Multisystemic Therapy

Conference
Manchester
National Picture
Cathy James
13th May 2016

1
What is Multisystemic Therapy?

• Community-based, family-driven treatment

for antisocial behaviour in young people
• Focus is on ‘empowering’ parents or carers
to solve current and future problems
• ‘Client’ is the entire ecology of young
person - family, peers, school,
neighbourhood
• Highly structured clinical supervision and
quality assurance processes
Multisystemic Therapy (MST) Overview 2
MST International Footprint

Breaking the cycle of criminal behavior by

keeping teens at home, in school and out of 3
trouble
MST Around the World

4
 Theoretical Underpinnings

Based on social ecological theory of

Uri Bronfenbrenner

• Children and adolescents live in a social ecology

of interconnected systems that impact their
behaviors in direct and indirect ways
• These influences act in both directions (they are
reciprocal and bi-directional)
Multisystemic Therapy (MST) 5
Overview
Social Ecological Model
Community
Service provider
School
Neighbourhoo
d
Peers
Extended Family
Parents
Family
CHILD Siblings
Members

Multisystemic Therapy (MST) 6

Overview
MST Theory of Change

Peers
Reduced
Improved Antisocial
MST Family
Functioning
School Behaviour and
Improved
Functioning
Community

Multisystemic Therapy (MST)

Overview
7
 How is MST
Implemented?
• Single therapist working intensively with 4 to 6
families at a time
• Team of 3 to 4 therapists plus a supervisor
• 24 hr/ 7 day/ week team availability: on call
system
• 3 to 5 months is the typical treatment time
• Work is done in the community, home, school,
neighbourhood: removes barriers to service
access
Multisystemic Therapy (MST) 8
Overview
How is MST Implemented?
Intervention strategies: MST draws from
research-based treatment techniques
•Behaviour therapy
•Parent management training
•Cognitive behavior therapy
•Pragmatic family therapies
‐ Structural Family Therapy
‐ Strategic Family Therapy
•Pharmacological interventions (e.g., for ADHD)
Multisystemic Therapy (MST) 9
Overview
 Range of MST Programmes
MST Standard
• Young people aged 11+-17+ years with serious
behaviour problems, at risk of out of home
placement
MST Child Abuse and Neglect
• Children aged 6 to 17 years on a child protection plan
for physical abuse and/or neglect
MST Problem Sexual Behaviour
• Young people aged 10+ who have committed a
sexual offence or have serious problematic sexual
behaviour
Multisystemic Therapy (MST) Overview 10
 Standard MST Referral Criteria
(ages 11+-17)
Inclusionary Criteria Exclusionary Criteria
• Young people at risk of out • Young people living
of home placement due to independently
anti-social or offending • Sex offending in the absence
behaviors, substance of other anti social behavior
abuse • Young people with severe
• YP involved with the youth Autistic Spectrum disorder
justice system • Actively suicidal, homicidal or
• YP who have committed psychotic
sexual offences in • YP whose psychiatric problems
conjunction with other are the primary reason leading
anti- social behavior to referral
Multisystemic Therapy (MST) 11
Overview
 Quality Assurance and
Continuous Quality Improvement
in MST
Goal of MST Implementation:
• Obtain positive outcomes for young people and
families
Quality Assurance/Improvement Process:
• Training and ongoing support (orientation training,
boosters, weekly expert consultation, weekly
supervision)
• Organisational support for MST programs
• Implementation monitoring (measure adherence
and outcomes, work sample reviews)
Multisystemic Therapy (MST) 12
Overview
 Government Approach England
£36 million invested since 2008 in evidence
based programmes
• Joint work between Department of Health and
Department of Education
• Aim to intervene early but also work with
young people with high levels of need
• MST development built on bottom up
developments as well as top down investment
 Programmes supported by the
National Implementation Service
A 16-week programme specifically designed for adoptive
parents with children aged 3-8. www.adopttraining.org.uk
A group training programme aiming to increase the positive
parenting skills of foster and kinship carers. www.keep.org.uk
An intensive community based systemic intervention working
with families where a young person is at risk of going into care
or custody. www.mstuk.org
A whole team training programme for staff in residential
children’s homes. www.resulttraining.org.uk
An innovative group programme using video interaction for
foster carers & kinship carers with babies and infants aged 0-4.
An intensive fostering treatment intervention for
children between 3-17. www.mtfc.org.uk
 MSTUK Network Partnership
• Development & organisational support for
implementation of licensed MST standard and MST
CAN programmes
• Training, consultation and support to sites -
monitoring and guidance on model fidelity
• Support for steering groups and programme managers
on sustaining services
• Support for local and national evaluation and audit
and for independent research
• Work on development of new
programmes/adaptations
• MST UK website –including members area
NATIONAL & LOCAL
 Development of MST in
England 2012 - 2015
2001 Cheshire East
Brandon Centre Coventry
Cambridgeshire Derby City
Derbyshire South
2007/2008 Essex:-2 teams
Barnsley & Rotherham Knowsley
Leeds Leeds South & East
Merton & Sutton Leicester 1
Reading Manchester
Sheffield Newcastle
Trafford Northamptonshire
North Yorkshire
2010/11 Nottingham City
Wirral Oldham & Tameside
Birmingham Portsmouth
Sandwell and Dudley
STEP Change (West London)
Tri-borough
MST Adaptations Wigan
Brandon Centre PSB & SA
Cambridgeshire CM & PSB 2016
Leeds CAN & FIT Birmingham 2
Newcastle MST CAN Leicester 2
Northamptonshire FIT Leicester MST-CAN
Nottingham City CAN Reading MST FIT
Sheffield PSB (blended team) Manchester MST CAN?
CAN: Child Abuse and Neglect Greater Manchester PSB?
FIT: Family Integrated Transitions
PSB: Problem Sexual Behaviour
SA: Substance Abuse
Creating “pilots”!
 MST Family Integrated Transitions
• Multisystemic Therapy (MST) is the foundation
• Focused on young people placed away from home but
transitioning back home
• In England initial focus on young people returning home from
residential care and developing a foster care model
• Incorporates teaching young people Dialectical Behavioral
Therapy (DBT) skills
• Work is undertaken in care setting and with the family
• Two sites piloting the model with residential care- Leeds and
Northamptonshire, Reading working with foster carers
• Developed by Dr Eric Trupin –University of Washington
Taking off…Implementing
Programmes
 MST Child Abuse and Neglect
• Works with families with children aged 6 to 17 years :
physical abuse and neglect
• Work with children and parents –focusing on trauma
and also parental substance abuse
• Aims to allow children to live safely at home
• 3 teams :80 families 91% children remain safely at
home
• Two new sites in 2016: Leicester and Nottingham
• Development of a UK based consultant : Dr Martin
Robinson
 MST Problem Sexual Behaviour
• Multisystemic Therapy (MST) is the foundation-adaptation
developed by Professor Charles Borduin
• Focus is young people with problematic sexual behaviour
aged 10-17 and their families
• Work on both sexually problematic behavior and other
behavioural or family problems
• Two current sites: Brandon Centre (London), Cambridgeshire
• Randomised Controlled Trial underway in London
• Challenge is sustaining a commissioning framework
• Work in Greater Manchester to scope a service funded via a
Social Impact Bond.
 MST Substance Abuse
• MST has always worked with young people
with substance misuse problems
• Additional training initially only available to
specialist SA teams
• Substance Abuse enhancement rolled out to
all new and existing teams 2015/16
• Teams can also opt for additional Contingency
Management training
 Developing Sustainable Programmes
• Strong multi-agency stakeholder engagement and
robust needs analysis
• Realistic costs of programmes and other services
• Recruiting and retaining skilled staff
• Systems, infrastructure and governance
• Baseline, outcome and follow up data
• Family stories and family engagement
 3 Phases of Implementation
Around 2-4 years from initial conceptualising through to full implementation

Direction of Travel - Forward

PLANNING DOING SUSTAINING

Phase 1 Phase 2 Phase 3

Getting Training on Continuing to

people & specific learn to use new
systems practices. evidence for
ready for Implementing, improving
change. adapting & practice.
evaluating.
 Evidence Base for MST?
Key Points:
•30+ years of Science and research
•Consistent and Long term Outcomes
•Evidence of cost effectiveness
•Development of UK based research
Multisystemic Therapy (MST) 26
Overview
 Data and Outcomes for MST
Multisystemic Therapy Teams
• 25 MST standard
• 3 MST Problem Sexual Behaviour
• 3 MST Child Abuse and Neglect
• 2 MST Substance Abuse
• 2 MST Family Integrated Transitions teams

35 teams providing MST across England to over 1,000 families

Outcomes for children (2014/15)

• At home 93%
• In School 82%
• No new offences 88%
 UK Evidence Base
• Butler at al 2011 Brandon Centre research trial of
MST standard –positive outcomes for MST versus
usual services
• Awaiting publication of START trial of standard
MST and outcomes from MST CAN research
• STEPs-B Randomised Controlled Trial of MST PSB
in the UK http://www.ucl.ac.uk/steps-
b/index.php
• Evaluation of the feasibility of MST FIT in a UK
Social Care context
 Butler at al 2011: take home
messages
 Study supports the superiority of the MST condition
in reducing offending and antisocial behaviour
 MST had some delayed impact on offending, the
nature and causes of which require further study.
 The results suggest that MST adds value to current
U.K. statutory based youth services.
 Provision of MST does not supplant existing services
but best used alongside statutory provision
 Outcomes-Young People

• Young person: hopes for a more positive future

Increased self-belief & aspirations
…I can work hard if I really want to and I can concentrate
so, I kind of believe in myself more as well than I did
before…now I believe I can get so far and no-one will stop
me. (YP41L)
[MST] helped with my…education and getting a reference
and getting a job... It made me put my head down and
focus on my education, that side of my life like, how to
earn, earn a good pay legitimately, yeah…
 Outcomes: Parents
Empowered, more confident and competent, improved
mental health
– It’s quite a frightening experience for a parent to lose total control of
their child… so having that list and sticking to the rules and being
consistent I feel like I’ve got some control…
– It’s a change, but I’m just assuming it’s because I think I’ve changed… I
can’t say that when [therapist] left that it had totally changed…but the
only thing I know is that I learnt a lot, improved on my parenting skills
– I’m not sort of a woman on the verge of a nervous breakdown. So, you
know, I’m a bit more relaxed…I was just desperately anxious…before…I
just was extremely tense. So it couldn’t have been easy to live with me
either…the emotion has been taken out of it, the kind of highly strung,
the anxiety. I am able to take his behaviour a bit less personally…
Long-Term Outcomes

Breaking the cycle of criminal behavior by

keeping teens at home, in school and out of 32
trouble
 Strengths
• MST has a strong research evidence base and also
great evidence of effectiveness in the UK
• MST provides an intensive, flexible service to families
in partnership with other agencies
• MST has clear guidelines for set-up, training and
implementation
• MST provides commissioners with clear data on both
process and outcomes of the intervention
• Wide range of outcomes for families and
communities
Contacts:
cathy.james4@nhs.net
Natalie.wilmot@kcl.ac.uk
Ben.robins@kcl.ac.uk
Websites:
http://mstuk.org
http://evidencebasedinterventions.org.uk/
www.mstservices.com