Multisystemic Therapy (MST)

Usability

Core Components

Multisystemic Therapy (MST) is an evidence-based, family and community intervention delivered to young people (10-17years) and their families with social, emotional and behavioural problems, who are at risk of out of home placement and other serious negative outcomes, for example school exclusion.   The primary goal of this intensive, multi-faceted intervention is to end the repetitive pattern of problem behaviour by helping young people remain safely in school and home, and out of conflict with the law. At its core, MST focuses mainly on enhancing family functioning, with improvements expected to translate to other systems in which the young person is embedded (including peer relationships, school and community).  

MST incorporates an MST analytic process and nine treatment principles. The MST treatment model/ analytic process facilitates individualised ‘fit’ assessments and enables the provision of individualised intervention processes which address the range of risk factors that drive adolescent antisocial/problem behaviours. The individualised ‘fit’ assessment identifies current problems, assesses the role of these problems in the context of the young person’s multiple systems, and provides guidance to the treatment process.

The change-process is driven by caregivers; hence MST therapists work with parents/caregivers to strengthen their capacity to address family needs for the purpose of achieving long-term success. Key MST aims include empowering parents(s)/caregivers with strategies to manage behaviours in young people; promoting commitment to education; increasing participation in positive activities (for parent/ carer and young people); reducing antisocial behaviours; bettering family relationships; and managing existing, underlying problems like substance use and mental health difficulties.

MST targets young people’s substance use through engaging caregivers, helping them identify signs of use, improving caregivers discipline strategies, reducing access to substances, changing the young person’s peer and community ecology and increasing supervision and monitoring at home, in the community and in school. MST also works to increase the young person’s attendance and engagement with education and pro-social activities and implements individual cognitive and behavioural intervention to alter core beliefs where necessary and increase peer refusal skills.

Where substance use is assessed as being particularly prevalent and problematic, therapists can also implement Contingency Management (CM), a compatible and standalone evidenced based intervention. Components of CM can be utilised, or it can be delivered whole cloth.

MST is delivered by MST therapists to young people and their families. It is delivered over three to five months, in multiple weekly sessions (offered daily or up to three times weekly) that last about 50 - 120 minutes. MST therapists make themselves available to young people and their families all day (24 hours a day) and all week (seven days a week) throughout the period of therapy via an MST on-call system. This means families can access support whenever it is needed.

Fidelity

Fidelity to the MST model is provided through a Quality Assurance/Quality Improvement Process.

• Training and ongoing support (initial orientation training, quarterly team booster training, weekly expert consultation, weekly supervision and frequent team and individual development planning)
• Organisational support for MST programmes
• Implementation monitoring (measures adherence and outcomes, work sample reviews*)
• Regular programme impact and implementation evaluations.

*Throughout treatment, several clearly defined adherence measures are tracked. The primary caregiver of the family reports how well the MST Therapist is adhering to MST’s treatment principles. In addition, the therapists on the MST team report how well the Supervisor, and Consultant are adhering to the treatment model using the Therapist Adherence Measure (TAM) which can be found at https://msti.org/tam. Model fidelity is critically important as research demonstrates that proper adherence and supervision results in improvements in youth outcomes (1)

MST providers use a website (MSTI.org) to track case level outcome data. At the time of discharge. MST measures three ultimate outcomes for each youth receiving treatment: 1) is the youth at home 2) is the youth in school or working and 3) was the youth arrested during MST treatment. Teams are also able to collect follow up data through the UK database.

Modifiable Components

In addition to the standard MST, adaptions for different populations have been developed to extend beyond working with young people with antisocial behaviour some of these adaptions are:

1) MST for Child Abuse and Neglect (MST-CAN) for families of children (aged 6-12 years) experiencing physical abuse and/or neglect; 2) MST-Building Stronger Families (MST-BSF) a programme for families experiencing child maltreatment and serious parent substance misuse 3) MST Family Integrated Transitions (MST-FIT) to facilitate successful reunification and home return of young people (11-17 years) who are in out of home placements; and 4) MST Problem Sexual Behaviour (MST -PSB) for young people (aged 10-18 years) who have sexually offended/ assaulted a family member.

Throughout 2020/2021, MST continued to provide treatment to young people and their families and quickly adapted to online and blended delivery. All workforce training and support was adapted to online delivery and outcome measures and evaluations evidenced the continued successful implementation of MST. Many key learning points have been gained throughout this process, including the potential to deliver MST to remote, rural communities.

MST is being delivered across a number of continents, including North and South America, Europe and Australasia. Within Europe teams are implementing MST in Belgium, England, France, Germany, Iceland, Ireland, Netherlands, Norway, Scotland, Sweden, Switzerland and Wales.

Supports

Implementation Support

MST implementation support in the UK and Ireland is provided by the MST UK &Ireland team hosted by King’s Health Partners and NES. The team provide support across all stages of MST site development as it relates to needs analysis; initial and on-going implementation including funding and sustainability; stakeholder engagement; staff recruitment and training; and continuing clinical consultation, training, fidelity monitoring and quality assurance.  

Licence Requirements

A licence is required to deliver this programme. Programmes are licensed by MST Services which is affiliated to the Medical University of South Carolina in the USA, MST-UK and Ireland are the licensed Network Partner of MST Services and support all programmes in the UK and Ireland.

Start-up Costs

Costs for start-up relate to each MST team and include initial start-up fees of approximately £7,000 and initial orientation training for all staff, which costs in the region of £700 per person, so approximately £3-£4,000 depending on the size of the team. These costs are subject to change and more information can be found through www.mstuk.org.

Building Staff Competency

Qualifications Required

Each MST team is made up of; 1) MST supervisor who is a masters qualified professional or equivalent, with post-qualification experience in MST, Cognitive Behavioural Therapy (CBT), Structural or Strategic Family or Behavioural Therapy. MST supervisors can be psychologists, family therapists, senior social workers/ probation officers/mental health nurses educated to master's level; 2) Three or Four MST therapists with relevant professional qualification and experience working with children and families in a community setting. Therapists must be degree qualified in a relevant discipline including, clinical psychologists, social workers, nurses, probation officers, family therapists etc; 3) MST programme administrator; 4) Back up Supervisor who provides annual leave cover and support with on-call rota. Families have 24 hours, 7-days a week access to therapy, so staff flexibility in working hours is required.

Training Requirements

MST supervisors and therapists are required to attend a 5/6-day MST orientation training. An additional 2-day supervisor orientation training is attended by MST supervisors. Teams are then provided quarterly ‘booster’ training designed for their own team’s specific needs.

Supervision Requirements

MST teams receive consultation and supervision from their assigned MST Consultant. The Consultant conducts weekly phone consultations, addresses challenges faced by the MST team, and ensures adherence to the MST model. MST Consultants provide feedback on treatment plans and case notes, and reviews audio recordings of therapy sessions. Consultants support clinical development plans for therapists and supervisors. Consultants also organise quarterly booster training sessions tailored to the needs of the MST teams. MST Consultants and Supervisors work together to produce biannual Performance Implementation Reports. The reports include team’s performance, family outcomes, and barriers to programme progress.

Evidence

Theory of Change

Consistent with Bronfenbrenner’s (1979) theory of social ecology, a primary assumption of MST theory of change is that adolescent antisocial behaviour is driven by the interplay of risk factors associated with multiple systems in which young people are embedded (family, school, peer, and community). With parents/ caregivers as the agents of change, MST employs a collaborative therapeutic process to address the interplay of risk factors.

MST incorporates an MST analytic process and nine treatment principles which therapists adhere to. The MST analytic process starts with understanding the range of behaviours that has brought the young person to be referred. The therapist will begin by collecting desired outcomes from the family and key stakeholders involved including social care, the school, and other professionals. From these, a number of overarching goals are co-created which are the goals that the family will work towards to inform treatment success.

The therapist draws on several evidence-based models including Cognitive Behavioural Therapy, structural and strategic family therapy and behavioural therapy. The intervention is idiosyncratic to the needs of each family and is guided by the assessment and the analytical process.

Research Design & Number of Studies

MST has been extensively evaluated both by the model developers and independent researchers. To date there have been over 85 published outcome, implementation and benchmarking studies conducted with over 58,000 participants, including 28 randomised trials.

In general, the MST research demonstrates a reduction in long-term re-arrest rates in studies with serious juvenile offenders, a reduction in out-of-home placements, improved family functioning, decreased substance use, fewer mental health problems and cost savings (2). MST has also demonstrated sustainable positive results in 22-year and 24.9-year follow-up studies with those that received MST having fewer arrests, fewer days in custody and fewer divorce, paternity or child support suits compared to management as usual (3,4).

Some of the best available evidence for MST in substance misuse management include three randomised controlled studies and one meta-analysis. The first study is a multi-centre, randomised controlled study conducted in England. The study includes 684 families with children (aged 11–17 years) with moderate-to-severe antisocial behaviour (5). The second study is a meta-analysis that evaluates the effectiveness of MST on juvenile delinquents and juveniles with antisocial behaviours (6). The third is a randomised controlled study conducted in USA. The study includes 118 substance-abusing juvenile offenders (mean age 15.7 years) (7). The long-term (4-year) follow-up study includes 80 of the 118 participants (8). The fourth is a progress report for two outcome studies that includes 200 juvenile offenders (mean age 14.4 years) and 47 serious juvenile offenders (mean age 15.1 years). Both studies were conducted in USA.

Outcomes Achieved

Child and young people Outcomes

• Significantly reduced variety of substance misuse and volume of substance use at 6 months follow-up (5)
• Significantly reduced substance use at post-treatment (6,7,9). Treatment effect not significant following trim and fill correction to address publication bias (6)
• Significantly lower rate of substance-related arrests based on arrest data collected over an average of 4 years post-treatment (9)
• Significantly higher rates of marijuana abstinence for MST participants (biological measures) at 4-years follow-up (8).

https://www.mstservices.com/mst-reports-research

Values

Multisystemic Therapy (MST) is an evidence-based, family and community intervention delivered to young people (10-17years) and their families with complex social, emotional and behavioural problems, who are at risk of out of home placement and other serious system consequences. MST applies a social-ecological approach with applied treatment strategies derived from strategic family therapy, structural family therapy, behavioural parent training and cognitive behavioural therapy.

• Do the underpinning theory, target population, and applied treatment strategies align with the requirements of your organisation?

Priorities

The key goals of MST are to end the repetitive pattern of antisocial behaviour by helping young people remain safely in school and home, and out of trouble. At its core, MST focuses mainly on enhancing family functioning, with improvements expected to translate to other systems in which the young person is embedded (including peer relationships, school and community).

• Are your organisation’s priorities in-line with the above key goals and core focus?
• Is your organisation looking to deliver an intervention that focuses specifically on substance use problems, or would your organisation prefer to deliver an intervention that addresses the range of risk factors in the network of interconnected systems tha

Existing Initiatives

• Does your service currently deliver interventions that specifically address its identified priorities?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

The MST team is made up of MST a Supervisor (e.g. psychologist, family therapist, senior social worker), three or four MST therapists (e.g. clinical psychologists, social workers, nurses), and an MST administrator. The MST team should have the relevant post-qualification experience, professional qualification, and working experience. MST supervisors and therapists are required to attend an MST orientation training. An additional supervisor orientation training is attended by MST supervisors. MST is delivered over three to five months, in multiple weekly sessions (offered daily or up to three times weekly) that last about 50 - 120 minutes. Families have 24 hours, 7-days a week access to therapy, so staff flexibility in working hours is required.

• Does your service have qualified and experienced practitioners who are available and interested in learning and delivering MST?
• Can your service support the time commitment required for practitioner training and intervention delivery?

Technology Support

Technology for recording sessions and supervision is required along with access to computers for developing case/clinical paperwork and access the MSTI website for program evaluation, fidelity monitoring, and quality assurance monitoring. Delivery of MST session is based on the family’s needs and is done in person, in the community.

• Can your practitioners access technology to record sessions for supervision?
• Does your service have the technology to support access to the MSTI site? i.e. laptops, internet access.

Administrative Support

Each team will have an administrator/Business Support Officer to help in collecting and inputting data and gathering feedback including tasks involved in adherence monitoring. The team have implementation support via the MST UK&I network partnership and are provided technical support in using all MST related systems.

• Can you support your MST team to provide 24 hours a day, 7 days a week care via an on-call rota?
• Can your organisation support the travel needs of the MST team? i.e to orientation training, to support families in their own home.

Financial Support

Costs for start-up relate to each MST team and include initial start-up fees of £7,000 and initial orientation training for all staff, which costs in the region of £700 per person, so approximately £3-£4,000 depending on the size of the team. Teams are then required to pay an annual licence fee for ongoing training and support from an MST consultant and for the structural support from MSTUK&I.

Across the UK&I, MST teams have been developed using a variety of funding options including local level, national grant funding and social impact bonds. Further information and support can be found at http://www.mstuk.org/mst-site-set/funding. As part of the site set up process, MST UK&I provide support for all aspects of programme developing including support and discussion about potential funding options.

Comparable Population

MST is an intervention for young people (10-17 years) with complex social, clinical and educational problems. These might include, being in conflict with the law, substance use, family conflict, difficulties in attending or engaging in education, training and employment and who, without intervention, are at risk of family break down and being placed out of home in care, custody or secure settings.

Evidence of effectiveness for substance use management come from studies that included juvenile offenders, substance-abusing juvenile offenders, and juveniles with antisocial behaviours.

• Is this comparable to the population your service would like to serve?

Desired Outcome

MST is associated with significant improvements across several substance use outcomes. These include reduced substance use, lower rate of substance-related arrests, and higher rates of cannabis abstinence.

• Is delivering MST for the treatment of substance use problems a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?