Multisystemic Therapy With
Problem Sexual Behavior Youth
and Their Families
__________________________________________
Charles M. Borduin, Ph.D.
Department of Psychological Sciences
Missouri Delinquency Project
University of Missouri
Richard J. Munschy, Psy.D.
Director of Clinical Training
MST Associates
MST-PSB: Why This Model?
1. Unquestionably the strongest empirical
support of any sex offender treatment model
for juveniles
2. Clearly matches the clinical elements
recommended by the major national and
international sex offender treatment
associations (ATSA, IATSA)
MST Efficacy/Effectiveness Trials with Juvenile Sexual Offenders
_________________________________________________________
♦ Study 1 (1990)
 At 3-year follow-up, MST-PSB effectively reduced:
 Sexual reoffending (12.5% for MST-PSB, 75.0% for Individual Counseling)
 Other criminal offending (25.0% vs. 50.0%)
 Incarceration (0.0% vs. 37.5%)
♦ Study 2 (2008)
 At 8.9-year follow-up, MST-PSB effectively reduced:
 Sexual reoffending (8.3% for MST-PSB, 45.8% for Usual Services)
 Other criminal offending (29.2% vs. 58.3%)
 Days Incarcerated (by 80%)
Study 1 ( International Journal of Offender Therapy and Comparative Criminology)
Study 2 (Journal of Consulting and Clinical Psychology)
MST Efficacy/Effectiveness Trials with Juvenile Sexual Offenders
_________________________________________________________
♦ Study 3 (in process)
 At 1 yr follow up, MST-PSB (2009)
♦ Reduced delinquency, sexually inappropriate behavior, deviant sexual
interests
♦ Reduced alcohol and substance use, psychiatric symptoms, out-of-home
placements
 At 2 yr follow up, MST-PSB (2013)
♦ Reduced delinquency
♦ Reduced sexually inappropriate behavior
♦ Reduced deviant sexual interests
♦ Reduced out-of-home placements
Study 3 (Journal of Family Psychology)
Association for the Treatment of Sexual Abusers
(Effective Policies and Practices, 2012)
_____________________________________________________
 Adolescent sexually abusive behavior is influenced by a variety of
risk and protective factors occurring at the individual youth, family,
peer, school, neighborhood, and community levels”.
 Only a minority of adolescents appear to have atypical sexual
interests, but if present, these interests require appropriate
interventions.
 Overall research support for polygraph and penile
plethysmography is lacking and use of these strategies with
adolescents raises ethical concerns”.
Association for the Treatment of Sexual Abusers
(Effective Policies and Practices, 2012)
_____________________________________________________
 “ Studies have repeatedly demonstrated the importance of family
involvement in the treatment of adolescents with sexual behavior
problems”
 “Some programs are more closely matching treatment intensity to
youth needs and estimated risk levels, and de-emphasizing
empirically unsupported treatment elements (e.g. requiring youth
to journal about sexual thoughts or discuss deviant sexual
fantasies during group sessions)”
Association for the Treatment of Sexual Abusers
(Effective Policies and Practices, 2012)
Recommendations:
_____________________________________________________
1. “It is crucial that developmentally appropriate interventions
designed for adolescents be used. Sanctions and treatment
approaches developed for adults should NOT be applied to
adolescents except in rare cases (e.g. when developmental
appropriate and research supported interventions have failed)”
2. “Risk assessment findings-which are currently often valued far
beyond their empirically established limits- need to be
appropriately integrated into comprehensive evaluations of risk
that properly take into account the youth’s social, family, and
environmental context”.
3. “Too often therapeutic interventions relegate parents and other
members of the youths’ environment to limits roles, rely on
unsupported assessment techniques, place youth in overly
restrictive settings, and simply last too long”.
International Association for the Treatment of Sexual Offenders:
Principles of Care for Juvenile Sexual Offenders (2006)





Youth are best understood within their family and social
contexts
Assessment and treatment should be developmentally
based
Assessment and treatment should focus on the youth’s
strengths
The development of sexual interest and orientation is
dynamic
Youth sex offenders are a diverse population and should
not be treated with a “one size fits all” approach
Miner et al. (2006). Sex Offender Treatment, 1, 1-7.
International Association for the Treatment of Sexual Offenders:
Principles of Care for Juvenile Sexual Offenders (2006)
continued




Treatment should be broad-based and comprehensive
The youth and family should be treated with respect and
dignity
Sexual offender registries and community notification
should not be applied to youths
Effective interventions result from research guided by
specialized clinical experience
Miner et al. (2006). Sex Offender Treatment, 1, 1-7.
Blueprints for Healthy Youth Development
(Colorado Institute of Behavioral Science, in partnership with the Annie E. Casey Foundation)
__________________________________________________
Objective: find programs that improve developmental
outcomes in the areas of behavior, emotion, education,
health, and social relationships
Selection standards: strong research design, evidence
of significant deterrence effects, multi-site replication,
and sustained effects
Comprehensive review of over 1,250 programs: MSTPSB was selected as one of 11 Blueprints Model
Programs and is the only Model Program serving PSB
youths
Other Recognition of MST-PSB
________________________________________________________
Substance Abuse and Mental Health Service
Administration National Registry of Evidence-based
Programs and Practices (SAMSHA)
Early Intervention Guidebook (United Kingdom)
Office of Juvenile Justice and Delinquency Prevention
(OJJDP)
California Evidence-Based Clearinghouse for Child Welfare
Critical Components of all MST models
_______________________________________________
 Addresses known causes of antisocial behavior comprehensively -at youth, family, peer, school, and community levels
 Provides intensive treatment where problems occur -- in homes,
schools, and neighborhoods
 Integrates evidence-based interventions
 Views caregivers as central to achieving favorable outcomes for
their youth -- resources are devoted to empowering caregivers to
be more effective with their adolescents
 Uses an intensive quality assurance system to support MST
program fidelity and youth outcomes
 MST provider organizations are accountable for family engagement
and youth outcomes
Intervention strategies:
All MST models draw from research-based treatment
techniques
♦
♦
♦
♦
Behavior therapy
Parent management training
Cognitive behavior therapy
Pragmatic family therapies
—
—
Structural Family Therapy
Strategic Family Therapy
♦ Pharmacological interventions (e.g., for ADHD)
Ecological Model
Community/Culture
Neighborhood
School
Peers
Family
Child
MST and MST-PSB
What’s Different?
Program Features
MST
MST-PSB
Length of Tx.
3-5 months
5-7 months
Case Loads
4-6 clients
3-5 clients
MST-PSB Augmentations
♦ Heavier utilization of structural/strategic family
therapy than standard MST
♦ Requires strong knowledge base of sexuality
♦ In general, higher frequency and intensity of
contact than standard MST
♦ Videotaping of therapy sessions as
training/supervision tool
Clinical Adaptations of MST for Treating
Juvenile Sexual Offenders
____________________________________________
Ensuring Community Safety: Help family and team
develop plan for risk reduction and relapse
prevention:



♦
Ensure sufficient safety rules uniquely developed for the youth
and containing specific contingencies are in place
Plans must address safety across youth’s entire ecology for
known and potential victims
Caregivers, with guidance from MST-PSB therapist, are in
charge of the safety plan (monitoring, managing, adapting)
Both physical and psychological safety must be considered
Clinical Adaptations (continued)
____________________________________________
Recognizing and Handling Denial: Therapist may
need to devote considerable time and effort in
helping family members to:



Acknowledge the youth’s sexual offense
Place full responsibility for the offense with the juvenile
offender, not with the victim or parents
Reduce denial or minimization of the offense by the offender,
parents, & sometimes even the victim
Clinical Adaptations (continued)
__________________________________________
Thorough Evaluation of the Grooming Process and
Cognitive Variables that May Contribute to
Offending



The offender’s modus operandi must be identified early in the
assessment process
Caregivers must be made aware of grooming strategies & must
develop rules to effectively circumvent the strategies
Attitudinal & cognitive factors linked with offending (e.g., attitudes
toward women & children, lack of empathy, thinking errors,
sexually inappropriate fantasies & patterns of masturbation) may
need to be addressed
Clinical Adaptations (continued)
__________________________________________
Assessing the Impact of Sexual Abuse on the
Intrafamilial Victim and Determining Related
Treatment Needs:




Preparing for disclosure of sexual abuse details
Evaluating the impact of sexual victimization
Interventions may be needed for behavior problems, PTSD,
sexual abuse education, & the grieving process
When possible the victim should be treated by a therapist
independent of the MST-PSB team. This therapist can then
ensure proper pacing for clarification work and, if indicated,
reunification
Clinical Adaptations (continued)
__________________________________________
Comprehensive Clarification Work Using a
Family Systems Approach
Typically initiated within sessions involving caregivers &
offenders
 Strong emphasis placed on creating a family environment
that will provide ultimate support for the victim
 Sessions ideally include the victim’s therapist as an
advocate and additional source of support for the victim
♦ Detailed sequences of offenses (inc both internal and
external events) are generated to create safety plans and
hold youth accountable

Clinical Adaptations (continued)
__________________________________________
Interventions that Focus on the Development of
Friendships Are Often Required




Understanding causes of peer estrangement and/or rejection
(e.g., aggression, low self-esteem)
Common problem areas include acquaintanceship skills,
communication skills, sharing & cooperation skills, problemsolving & conflict resolution skills
Skills Training sessions with the adolescent may use modeling,
coaching, behavioral rehearsal, & operant learning procedures
Ecological support for newly acquired skills is essential
Clinical Adaptations (continued)
__________________________________________
Assessing the Offender’s Own Victimization, the
Impact of the Abuse, and Related Treatment
Needs

Trauma sensitive interventions

Sequencing of interventions
What makes an appropriate MST PSB case?
Child and Family Characteristics  Children between ages of 10 and 17 with problem sexual behavior
(i.e. has sexually abused an identifiable victim)
 Children may also present with other behavioral problems/
disorders (i.e. runaway, truancy, aggression, illegal activity,
substance use, oppositional behavior, etc.), and may have comorbid psychiatric illness
 Children living with or returning to family (may be parents,
extended family or kinship care) with whom child has a long-term
relationship and who are willing to play a long-term parenting role
Appropriate Case Continued
 Parents/caregiver willing to participate in treatment and meet
several times per week as treatment focuses heavily on supporting
caregivers in addressing behavioral issues and helping them be
successful in managing youth’s behavior. There must be at least
one caregiver who acknowledges that the problem sexual behavior
occurred and who will actively engage in safety planning and
management (some level of minimization may be present but cases
cannot be opened when there is absolute unequivocal denial)
 Children typically at risk for out of home placement including
residential treatment, juvenile detention, group home, foster care,
etc.
 Children returning home from an out of home placement
(residential, , detention, group home, etc) within 30 days of
referral.
Appropriate Case Continued
Children returning home from foster care during the
course of MST-PSB : the child must be returned to the
home no later than 120 days after the cases is opened to
allow for reunification, safety planning and
generalization in the natural environment. MST-PSB
will be delivered concurrently in both environments until
transition is complete, at which time it will be delivered
solely in the family home/environment.
Child must have an Axis I diagnosis and be DC
Medicaid/Medicaid MCO eligible
District resident or wards of the District
Exclusionary Criteria for MST PSB
Children who are actively suicidal, homicidal, or
psychotic without medication stabilization
Children with Pervasive Development Delays
Exclusionary Criteria for MST PSB
Children without a viable and committed family
placement and/or children placed in a non-family foster
home for less than two years:
 Exceptions may be allowed for extenuating
circumstances, such as children and families who are
formally in a pre-adoptive process. In such situations,
the referral will be reviewed by the MST Expert who
is consulting with the team.
Children who will not be returning home from
residential, group homes, detention, etc., within 30 days
of the referral or from foster homes within 120 days
THE CASE STUDY
OF SAM
Family Background
Sam
o
o
o
Age 12
No known cognitive delay
Axis I: ADHD, Mood Disorder (at date of admission)
Problem Sexual Behaviors
o Behaviors confirmed with two younger brothers
o Also suspected with youngest brother
o Digital and object penetration
Family Background
o Initial placement with maternal grandmother at 3
months old
o Domestic Violence in the home placement
o Suspected family history of sexual abuse
o Physical aggression resulted in return to living with
Mom at age 9
Situation at Admission
o Court involved
o
o
Initially charged with multiple counts of sexual assault
Pled down to one charge of assault
o Living in a shelter house
o
Goal of reunification
o System involvement
o
o
o
o
o
o
o
Two Core Service Agencies
Legal
School
Probation
Shelter house
CFSA
Victims’ therapist
Presenting Behaviors
o Physical aggression
o School behaviors
o Problem sexual behavior progression
o
o
Family pets
Younger brothers
o About a year
Genogram
Desired Outcomes
Sam: I don’t want to do PSB anymore
Sam: I want to live at home.
Mom: I want to know why and why it happened to all of my children.
Mom: I want education on why it happens.
Mom: I want education on why I didn’t see it.
Public Defender: Interest in reunification for the family.
CSA: Interest in elimination of problem sexual behaviors.
Overarching Goals (OAGs)
1) Sam will not exhibit any inappropriate sexual behavior
towards younger children or others, as evidenced by
displaying appropriate, healthy boundaries and engaging
in healthy age-appropriate relationships, per reports from
Mom, his brothers, school, and the treatment team.
2) Sam will return to live at his home with the agreement of
all family members, as evidenced by reports from Sam,
his mother, his brothers, and the treatment team.
Strengths & Struggles
STRENGTHS
STRUGGLES
Mom is very high functioning
cognitively
Sam was eager to return home
Mom’s mental health
Strong treatment team
Mom reluctant to talk about
incidents
Mom is a strong advocate
Sam’s experience was triggering for
Mom
Low affect between Mom and Sam
No major school issues reported
during treatment
Inconsistency in personal supports
Fit Factor: Negative feelings from Sam toward
his siblings
Evidence: Sam was placed outside of the home
at three months of age and had to live with
grandmother while the other children were raised
by Mom and Dad
Fit Factor: Low boundaries
with peers
Evidence: Frequent
behaviors of handholding with
other male peers led Mom to
believe he was possibly
comfortable doing other things
with peers
Fit Factor: Access to siblings and
behaviors went unchecked
Evidence: Behavioral concerns with
MGM led to placement change, these
continued to occur at home with the
siblings and there was no change in
monitoring or structure.
Fit Factor: Exposure to sexualized
materials
Evidence: Sam watched a lot of
Law and Order: SVU when he was
living with his grandmother.
Fit
Factor:
Low
supervision
Evidence: Mom
unaware of events
taking place. Sam had
ways to prevent her
from knowing. Mom’s
history of abuse also
limited her ability to
see the symptoms.
Initial Fit:
Sam forcing
penetration
on his
siblings
Fit Factor: Challenges
confronting the issue
Evidence: Mom initially did
not want to talk about the
PSB as it was admitting and
acknowledging that her
children were hurt.
Fit Factor: Potential victim of
sexual abuse
Evidence: Mom was abused by
her mother and then placed Sam
with her mother as caregiver.
There were also others in
network as abusers. Likely that
Sam encountered some of them.
Fit Factor: Unclear
sequence of PSB
Evidence: Mom doesn’t
want to know. It is hard to
hear about what happened
to her children.
Fit Factor: Mental health
concerns
Evidence: There are
multiple diagnoses by
multiple professionals.
ADHD confirmed, others are
questionable.
Safety Planning
o Safety plan documented and implemented immediately
o Two plans
o
o
In-home, directed at younger children
Projected for reunification, directed at Sam
o Cooperation from all family members and collaterals
o Primarily oriented towards siblings, but didn’t allow any
unmonitored contact with youth younger than Sam
o
Stay Away Order
o Initially no contact whatsoever between Sam and victims
Safety Planning – Younger Children
Safety Planning – Sam
Sequencing and Clarification
o
o
o
o
o
o
o
Affect development first
Conducted with Mom and Sam in the office
Communication barriers
Quick description of behaviors, required gaining more detail
Addressing barriers
Multiple sessions
Over the course of several sessions, Sam disclosed that he
anally penetrated Sean and Evan over the course of about a
year with a bamboo stick
o Sam admitted to all of the PSB, but struggled to remember
exact incidents as they blurred together in his mind
Low boundaries in the home
Low
Supervision
Low coping skills
(anger)
Major
Drivers of
PSB
Attempt to assert
dominance over siblings
Family and
Personal History of
Victimization
Negative feelings
toward siblings
because they have
always lived with
Mom
Low ability to
empathize
Revenge against
siblings for getting in
trouble earlier in the
day
Desire to harm
others in
retribution for
personal feelings
Exposure to
sexualized themes
in television
Community System Involvement
o Court
o
o
o
o
Reports
Attendance
Advocacy
Family preparation
o Treatment Team
o
o
o
o
o
Monthly team meetings
Clarification of incidents
Frequent communication
Addressing barriers
Contact with victim’s therapist
Caregiver Interventions
o Peer to Peer Parent Support Worker
o Couples work – attempts to increase support for
Mom
o Addressing Mom’s feelings of guilt
o Housing
o Connecting Mom with individual therapy to process
her own victimization
o Affect development
Victim Interventions
o Individual therapist
o
o
Court appointed
Transition to CSA
o Involvement in development and revision of behavioral
plans
o
o
o
Safety
Chore Chart
Reward System
o Individual apologies from Sam to each of his brothers
o Continued checking in throughout reunification process
Steps Towards Reunification
o
o
o
o
o
o
Clarification
Apology from Sam to Sean, Evan, and Nicholas
Teaming
Support with practical needs
Housing
Progression of visits:
o
Short meetings
o Office
o Home
o
o
o
o
Day visits
Overnight stays
Weekend visits
Week visits
o Safety planning and assessment with each stage of progression
Social Skills & Sexual Education
o Communication
o Prosocial activity
o Sexual education
o Relationships
o
o
o
Families
Sexual
Friendships
o Age appropriateness, consent, coercion, intimacy
o Sexual identity
Sustainability Work
o Maintenance and revisions around safety planning
o Making decisions about appropriate touching/affection
between the family members
o Individual therapy for Mom
o Understanding that this is habit building
o Transition to lower intensity services
o
o
Community support workers
Individual therapists
o Generalization
QUESTIONS?
For model level questions: munschy@mstpsb.com
For local implementation/information:
Youth Villages:
District Manager – Austin Hicks
austin.hicks@youthvillages.org
Regional Supervisor – Kelly College
kelly.college@youthvillages.org
Team Leads – Emily Besançon and Mikeyda Travers
emily.besancon@youthvillages.org
mikeyda.travers@youthvillages.org
MST with Juveniles who Sexually Offend
www.mstpsb.com
SAFETY
SCIENCE
SOCIAL ECOLOGY