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Evaluating MST

Strengths and Limitations

Multicultural implications

Lets pick sides!

  • Adaptability = Universality?

  • It's flexible but what are the nature of it's goals?

  • Your turn!

Research Findings

Evidence based?

Selling points...

Lessons from a systematic review of effects of multisystemic therapy Julia H. Littell

Publication Bias

Conflicts of interest

Main results of the single largest, most rigorous experiment on MST arenot published in peer-reviewed journals or books

Authors are less likely to be critical of their own programs and studies than independent reviewers, particularly when additional funding for services and research is at stake. MST program developers authored or co-authored a number of prior reviews.

Uncritical analysis

Prestigious sources

The author makes the accusation that knowledge derived from these sources appears to be based on authority and tradition, rather than the best available scientific methods.

The MST literature has paid too little attention to implementation, data collection, and analytic issues that can affect the internal validity of inferences drawn from findings of randomized experiments

Research on the client's perspective

Strengths

Perceived Outcomes

  • Convenience: "It was easy for me because I didn't have to go to the person... They're coming into my home; it's my territory. I feel happy, I'm safe."
  • Ecological approach: "to put in place a wider network of support for the parent, and to open up new possibilities for the young person in terms of education, employment, and more prosocial activities."
  • Practical, solution focused approach 
  • Person centred, collaborative approach: "It was almost as if it was a hug... rather than a tablet.... it was almost as if she cared about us as a family. And because she cared that much I had to give it 100%. "
  • Improved relationships between parents and youth
  • Young person choosing to create a different future
  • Behaviour mostly improves
  • Situation can deteriorate after therapist leaves: "We did have a positive relationship while the MST was going on and even a few weeks after it finished, but after that it just went downhill again. I think what happened was partly my fault because the strategies that were in place sort of like went out the window"

Guidelines, Strategies, Techniques

The therapists role in MST

  • What role was I taking with the parent?
  • Key to every intervention is CONTEXT
  • Nothing new: Intervention strategies are integrated from other pragmatic, problem-focused treatment models (PFT, BT, CBT)
  • Challenge the empirically identified determinants of anti-social behaviour

How this ends up looking...

  • MST encourages the therapist to consider the full context and effect change wherever is deemed a priority
  • A comparison...

Community Mental Health Clinician

9 Principles

Principle 9: Generalization

How might they apply to the case of Billy?

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.

Principle 8: Evaluation and accountability

  • Preliminary assessment
  • Meet with youth once a week in my office for individual therapy
  • Probably get a voicemail or two from the parents to tell me about a conflict after it happened
  • Visit the school once for a case conference, once to check up on progress
  • Encourage the parents to involve the youth in pro-social activities

MST Therapist

Intervention effectiveness is evaluated continuously from multiple perspectives with MST team members being held accountable for overcoming barriers to 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 1: Finding the fit

Principle 7: Continuous effort

Goals

An assessment is made to understand the "fit" between identified problems and how they play out and make sense in the entire context of the youth's environment. Assessing the “fit” of the youth's successes also helps guide the treatment process.

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 2: Focusing on positives and strengths

Principle 6: Developmentally appropriate

MST Therapists and team members emphasize the positives they find and use strengths in the youth’s world as levers for positive change. Focusing on family strengths has numerous advantages, such as building on strategies the family already knows how to use, building feelings of hope, identifying protective factors, decreasing frustration by emphasizing problem solving and enhancing caregivers’ confidence.

"I failed a math test"

"How does that feel?"

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 3: Increasing responsibility

Principle 5: Targeting sequences

  • Meet with the Family in the home to get a sense the context of the youths behaviour
  • Meet with the child/family/school daily if needed
  • Develop specific goals, with plans, and with timelines to achieve them
  • On-call 24 hours a day 7 days a week (low caseloads 4-5 allow for this)
  • Take an active role in introducing and maintaining the youth's attendance in pro-social activities
  • Virtually become part of the family system

Principle 4: Present focused, action oriented and well defined

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

Interventions are designed to promote responsible behaviour and decrease irresponsible actions by family members.

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. Such interventions enable participants to track the progress of the treatment and provide clear criteria to measure success. Family members are expected to work actively toward goals by focusing on present-oriented solutions, versus gaining insight or focusing on the past. When the clear goals are met, the treatment can end.

  • 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 start to 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

"I failed a math test"

"I've hired a tutor"

MST Award?

"Whatever it takes" award

MST Model

Meet Billy...

Meet Billy's Parent

Comparing Philosophies

Out-of-Home

MST

#1 -Environment is the problem

#2 - Address the problems in the home context

#3 -Intervention happens at the ecological level

#1 -The youth is the problem

#2 - Removing youth from their negative situation is helpful

#3 -Intervention happens at the behavioural level

#4 - Treat everyone the same(aculturality)

#5 - professionals can fix kids

#4 - Treat situations uniquely

#5 - Families/communities support kids

Multisystemic Theory

  • Developed by Dr. Scott Henggeler, who prior to developing MST was working for the Virginia department of pediatrics, not having much success with anti-social children...

MST now

  • Spent the early 90s developing MST at the medical university of south Carolina

  • In 1996 they went for it, and launched MST Services, a website that basically sells the therapeutic model running trainings all over the US and even going international at this point

This hasn't worked so well...

  • Out-of-home care has a mixed track record at best (downsides anyone?)

  • Community therapy practice with anti-social behaviours suffers from "no-shows" and poor results

  • Let's maybe try something else...

What are the assumptions?

#1 -The youth is the problem

#2 - Removing youth from their negative situation is helpful

#3 -Intervention happens at the behavioural level

#4 - Treat everyone the same(aculturality)

#5 - professionals can fix kids

Origin of MST

  • To understand where MST came from we need to understand Out-of-Home placement

Pop quiz

Pop Quiz #2

What are out-of-home placements?

How does someone end up in an out-of home placement?

Jeff gets sidetracked

  • My old job
  • The 3 Step Shuffle...

Return

Isolation

  • Some went back to live with families
  • Some aged out then went into community living
  • Some went to prison
  • Located in a rural environment
  • Faux-secure custody
  • Limited if any access to previous community

Behavioural Intervention

  • Structured days
  • Behavioural rewards (checkmarks, allowance)
  • Behavioural consequences (house rules, levels)

Multisystemic Therapy might be for you!

What I've learned about MST...

  • It's kind of offensive
  • It's Designed specifically for juvenile offenders (more of a cost saving scheme than therapy...)
  • It's actually a pretty brilliant idea

(if you can reconcile your moral objections)

A Sales Pitch

Are you...

Or maybe...

Do you...

  • A youth worker wanting to help youth overcome adversity but you don't actually want the youth to have any say in this?
  • A therapist who doesn't like talking about feelings?
  • Want to create social change for marginalized individuals, but to you social change means helping people buy into the culture of majority?

The little Acronym that could...

Based on Jim Harvey's speech structures

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