Multisystemic Therapy:
A positive and strength-focused use of
the peer relationship in effective
interventions
Zoë Ashmore
Gerard Stuart
Multisystemic Therapy
(MST)
•
Intensive, community based – aims to keep young person
at home, in education, stop offending.
•
3 teams 5 years ago in UK- now 40+ standard.
•
1st team in UK was in Northern Ireland, now 3.
•
Central to the MST treatment model is the MST Analytic
Process
•
9 principles- means that MST is individualised to the needs
of the young person and family.
Referral
Behavior
Desired Outcomes
of Family and Other
Key Participants
Overarching
Goals
MST
Analytical
Process
Environment of Alignment and Engagement
of Family and Key Participants
MST Conceptualization
of “Fit”
Re-evaluate
Prioritize
Assessment of
Advances & Barriers to
Intervention Effectiveness
Intermediary
Goals
Measure
Intervention
Implementation
Do
Intervention
Development
The Guiding 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.
3.
INCREASING RESPONSIBILITY
Interventions should be designed to promote responsible behavior 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.
5.
TARGETING SEQUENCES
Interventions should target sequences of behavior within or between
multiple systems that maintain the identified problems.
The Guiding Principles of MST (cont’d)
6.
DEVELOPMENTALLY APPROPRIATE
Interventions should be developmentally appropriate and fit the
developmental needs of the youth.
7.
CONTINUOUS EFFORT
Interventions should be designed to require daily or weekly effort by family
members.
8.
EVALUATION AND ACCOUNTABILITY
Intervention efficacy is evaluated continuously from multiple
perspectives with providers assuming accountability for overcoming
barriers to successful outcomes.
9.
GENERALISATION
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.
How is MST Implemented?
• Single therapist working intensively with 4 to 6 families at
a time (not individuals)
• “Team” of 3 to 4 therapists plus a supervisor
• 24hr/ 7 day/ week team availability
• 3 to 5 months is the typical treatment time (4 months on
average across cases)
• Work is done in the community, home, school,
neighborhood etc. (not office-based)
How is MST Implemented?
(cont’d)
• MST staff deliver all treatment – typically no services are
brokered/referred outside the MST team
• Never-ending focus on engagement and alignment with
the primary caregiver and other key stakeholder (e.g.
Social Services, school etc.)
• MST staff must be able to have a “lead” role in clinical
decision making for each case
• Highly structured weekly clinical supervision and Quality
Assurance (QA) processes
Theory and Models
• Systems Theory (von Bertalanffy 1968)
• Social Ecological Theory (Bronfenbrenner 1979)
• Causal Model of Delinquency (Elliott et al 1985)
• Strategic Family Therapy (Haley 1976)
• Structural Family Therapy (Minuchin 1974)
• MST Theory of Change (Henggeler et al 2009)
• MST draws from research-based treatment techniques:
•
•
•
•
Behaviour Therapy
Parent Management Training
Cognitive Behaviour Therapy (CBT)
Pharmacological Interventions (e.g. for ADHD)
Whole Child Model
Extended Family
TV
Advertising
Family
Friends
Peers / Friends
Immediate
Community/
Neighbourhood
Police
Mass
Media
CHILD
Home &
Family
Local
Media
Housing
Computer /
Internet
Play / Leisure
Church
School
Workplace
Health
Community and
Voluntary
Organisations
LAW – International / Domestic Including Rights
Adapted from
Bronfenbrenner’s
Ecological model of the
Environment
MST Theory of Change
Peers
MST
Improved
Family
Functioning
School
Community
Changing Relations with Peers
Reduced
Antisocial
Behavior and
Improved
Functioning
10
MST Evidence Base
• 30+ years of research including 20 RCTs, 11 independent
evaluations
• Long term studies at 14 & 22yrs showing 33% fewer days spent in
custody, 37% less family dispute costs. (Schaeffer & Borduin (2005)
Sawyer and Borduin (2011))
• In Norway 2 year follow up, more effective than usual services at
reducing out of home placements (Ogden & Hagen (2006))
• Brandon centre RCT compared MST /YOS – greater reductions in
non-violent offending after 18 mths Butler et al (2011)
• Outcomes linked to fidelity to MST model (Henggeler et al (1997) Ogden
and Halliday- Boykins (2004))
• Start trial began 2010 RCT for 684, reporting Spring 2014
• NICE guidelines, March 2013 for conduct disorder and anti-social
behaviour recommend MST for 11 to 17 yr olds
Peers Research
• Family maltreatment, adverse contexts and
involvement with deviant peers were risk factors for
developing conduct problems (Dodge, Greenberg, Malone, &
Group, 2008).
• Anti-social friends continue to reinforce disruptive
behaviour and a delinquent peer group make antisocial behaviour more likely to occur (Coleman & Hagell,
2007).
• Young people make riskier decisions when in peer
groups than when alone (Gardner & Steinberg, 2005).
• Interventions addressing peers in collaboration with
parents can reduce offending. (Huey et al 2000)
Key messages from peer research for young people
•
Problems with peer relations are powerful predictors
of anti social behaviour (Dodge et al 2006, Lahey et al 2003
Loeber and Farrington 1998)
•
Most young people commit crime in context of peer
activities
Case study- Jane
• Jane is 15.
• Lives with her mother, and her 17 year-old sister.
• Parents are living apart but are in regular contact and their
relationship is good and they work well together.
• Mum has a partner who does not live in the family home. Dad
lives with a partner
• Mum also has good support from her sister.
• Low engagement with school by Jane.
• Strong association with negative peer group.
• Limited engagement with pro-social activities in the community.
Case study- Jane (Referral Behaviour)
(Baseline)
BEHAVIOUR
FREQUENCY
INTENSITY
DURATION
Verbal abuse
Daily
High
8 months
Physical Aggression
Sporadically
Medium
8 months
Theft
Sporadically
Medium
8 months
Physical Aggression
with Peers
Sporadically
High
6-8 months
Misuse of Alcohol
3 times per week
Medium
6 months
Truancy
Almost daily
High
5 months
Self-harm
Sporadically
Medium
6 months
Absconding from
the family home
Sporadically
High
Approx. 6 months
Case study- Jane (Negative Peer “Fit”)
Low affective Relationship at home
Limited expectations
from parent
High conflict at home
Poor home / school link
Access to alcohol
via peers
Access to drugs
via peers
Association
with
Negative
Peer Group
No consequences
Parent had no
links with
peer group
Boredom
Non-attendance at school
Low supervision / monitoring
No positive
re-enforcement
Not engaged in
pro-social activities
Case study- Jane (Negative Peer “Fit”)
Low affective Relationship at home
Limited expectations
from parent
High conflict at home
Poor home / school link
Access to alcohol
via peers
Access to drugs
via peers
Association
with
Negative
Peer Group
No consequences
Parent had no
links with
peer group
Boredom
Non-attendance at school
Low supervision / monitoring
No positive
re-enforcement
Not engaged in
pro-social activities
Priority Drivers
Driver - Parent had no links with peer group
Intervention:
Intermediary Goal - Mum will develop links with Jane’s peer group
Intervention Steps –
- Mum to identify who Jane’s friends are (social network sites, phone
contacts, face to face when they come to the door).
- Mum to introduce herself to these peers.
- Mum to explain her concerns regarding Jane and seek peer support to
assist her in keeping Jane safe.
- Mum to gather contact details from these peers (phone numbers,
addresses).
- Mum to make contact with the parents of Jane’s peers to seek their
support.
- Mum to offer reciprocal support to the parents of Jane’s peers
Priority Drivers
Driver - Low supervision / monitoring
Intervention:
Intermediary Goal – Mum will increase her supervision and monitoring of Jane
Intervention Steps –
- Mum will set clear limits on those with whom Jane is permitted to
associate.
- If Jane is going out mum will ask Jane where she is going, who she is with,
what they plan to do, and when she will be home.
- Mum will monitor Jane’s social networking site.
- Mum will contact peers to verify what Jane has told her.
- Mum will personally verify the information Jane gives her, or use supports
in the community to do so.
Outcomes
• Significant reduction in physical aggression in the family home
(only one incident of physical aggression)
• Significantly improved family relationships
• Jane re-engaged with education
• Improved communication between home and school
• Reduction in alcohol misuse (from three times per week to
approximately once a month)
• Significant reduction in self harming behaviour – parents
reacting to and managing such behaviour more effectively
• Virtual elimination of theft from the home (only one incident
which mum appropriately addressed - stolen items were
recovered)
Outcomes
•
Jane dis-engaged with negative peer group and moved to
positive peer group and pro-social activities - she became a
leader in the local youth club
• Increased parental capacity to manage and maintain the
positive behaviour change
• Jane remained at home
Instrumental Outcomes
2009 – 2012 (n= 86 cases)
• 90.7% at home
• 87.2% in school/ training
• 83.7% with no new arrests
Conclusion
• MST is effective in intervening in peer domain
• Forensic Psychology – still dominated by secure
accommodation and not enough influencing
community forensic settings
• Neglecting the powerful pull of peers in reducing
offending - few interventions target peers
• Addressing the systemic factors (systems theory /
whole child approach) not just individual factors
for the young person is more effective - current
challenge to services to make these changes,
especially statutory sector
For further information on MST:
Websites:
www.mstuk.org
www.mstservices.com
Zoe.ashmore@kcl.ac.uk
Gerard.Stuart@extern.org