Essay: Proposal for a Multisystemic therapy team

I would like to propose the introduction of an MST Therapy Team. In this proposal, I aim to give some brief background information of the intervention. I hope to give you an understanding of how the intervention could be delivered and maximising its effectiveness in the forensic population. I will also analyse how I propose to evaluate the effectiveness of the intervention that could be offered within the context of the evolving ‘what works’ ‘what doesn’t work’ works in reducing criminal behaviour.
Introduction
Multisystemic therapy (MST) is an intensive, multimodal, home-based, and family intervention for youth with serious antisocial behaviour with an aim to improve family and individual functioning. MST was originally developed to address needs of violent and chronic youth offenders and multiproblem families. (Henggeler & Borduin, 1990; Henggeler et al., 1986). In this vein it has been termed a ‘family preservation’ model (Henggeller, 1996) as its treatment aims was decreased criminal activity, decreased arrest rates, maintaining youth in school/ working, and to develop an effective alternative to incarceration or out-of-home placement for serious juvenile offenders.
In terms of the youth justice system, it has been put forward that its beginnings lie in idealistic attempts to solve social problems through tackling the deprivations of young working-class people in order to divert them from criminality and to encourage them to play a constructive role in society. (Goldson et al., 2002). It has been argued there should be a marked increase and diversification of custodial sentencing in what has been termed the ‘back end’ or ‘deep end’ of the youth justice system. (Goldson, 2006)
Youth crime discourses are progressively underpinned by the rhetoric of rationality- evidence based responses, ‘what works’ practices and the need to ensure that programmes are routinely evaluated and outputs are robustly monitored. (Maguire, 1995)
In the positivist perspective, included are sociological approaches which stress importance of social factors as causes of crime and social ecology explanations which have traditionally been influenced by human geography and biology. Also included in this perspective are anomie, strain and subculture theories. MST interventions are aimed to target the known determinants of juvenile antisocial behaviour in the natural ecology (Elliott et al., 1985, Farrington, 1998) The primary theories guiding MST are social-ecological theory (Bronfenbrenner, 1979) and family systems theory (Haley, 1976, Minuchin, 1974). MST sees youth as embedded in a multiple interconnected systems including family members/ siblings, caregivers, extended family, peers, neighbourhood, school, and community (see social-ecological model diagram below, Fig 1). In assessing the major determinations for identified problems, the clinician considers the reciprocal and bi-directional nature of influences between a youth and his or her family and social network, as well as more indirect effects of more distal influences (e.g. workplace, school) (see diagram below, Fig 2) . For a treatment to be effective, the risk factors across these systems must be identified and addressed. Hence ‘ecological validity’ of assessing and treating youth in the natural environment is emphasised under the assumption that favourable outcomes are most likely due to generalizability and sustainability when skills are practiced and learned where a youth and family actually live.
Fig 1 ‘ Illustration of the socio-ecological theory model
Fig 2 ‘ Diagram of distal factors
Three randomised control trials recognised short term and long term effectiveness of MST in reducing youth antisocial behaviour for chronic juvenile offenders (Hengeller & Schott, 1992; Borduin et al. 1995; Hengeller, Melton, Smith, Schoenwald & Hanley, 1993). Since this time, there have been several independent studies of the effects of MST on antisocial behaviour in youth conducted by researchers (Satin, 2000; Leschield & Cunningham, 2001). MST holds related research studies at the Family Services Research Centre (FSRC) at the Medical University of South California (Scott Hengeller, director). He has conducted a federal funded research programme on MST and other community based interventions since 1992. Included under this, randomised trials of MST, have been modified to intervene with families displaying problems with child neglect/ abuse, with chronic health care conditions (i.e. insulin dependent diabetes complicated by poor medication compliance), with delinquency related to substance abuse, and psychiatric/ serious mental health problems.
MST interventions are not delivered as split elements. They are in contrast with ‘combined’ and multicomponent approaches (Kazdin, 1996; Liddle., 1996). Instead, they are strategically selected and integrated in ways that are intended to make and realise the benefits of interfaced interaction for a particular youth and family, which means no two interventions are the same.
MST theoretically uses combination of empirically-based interventions (e.g. cognitive behavioural therapy, functional family therapies and behavioural parent training) to address several variables (I.e. family, peer groups, schools) that are shown to be factors in juvenile behaviour.
Target/ population
The age of target population is 10-17 years old. The forensic population context I have chosen would be targeted. The classification is families with a young person who is at risk of going into care due to serious anti-social behaviour/ or juvenile offending. Diagnoses of target population as conduct disorder (CD) and juvenile offenders. The level of need would be in the moderate-complex-high risk range. Referrals would be taken and discussed at referral meetings and contact and the MST supervisor would be advisory to determine whether MST is or not suitable for a youth.
Background
Research with serious and violent juvenile offenders often involves correctional sanctioning and incarceration in a correctional institution is the most common. Conversely, as has been emphasised in literature, is that research clearly shows punitive sanctions are generally ineffective in decreasing criminal activities (Andrews & Bonta, 2006; Lipsey, 1999).
Effective interventions have been explained as found on principles of best practice, in that they adjust the intensity of intervention to the risk level of the youth (risks need), that treatments direct interventions at the specific needs of youth, and take account of responsivity factors in selection of the intervention. In terms of the principles, it is held possible that a clinician will pick standardised treatments that have proven effective in dealing with high risk youth (evidence-based programmes). (Mcmurran, 2006).
Developmental theories have been advanced to explain the commission of serious juvenile antisocial behaviour. These theories incorporate social learning theory perspective into a comprehensive range of integrative frameworks (see Andrews & Bontra, 2006, Rutter, 2003, Guerra, Williams, Tolan & Modecki, 2008). Theoretical framework is supported by research on correlates and causes of delinquency. The most fundamental is based on prospective longitudinal designs (Farrington, 1997, 2003, 2006).
I have considered a number of structured intervention programmes for dealing with individual deficits with some efficacy in this report including Anger Control Therapy (ACT), Aggression replacement training (ART), EQUIP program, which have been deliberated in the context of the proposing the chosen MST intervention.
I will briefly evaluate the consideration of alternative approaches. Aggression replacement training (ART) addresses a range of targets for violent aggression in youth to change ‘ prosocial interpersonal skills, anger control skills, and moral reasoning skills.
Aggression Replacement Therapy (ART)
In an original Annsville Youth Centre study New York (Goldstein et al., 1986) compared three groups of principally non-violent youths. A 10-week ART group, in comparison to 2 control groups; no-ART brief instructions to motivate to display skills they already had; and a no-treatment control, significantly improved and transferred 4 of the ten skills. ART youths exhibited less and lower intensity acting out behaviour to control groups at 11 weeks. A 1 year follow up of ART group youth’s rated significantly better by parole officers in community functioning measures. The transfer of the gains acquired in the training setting showed at least moderate carry over (Goldstein & Glick, 1994).
In this context, I believe the MST intervention is of more what I term environmental cogency in that forensic psychology can be evaluated to still be dominated by secure accommodation. MST is effective in intervening in the peer domain, and addresses systemic factors not just individual factors for antisocial behaviour. Furthermore, it appears very difficult for transfer effects of ART successfully for gains acquired to carry over into community settings.
The sample size was relatively small (N=60) and the study was underpowered to investigate the mechanisms of change. Goldstein & Glick replicated the Annsville investigation at MacCormick Youth Centre a maximum security institution for male youths aged 13-21 years, incarcerated for substantially more serious violent and sexual offences. The ART group improved on same 4 of 10 skills and socio-moral reasoning. However, the number and seriousness of behavioural incidents did not differ between control groups. This is attributed to the contextual controlled secure environment.
Furthermore three community-based evaluations recognised the short term effectiveness of ART intervention in reducing arrest rates. (Goldstein et al., 1989) Researchers have discussed the limitations of efficacy evaluations, that the samples used are chiefly non-violent youth (see Hollin and Mcmurran, 2006). Additionally, Coleman et al. (1992) reported improvement in just three skills with disturbed populations of children and adolescents. The Gang Intervention Project in an entire gang cohort study in Brooklyn reported improvements for ART- group members in each of seven skills categories compared to pre-test and controls, but no significant change in anger control scores and improvement in only one area of community function ‘ employment. (Goldstein & Glick, 1994). A two year mixed methods, quasi experimental longitudinal study of ART in Australia youth justice controlled setting (Currie et al., 2012) has supported the effectiveness of ART reporting significant reductions in aggressive behaviours and increasing pro-social attitudes in young violent offenders. However, the study is limited in a very small sample size (n=20), moderate effect sizes, no control group and reliance on self-report measures. The Washington State study (2007) found that when ART model is adhered to, the program after 12 -month follow up, recidivism rates for youth assigned to ART were generally lower than rates of comparable youth. However, no long term follow up was obtained.
Furthermore, several outcome studies of ART as an evidence-based programme have been conducted in Europe (Gundersen et al., (2006), & Moynahan et al., (2005)).
On the whole, although there is sufficient evidence to support interpretation that aggression and violence can be reduced by well-targeted multimodal CBT interventions for violence; MST intervention reduced significantly further non-violent offending for serious youth offenders.
EQUIP program
The EQUIP program is also a group based treatment programme designed specifically for anti-social behaviour problems. The program consists of mutual self-help meetings, focusing on moral judgements, cognitive distortions and social cognitive components to allow youth to increase levels of socio-moral reasoning and pro-social skills. (Gibbs et al., 1995)
A study by Leeman et al., (1993) found EQUIP youths were a third less likely to be reincarcerated than control group. Institutional conduct was also significantly better. At 1 year post follow up following release from the institution, the recidivism rate was 15% compared to 41% for the control group.
Further control studies (Wilson, 2002) in NZ, found that at follow up most of offenders in both groups had re-offended, there also was not significant differences in re-imprisonment rates, however 45% of non-EQUIP youth were violently re-convicted compared to 25% of EQUIP youth.
Implementation/ delivery of MST with juvenile offenders
Master- level therapists provide Multisystemic therapy (MST) at the youth’s home and community locations (e.g. school), using a home-based model of service delivery implementation. The therapists are available to the youth and his/her family 24 hours a day, 7 days a week. The advantages of the home-based service delivery model include the removal of barriers to service access (i.e. transport, child care) and increased validity of the assessment and intervention process. MST teams typically consist of four therapists, each of whom works a small caseload (between one and five families). On average, the treatment lasts for four months, six months for adaptations, with the therapist spending several hours per week with the youth and his/her family. Treatment is intensive, averaging approximately 60 hours of direct contact and indirect (telephone, collateral) contact over a 4 month period. An experienced, doctoral-level, mental health professional trained in MST and in MST supervision procedures supervises each team. MST supervisors are an integral part of the MST therapy team. MST supervisors are in turn supported by MST consultants. These consultants are doctoral-level clinicians who work with therapists, supervisors and administrators to enable adherence to the treatment model at all levels of the organisation in which the model is nested.
Research supporting the effectiveness of MST with serious antisocial behaviour in youth
The first controlled study of MST with juvenile offenders was conducted in 1986. The results of the study showed that compared to youth in his control condition, youth who received MST intervention showed significant decreases in outcome measures with association with delinquent peers, individual psychopathology, conduct problems and their families experienced significant improvement in functioning. (Hengeller et al.,1986). Subsequently, two federal funded control trials evaluated the effectiveness of MST with chronic and juvenile delinquency served by therapists based in community mental health centres.
Hengeller et al. (1992) randomly allocated 84 juvenile offenders to MST matched with usual services provided by a Department of Youth. The findings showed significant differences in redivicism rates 59 weeks post referral, with rates of 42% and 62% respectively. MST youth spent on average 73 fewer days incarcerated (out-of-home placement) in Department of Youth Service facilities. The MST youth also displayed broad improvements in family and peer relations and decreased adolescent mental health symptomology compared to the control condition. The sample size was relatively small.
Hengeller, Melton et al. (1997) again evaluated the effectiveness of MST with chronic and juvenile youth opposed to an intervention provided by a therapist at a local mental health outpatient agency branch of the juvenile court. These early efficacy trials supported the potential of MST to effect significant results for youths and their families. Further trials supported the intervention’s ability to decrease the arrest rates of youth offenders and to improve family functioning (Melton & Smith, 2002; Chapman & Saldana, 2009). Hengeller and Schaeffer (2010) summarised 15 published randomised and two quasi-experimental clinical trials with youth with serious antisocial behaviours and clinical problems such as violence, sexual offending, serious emotional disturbance and delinquency with substance abuse. They suggest that MST has been well validated and is a widely disseminated treatment of antisocial behaviour in youth.
Hengeller et al., (2010) have determined that treatment fidelity played a significant role in favourable outcomes. They advise that higher therapist fidelity to the model holds greater association with longer term youth effects.
Studies demonstrate good transportability of MST (Ogden et al., 2004; Timmons- Mitchell et al., 2006). Curtis et al. (2009) did a comparison study of pre- post- findings from treatment interventions in NZ compared to trials in USA and found significantly high rates of treatment completion (98%) and clinical outcomes reliable with mentioned studies.
Butler et al. (2011) conducted first independent replication in the United Kingdom ( London suburbs study) found MST produced significant decreases in non- violent offences at 12 month follow-up. There was also a decrease in measured psychopathic traits. However, Sundell et al. (2008) failed to support efficacy of MST in treating youth with conduct disorder. Hengeller et al. (2010) reported the failure may be due to small programme fidelity and low supervision. Others have argued that it is premature to draw conclusions about MST and that under closer scrutiny results have been more unpredictable (Littell et al., 2005).
Assessment tools
I propose to use in this study PCL-YV as an assessment of personality traits and can be described in the context of risk and general functioning. I chose to use this for a comparison of pre- post ‘rating from treatment interventions for the effectiveness of MST in reducing conduct disorder. It is felt SAVRY risk assessment tool will be an appropriate measure of moderate to high risk youth of violence and delinquency. Strengths based approaches are advocated when intervening with adolescents. The protective factors incorporated into the risk assessment to consider protective factors. Ward (2003) has been an advocate of strength based approaches. The ‘Good Lives Model’ (GLM) theorises human beings are predisposed to seek ‘primary needs’ to maintain wellbeing, but they may seek them in unhelpful ways. I.e. a youth offender has been excluded from school may have learnt to achieve primary human need of mastery through committing burglary. As delinquent youth are a heterogeneous population who differ in their personality, verbal skills, conceptual thinking, and motivation the treatment design needs to consider variances. It is felt WAIS-II will be required. Youth offenders also experience high levels of co-occuring mental health problems (Kanary et al., 2013) so screening for mental health conditions (such as depression, anxiety and ADHD) will be necessary.
Motivational approaches
Youth offenders are characterised as oppositional, resistant and ambivalent. Research with at-risk adolescents has shown interventions that use Motivational Interviewing (MI) can be effective. It is noted motivating offenders to engage is recognised as fundamental because treatment completion is associated with lower recidivism, whereas non-completion has a neutral or even negative association with recidivism (Cann et al., 2003). I have reviewed The Personal Concerns Inventory (Offender Adaptation) (Sellen et al., 2010). Respondents who complete the PCI-OA, it could serve as an adjunct therapy, to reduce resistance and promote readiness to change.
Evaluation
The randomised control study will evaluate whether MST is more effective in reducing youth offending and out-of-home placement in a large UK sample of serious juvenile offenders and their families than a targeted usual services delivered by youth offending teams. It is felt that 112 participants will be representative.
The primary referral criteria will be staff judgement that the youth was at imminent risk for out-of-home placement because of serious criminal activity (e.g. crimes against persons, other offences).
Pre-treatment and post-treatment batteries would be completed by both families in MST condition and targeted usual services. A multimethod and multifocal measurement outcomes would be used to measure goals such as criminal behaviour and arrests; using self-reports and re-conviction records; and family relations, peer relations, social competence and symptomology outcomes measures to ensure interventions target criminogenic needs as a means of reducing re-offending.
Final recommendations
MST studies have found that in terms of ethnic minority youth the intervention have not been culturally tailored and were less effective with minority youth. For example, Fain et al. (2014) found that relative to comparison group, the MST youth improved in rates of re-arrest, incarceration and completion of community service, however; improvements were only found among Hispanic Youth, not African American youth. Participants would need to be assessed for differences on demographic variables.
Conclusion
In conclusion, treatment delivery needs to be adapted to account for youth offender characteristics. MST may target compatible populations. There may be limitations to consider in funding options, program delivery and close monitoring of treatment fidelity and programme integrity. These factors will be crucial to successful delivery of MST.