What is Multisystemic Therapy (MST)
The Brandon Centre ran the first randomised controlled trial of Multisystemic Therapy (MST) in the UK in partnership with Camden and Haringey Youth Offending Services. The trial ended in 2010 and the Centre’s MST standard service is now commissioned by Camden and Enfield.
What Is MST?
MST was developed by the Family Services Research Center at the Medical University of South Carolina. It was apparent that mental health services for serious young offenders were minimally effective at best, extremely expensive and not accountable for outcomes. They reviewed the research literature and looked for interventions with documented success in shaping good outcomes for anti-social young people. They also noted which interventions, some quite popular, have no empirical support. This process of discarding ineffective techniques while gleaning those most effective means that MST is really more an amalgam of best practices than a brand new method.
MST adopts a social-ecological approach to understanding anti-social behaviour or emotional problems. The underlying premise of MST is that young people’s difficulties are multi-causal; therefore, effective interventions would recognise this fact and address the multiple sources of influence. These sources are found not only in the young person (values and attitudes, social skills, biology, etc) but also in the young person’s social ecology: the family, school, peer group and neighbourhood. It is a key premise of MST that community-based treatment informed by an understanding of the young person’s ecology will be more effective than costlier residential treatment. Research has shown that treating the young person in isolation of the family, school, peer and neighbourhood systems means that any gains are quickly eroded upon return to the family, school or neighbourhood. Custody stays could also be counter-productive because an already troubled young person is immersed in a peer culture where antisocial values predominate.
MST uses the family-preservation model of service delivery in that it is home-based, goal-oriented and time-limited. It is present-focused and seeks to identify and extinguish behaviours that are of concern not only to referring agents but also to the family itself. In fact the entire family is involved with MST, in contrast to the many interventions that define the young person as the “identified client.” MST involvement will typically be between three and five months.
Collaboration with community agencies is a crucial part of MST. The school is a key player and workers may be in daily contact with teachers and administrators. MST Therapists will also work in close partnership with referrers. The MST Team will work closely with youth justice officers, social workers or mental health workers to ensure that MST is implemented to maximum effect in the context of the requirements of the referring agency. There may be a need to involve the young person in substance abuse treatment or seek a psychiatric consultation about a parent, for example.
While the initial MST involvement may be intensive, perhaps daily, the ultimate goal is to empower the family to take responsibility for making and maintaining gains. An important part of this process is to foster in the parents the ability to be good advocates for their children and themselves with social service agencies and to seek out their own supports. In other words, parents are encouraged to develop the requisite skills to solve their own problems rather than rely on professionals.
MST is a flexible intervention tailored to each unique situation. There is no one recipe for success. Instead, there are nine guiding principles:
1. The primary purpose of assessment is to understand the “fit” between the identified problems and their broader context
2. Therapeutic contacts should emphasise the positive and should use systemic strengths as levers for change.
3. Interventions should be designed to promote responsible behaviour and decrease irresponsible behaviour among family members.
4. Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.
5. Interventions should target sequences of behaviour within or between multiple systems that maintain the identified problems.
6. Interventions should be developmentally appropriate and fit the developmental needs of the young person.
7. Interventions should be designed to require daily or weekly effort by family members.
8. Intervention efficacy is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.
9. Interventions should be designed to promote treatment generalisation and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.
The MST-specific training augments the education and experience therapists bring from their chosen fields (usually psychology or clinical social work training).
What do MST Therapists do?
MST Therapists do the work in the family home rather than in a clinic and are on call 24 hours a day. Appointments are made to suit the family so they may take place in the evening or at weekends. The Therapists tailor their working week and time-off accordingly and in co-ordination with the Supervisor and the other therapists. The MST Team will cover each other so that during time off, families can be supported and be in contact with the team. Remuneration takes account of the flexibility expected of the therapist. The average caseload is four to six families. In the beginning, the worker may be in the home every day. As needed, they will spend time at school and meet with the young person’s peer group and extended family. A key part of the process begins with engaging the family, a significant challenge in some cases.
MST Therapists are closely supervised and monitored for adherence to the MST principles and receive weekly guidance and feedback about their interventions with the families on their caseloads.
The MST process begins with the identification of the problem behaviours, a process that involves the whole family. In other words, parents are key in identifying treatment targets. Examples of these behaviours include non-compliance with family rules, failure to attend school, failure to complete school work, substance use, disrespect to authority figures, and assaultive behaviour. While the focus is on elimination of problem behaviours, this is accomplished in great measure by building on strengths. The assessment process also involves identifying the strengths in the young person and his/her family, which can include a hobby, athletic ability, a trusting relationship with an extended family member or teacher, warmth and love among family members. The next step is an assessment of the factors in the young person’s ecology that support the continuation of the problem behaviours and the factors that operate as obstacles to their elimination. These factors may be found in any sphere of the young person’s ecology: family, peers, school, neighbourhood or the linkages among them. Therefore, therapists are called upon to find information from all of these sources, by going to the school, spending time with the peer group, or speaking with extended family members. Examples of these factors might include poor discipline skills on the part of the parents or teachers, marital discord, parental substance use, poor supervision, peer reinforcement of problem behaviours, neighbourhood culture, that condones violence or encourages antisocial values, low commitment to education, chaotic school environment, poor parent-to-school communication, or financial stresses experienced by the family.
By identifying the “fit” between the problems and the broader systemic context, MST Therapists are defining both the targets of intervention and the indicators of whether the measures undertaken have been effective. A therapeutic strategy should produce observable results in the problem behaviour or else the strategy is revised. In other words, positive changes in the behaviour (eg, school attendance) is used as indication that the intervention (eg, parent contacting the school daily) is on the right track. Failure to achieve positive changes requires a reassessment of the “fit” and plainly indicates the need to try a new approach. The MST service providers are ultimately accountable for overcoming barriers to change. Blaming language such as “sabotage,” “resistance,” and “intractable problems” are not permitted. In fact, diagnostic labels of any type are discouraged in favour of a perspective that focuses on challenges and strengths.
MST is designed to be an intense but short-term involvement that can result in the generalisation of treatment gains over the long-term. Ideally, the frequency and duration of contacts will decrease over time, being intense in the beginning but lessening as improvements are observed. No social service intervention can last forever, so the ultimate goal is to empower the family or other caregiver to continue with the strategies and interventions that were successful. The clearly articulated definition of success permits objective definition of when the case can be closed.
How do we know that MST works?
Several randomised and quasi-experimental studies of MST have been conducted in the USA, in Missouri, South Carolina, and Texas, and others are now underway, including the first randomised controlled trial of MST in the UK run by the Brandon Centre in partnership with Camden and Haringey Youth Offending Services.
MST has been demonstrated to reduce rates of criminal activity (officially recorded and self-reported) and institutionalisation. The MST approach is also successful at engaging and retaining families in treatment and encouraging completion of substance abuse programming. It can result in improvements in family functioning and cohesion. These results are notable in a field where successes are few and far between but especially remarkable because MST has been effective in inner city urban areas, Therefore, any differences between them can be linked unambiguously to the MST intervention. In short, the control group helps us rule out other possible explanations for observed changes (eg they grew out of the behaviour, only treatment-amenable young people received MST, etc). It also allows a basis of understanding what probably would have happened to these young people if they had not had MST.
Does MST work with older teens?
Some have asked if the MST approach is as effective with young offenders over 15. Reference to the USA research indicates that successful outcomes are achieved and maintained for young people of all demographic categories, both male and female, and young people of all ages.
Where can I find more information about MST?
The Family Services Research Centre has published many scholarly articles about MST research. Dr Scott Henggeler has written an excellent summary called Treating Serious Anti-Social Behaviour in Young Persons: The MST Approach, which is available on the website of the National Criminal Justice Reference Service. There is also a great deal of information available on the MST website: www.mstservices.org.
For more information please contact the Brandon Centre MST Team on 020 7424 9935 or email familyservice@brandoncentre.org.uk
