Multisystemic Therapy: A positive and strength-focused use of the peer relationship in effective interventions

1. Multisystemic Therapy:A positive and strength-focused use of the peer relationship in effective interventions Zoë Ashmore Gerard Stuart

2. 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.

3. Referral Behavior MST Analytical Process Desired Outcomes of Family and Other Key Participants Overarching Goals 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

4. 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.

5. 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.

6. 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)

7. 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

8. 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)

9. Whole Child Model Local Neighbours Culture Extended Family Computer / Internet Ideology Housing TV Advertising Immediate Community/ Neighbourhood Family Friends Advertising Home & Family CHILD Police Peers / Friends Mass Media Play / Leisure School Management Local Media Church School All Government Departments and Policies Health Workplace Local Statutory Agencies Information Technology Community and Voluntary Organisations Adapted from Bronfenbrenner’s Ecological model of the Environment LAW – International / Domestic Including Rights

10. MST Theory of Change Changing Relations with Peers

11. 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 mthsButler et al (2011) • Outcomes linked to fidelity to MST model (Henggeleret 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 yrolds

12. 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 anti-social 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)

13. 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

14. 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.

15. Case study- Jane (Referral Behaviour) (Baseline)

16. 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 No consequences Access to drugs Parent had no via peers links with peer group Boredom Non-attendance at school No positive re-enforcement Low supervision / monitoring Not engaged in pro-social activities Association with Negative Peer Group

17. 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 No consequences Access to drugs Parent had no via peers links with peer group Boredom Non-attendance at school No positive re-enforcement Low supervision / monitoring Not engaged in pro-social activities Association with Negative Peer Group

18. 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

19. 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.

20. 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)

21. 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

22. Instrumental Outcomes 2009 – 2012 (n= 86 cases) • 90.7% athome • 87.2% inschool/ training • 83.7% with no new arrests

23. 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

24. For further information on MST: • Websites: • www.mstuk.org • www.mstservices.com • Zoe.ashmore@kcl.ac.uk • Gerard.Stuart@extern.org