Multisystemic therapy

Multisystemic Therapy (MST) (so-named because it addresses the different systems in an adolescent's life) is a type of adolescent psychotherapy and is is an intensive, family-focused and community-based treatment program for chronic and violent youth. The evidence-based therapy is goal oriented and aims at helping caregivers manage and nurture their challenging adolescents more effectively.

While the most widely disseminated form of MST is juvenile justice, which addresses the problems of adolescents who typically have significant histories of committing crime, there are variations that deal with such issues as substance abuse, problem sexual behavior, abuse and neglect, psychiatric disorders and a range of other serious behavioral issues.

History
The seeds from which MST grew were planted in the 1970s when Dr. Scott W. Henggeler was getting his Ph.D. at the University of Virginia and beginning his professional career at Memphis State University. Out-of-home placements, such as juvenile detention, residential treatment, psychiatric hospitalization and boot camps, have proved largely ineffective in achieving positive and lasting results. Out-of-home placements may be unsuccessful because the adolescent returns home to the same conditions that were there before he or she left. The youth often resumes drug use, stealing, truancy, staying out late or all night with other out-of-control youths. Added to this mix is the juvenile offender may have picked up new ideas for criminal activities while in out-of-home placement.

In addition, at the time, he came to believe that existing treatments of juvenile offenders had diminished chances of success because they often ignored the known risk factors for delinquency and were poor at engaging families in treatment. Specifically MST was developed to address the abundance of empirical evidence that treatments for antisocial behavior have been largely ineffective and the fact that serious antisocial behavior is determined by the interplay of individual, family, peer, school, and neighborhood factors

Based on this, he designed a treatment, MST, that aimed to address risk factors comprehensively and provided treatment directly where problems occur—in homes, schools and community settings. And, he recognized that empowering families was the key to improving the lives of juvenile offenders. In 1992, the Family Services Research Center at the Medical University of South Carolina was formed to pursue the development, validation and dissemination of evidence-based treatments, including MST. In 1996, MST Services was established as the university-affiliated, technology- transfer organization for MST. MST Services offers comprehensive assistance to agencies that use MST.

Goals of MST
The goal of MST is to reduce youth criminal activity and antisocial behaviors and to achieve these outcomes at a cost savings by decreasing rates of incarceration and out-of-home placement. MST aims to achieve these goals by empowering youth and parents with the skills and resources needed to independently address the difficulties and cope with their complex environmental and social problems MST revolves around nine guiding principles.

Principles
MST is based on nine principles.

Principle 1: Finding the fit An assessment is made to understand the "fit" between identified problems and the entire context of the youth's environment. Assessing the “fit” of the youth's successes also helps guide the treatment process.

Principle 2: Focusing on positives and strengths MST therapists and team members emphasize the positives they find and use strengths in the youth’s world as levers for positive change.

Principle 3: Increasing responsibility Interventions are designed to promote responsible behavior and decrease irresponsible actions by family members.

Principle 4: Present focused, action oriented and well defined Interventions deal with what’s happening now in the delinquent’s life. Therapists look for action that can be taken immediately, targeting specific and well-defined problems. Family members focus on present-oriented solutions, versus gaining insight or focusing on the past.

Principle 5: Targeting sequences Interventions target behavior sequences within and between the various interacting elements of the adolescent’s life—family, teachers, friends, home, school and community—that sustain identified problems.

Principle 6: Developmentally appropriate Interventions are set up to be appropriate to the youth’s age and fit his or her developmental needs. A developmental emphasis stresses building the adolescent’s ability to get along well with peers and acquire academic and vocational skills that will promote a successful transition to adulthood.

Principle 7: Continuous effort Interventions require daily or weekly effort by family members so that the youth and family have frequent opportunities to demonstrate their commitment. Advantages of intensive and multifaceted efforts to change include more rapid problem resolution, earlier identification of when interventions need fine-tuning, continuous evaluation of outcomes, more frequent corrective interventions, more opportunities for family members to experience success and giving the family power to orchestrate their own changes.

Principle 8: Evaluation and accountability Intervention effectiveness is evaluated continuously from multiple perspectives with MST team members held accountable for achieving successful outcomes. MST does not label families as “resistant, not ready for change or unmotivated.” This approach avoids blaming the family and places the responsibility for positive treatment outcomes on the MST team.

Principle 9: Generalization Interventions are designed to invest the caregivers with the ability to address the family’s needs after the intervention is over. The caregiver is viewed as the key to long-term success. Family members drive the change process in collaboration with the MST therapist.

Target Population
MST was specifically designed to respond to the needs of adolescents who exhibit serious antisocial behavior, but has also been applied to situations of abuse and neglect, substance abuse, and adolescent sex offenders (Henggeler, 1999). MST typically targets chronic, violent, or substance-abusing juvenile offenders between the ages of 12 to 17 years who are at high risk for out-of-home placement and their families. The “typical” MST youth is between the ages of 14 and 16 years, lives in a home characterized by multiple needs and problems, and has had multiple arrests

Treatment Model and Unique Aspects
MST was developed using an ecological model framework with the foundation of the MST model being increasing the parenting skills of caregivers and changing the behavior of violent and criminal youth. Unlike many other treatment models where the troubled youth sees a therapist at a clinic once a week, MST therapists go to the youth’s home, school and community. In this way, the whole environment of the youth can be focused on and positive change effected. Also, MST integrates intervention techniques that have the most empirical support, including behavioral therapy, cognitive-behavioral and pragmatic family therapies. Because of the collaboration with family and caregivers, treatment goals that the therapist can help achieve are established. Also, the therapist receives specialized training in delivering MST and the nine guiding principles of MST. As mentioned, MST therapists also carry a small caseload and are available 24 hours a day, seven days a week. This includes the team of four to six therapists with one supervisor assigned for every case, which allows for support with providing therapy. Furthermore, Parents and caregivers are brought into the process and family members collaborate with MST therapists in designing a treatment plan. . The treatment plan is not only driven by the family, but also involves all family members to engage everyone in the treatment process. The plan builds on the strengths in their lives, which makes it more likely the family will be successful during and after treatment. MST has high rates of treatment completion because therapists provide treatment in the families’ homes and other community settings. Going to the home overcomes the high dropout rates of other treatments because caregivers often have trouble getting their families to appointments.

Overall, to help with youth transition back to their home, MST interventions work to:
 * Increase the caregivers' parenting skills
 * Improve family relations
 * Involve the youth with friends who do not participate in criminal behavior
 * Help him or her get better grades or develop a vocation
 * Help the adolescent participate in positive activities, such as sports or school clubs
 * Create a support network of extended family, neighbors and friends to help the caregivers maintain the changes

Adaptations
There are currently 13 adaptations being studied. Four are in the later stages of development and implementation.
 * Child Abuse and Neglect (CAN)


 * Psychiatric
 * Substance Abuse
 * Problem Sexual Behavior

Evidence of Effectiveness
Studies have shown MST to be more effective than standard treatments. MST has been implemented in eight randomized clinical trials with over 700 serious, violent, substance abusing juvenile offenders and their families as well as abused and neglected youth and youth experiencing serious antisocial behavior. Follow-up studies with youth and families have also been conducted to support the long-term effectiveness of MST. In addition, studies have begun to look at fidelity of treatment in diverse populations. The demographics of youth in these studies receiving MST mirror those in the juvenile justice system (i.e. males from single-parent households characterized by economic disadvantage). Overall, evaluations of MST have demonstrated reductions of 25% to 70% in long-term rates of re-arrest, reductions of 47% to 64% in out-of-home placements, extensive improvements in family functioning, decreased mental health problems for serious juvenile offenders, and cost savings in comparison with usual mental health and juvenile justice services. Furthermore, studies have found MST to have similar outcomes for youths across the age range of 12 to 17 years, for males and females, and for African American and White youths and families. Lastly, MST has been found to be effective internationally in Australia, Canada, Denmark, Norway, Northern Ireland, England, New Zealand and Sweden. Most of these studies, however, have been closely supervised by Dr. Scott W. Henggeler, its founder, causing questions of research bias. A meta-analysis by the Cochrane Collaboration found that there is no evidence to suggest that MST is any more effective than other services for youth.

Cost Effectiveness
The Washington State Institute for Public Policy evaluated MST to determine the bottom-line economics.

“Based on the Institute’s estimates, a typical average cost per MST participant is about $4,743. Overall, taxpayers gain approximately $31,661 in subsequent criminal justice cost savings for each program participant. Adding the benefits that accrue to crime victims increases the expected net present value to $131,918 per participant, which is equivalent to a benefit-to cost ratio of $28.33 for every dollar spent.” Similarly, a recent report by the Midland County Michigan Probate Court showed that MST cost benefits ranged up to $199,374.

In a 2010 Midland, Mich., study, MST was shown to:
 * save the county almost $2 million with MST
 * have an average saving per youth served of $198,216
 * lead to healthier families and reduced recidivism

Alternative to Incarceration and Out-of-Home Placement
According to the Juvenile Policy Institute, the average cost of out-of home-placement for a youth is $240.99 per day. MST programs are intended for youth with serious clinical problems (violence, criminality, drug abuse) who are at very high risk of out-of-home placement in residential settings. Fourteen of the 21 published MST outcome studies, 10 of which focused on youth presenting very serious criminal or antisocial behavior, examined incarceration and out-of-home placement outcomes. Across these studies, MST produced, on average, greater than a 60% reduction in residential placements in comparison with youth receiving more traditional services. MST greatly reduced rates of incarceration, hospitalization and other costly residential services.

Dissemination
As of 2010, MST Services has a network of partners with 480 teams in 31 states, the District of Columbia and 12 foreign countries

In the United States, MST is being used in Washington, California, Nevada, Arizona, Colorado, New Mexico, Texas, Oklahoma, Nebraska, Minnesota, Missouri, Louisiana, Illinois, Michigan, Ohio, Pennsylvania, New York, Maine, Virginia, North Carolina, South Carolina, Georgia, Alabama, Florida, Rhode Island, Massachusetts, Connecticut, New Jersey, Delaware, Maryland, and New Hampshire.

Australia, Canada, Denmark, England, Iceland, Ireland, the Netherlands, New Zealand, Norway, Sweden, Switzerland and Scotland are implementing MST.

Recognition
MST has been cited by numerous organizations and governmental entities for its success in reducing long-term rates of rearrest and out-of home placement for violent and chronic juvenile offenders.


 * The Blueprints for Violence Prevention  The Blueprints for Violence Prevention identifies outstanding violence and drug prevention programs that meet a high scientific standard of effectiveness.
 * U.S. Surgeon General The surgeon general serves as "America's doctor" by providing the best scientific information available on how Americans can improve their health and reduce the risk of illness and injury.
 * Washington State Institute for Public Policy The institute conducts nonpartisan research using its own policy analysts and economists, specialists from universities and consultants to determine the cost benefit of treatment models.
 * Centers for Medicare and Medicaid Services (CMMS) A United States Department of Health and Human Services agency, CMMS administers Medicare and helps states run Medicaid. Because CMMS has endorsed MST, some states can use Medicaid funding to partially pay for the program.
 * Coalition for Evidence-Based Policy The coalition identifies social interventions that produce sizable and long-term benefits. Its purpose is to give policymakers and practitioners the information needed to distinguish the few interventions that have rigorous, scientific evidence to back them up.
 * Substance Abuse and Mental Health Services Administration (SAMHSA) Part of the United States Department of Health and Human Services, SAMHSA seeks to lessen the negative impact of substance abuse and mental illness throughout the U.S.
 * New Freedom Commission on Mental Health The commission studies public and private mental-health services to find effective treatments, services and technologies.
 * Office of Juvenile Justice and Delinquency Prevention (OJJDP) OJJDP works to enhance juvenile-justice policies and practices.
 * National Institute of Drug Abuse (NIDA) The institute encourages scientific research on drug abuse and works to disseminate treatments that work.
 * Institute of Medicine of the National Academies (IOM) A nonprofit organization, IOM works independently of the government in giving unbiased advice on medicine and health so that informed decisions can be made toward improving health in the U.S.
 * Institute for Public Policy Research (IPPR) A United Kingdom organization, IPPR researches and analyzes policy on wide-ranging topics from global warming to juveniles engaged in criminal activity.
 * Office of Justice Programs (OJP) OJP, part of the U.S. Justice Departments, helps state and local justice systems develop strategies for dealing with crime.
 * Center for Substance Abuse Prevention (CSAP) CSAP, a part of SAMHSA, is charged with providing national leadership in the fight against substance abuse. MST is listed in CSAP’s National Registry of Effective Prevention Programs and was a recipient of a 2000 Exemplary Substance Abuse Prevention Program award.
 * Center for Substance Abuse Treatment (CSAT) An agency under the umbrella of SAMHSA, CSAT’s mission is to increase the accessibility and improve the quality of community-based, drug-and-alcohol treatment services.
 * National Institutes of Health (NIH) NIH is the federal agency that conducts and gives backing to biomedical and health-related research. The agency has found MST effective, saying “program evaluations have demonstrated reductions in long-term rates of rearrest, violent crime arrest, and out-of-home placements.”
 * National Alliance for the Mentally Ill (NAMI) NAMI is a nonprofit, grassroots advocacy organization that works to improve the lives of people with mental illness. It has lauded MST for being “successful in reducing costly out-of-home placements and criminal recidivism.”
 * Mental Health America (MHA), formerly called the National Mental Health Association, is a national, nonprofit organization that promotes better mental health and helps those with mental illness. In 2004, MHA wrote, “Research indicates that Multisystemic Therapy (MST) is one of the best available treatment approaches for youth who have mental health treatment needs and who are involved in the juvenile justice system.”