dominates Degrees are licenses to practice as one desires until
retirement
Change to Performance Contracts to Promote: Accountability Outcomes Use of evidence-based practices
QUESTIONS OR MORE INFORMATION
• Research Related: Scott W. Henggeler <[email protected]>
• Publication Requests: <musc.edu/fsrc>
• Dissemination/Site Development:
Marshall Swenson, 843 856-8226 <[email protected]>