Program Goals/Target Population
The overriding goal of Multisystemic Therapy (MST) is to keep adolescents who have exhibited serious clinical problems (e.g., drug use, violence, severe criminal behavior) at home, in school, and out of trouble. Through intense involvement and contact with the family, MST aims to uncover and assess the functional origins of adolescent behavioral problems. It works to alter the youth’s ecology in a manner that promotes prosocial conduct while decreasing problem and delinquent behavior.
MST targets youths between the ages of 12 and 17 who present with serious antisocial and problem behavior and with serious criminal offenses. The MST intervention is used on these adolescents in the beginning of their criminal career by treating them within the environment that forms the basis of their problem behavior instead of in custody, removed from their natural ecology.
MST typically uses a home-based model of service delivery to reduce barriers that keep families from accessing services. Therapists have small caseloads of four to six families; work as a team; are available 24 hours a day, 7 days a week; and provide services at times convenient to the family. The average treatment occurs over approximately 4 months, although there is no definite length of service, with multiple therapist–family contacts occurring each week. MST therapists concentrate on empowering parents and improving their effectiveness by identifying strengths and developing natural support systems (e.g., extended family, neighbors, friends, church members) and removing barriers (e.g., parental substance abuse, high stress, poor relationships between partners). In the family–therapist collaboration, the family takes the lead in setting treatment goals and the therapist helps them to accomplish their goals.
Therapists with special MST training deal with a relatively small number of cases, due to the intensive nature of the intervention. Sessions at the home of the adolescent may occur every day or once a week, depending on the needs of the family and the stage in the program.
Systems and social ecological theories form the theoretical foundation of MST. As a family-based home intervention, MST identifies the practical issues that impact the youth’s serious antisocial behavior within his or her social environment. Various therapies inform the specific treatment techniques used, including behavioral, cognitive–behavioral, and the pragmatic family therapies.
The Henggeler and colleagues (1992) study reported the results of a randomized control trial of Multisystemic Therapy (MST) in
The MST treatment for the 43 families lasted an average of 13.4 weeks, with 33 hours of direct contact and therapists providing 24-hour case coverage. Sessions typically lasted between 15 and 90 minutes and were held weekly or as frequently as daily, depending on the treatment stage and the severity of the crises experienced. The service-as-usual group received court orders (including curfews, school attendance, and program participation), which were monitored by probation officers who met with the youths at least once a month. Failure to comply with court orders was met with a court review, and possible referral to a DYS institution, with some receiving substantive services due to a combination of family difficulties and resistance associated with mental health issues.
The study measured participants’ criminal behavior, incarceration, self-reported delinquency, family and peer relations, social skills, and problem behaviors. Pretest and posttest surveys were administered, and archival records for arrests and incarceration were collected on average at 59.6 weeks post referral. One-way analyses of variance (or ANOVA) were used to test differences between groups in arrest and incarceration data, and one-way analyses of covariance (or ANCOVA) were used to test for differences between groups on self-reported delinquency and psychosocial measures at posttest, with pretest scores as covariates.
Borduin and colleagues (1995) examined the long-term effects of a randomized control trial of MST and an individual therapy in
There were, however, significant differences in the duration of treatment for program completers, with MST participants averaging 23.9 hours, compared to 28.6 hours for the comparison treatment group. The study measured participant and family member psychiatric symptomatology, adolescent behavior problems (as reported by the mother), family functioning and interactions, peer relations, and criminal activity collected from State records at 3.95 years following release from probation.
Data was analyzed using multivariate analyses of variance (or MANOVA); survival analysis was used to assess the impact of the treatment conditions on criminal activity.
An independent randomized clinical trial of the effects of MST was conducted by Timmons–Mitchell and colleagues (2006). The study examined recidivism at 18 months and youth functioning at 6 months posttreatment. The study consisted of 93 youths who came before a family court in a
The average age of the sample was 15.1 years at the time of enrollment; 22 percent of the sample was female. The participants were 77.5 percent white, 15.5 percent African American, 4.2 percent Hispanic, and 2.8 percent biracial. There were no significant differences between groups in age, racial or gender make up, or in previous criminal history (age of first offense and number of previous offenses, misdemeanors, and felonies).
The treatment group was enrolled in the MST program for an average of 144.84 days. Service delivery was provided to the 48 families with a high level of fidelity to the MST program. TAU participants’ access to services was monitored by probation officers and court services. While the TAU group did have referrals to anger management, drug and alcohol, and individual and family therapy services, records indicated that attendance was sporadic and that the group had an overall low level of service use.
Arrest data was collected for the MST group for the 19 months posttreatment. For the TAU group, who do not have a clear treatment end point, arrest data was counted if the arrest occurred between 6 and 24 months postrecruitment. For the same reason, adolescent functioning data was collected at baseline, immediately after treatment, and at a 6-month follow- up for the MST group, and at baseline, and 6 months and 12 months postrecruitment for the TAU group. The arrest data was collected from family court records. Child functioning was measured using six areas of the Child and Adolescent Functional Assessment Scale: school and work, home, community, behavior toward others, moods/emotions, and substance use. Offense data was analyzed with likelihoods and relative odd ratios using logistic regression and survival analysis. Adolescent functioning data was analyzed using general linear modeling.
Crime, Arrests, and Incarceration
Results of the Henggeler and colleagues (1992) study at 59 weeks postreferral showed the Multisystemic Therapy (MST) treatment group had just more than half the number of rearrests than the usual-services comparison group. Significant differences were also found in recidivism rates, with 42 percent for the MST group and 63 percent for the comparison group. On average, MST participants spent significantly fewer days (73 days less) than the comparison group incarcerated in Department of Youth Services facilities. At 59 weeks postreferral, 20 percent of the MST group had been incarcerated, compared to 68 percent of the comparison group. At the posttest, the comparison group self-reported delinquency scale scores were nearly three times greater than the MST intervention group.
Family and Social Skills
The treatment group reported significantly higher family cohesion than the comparison group at posttest. While the comparison group’s score for family cohesion decreased from pre- to posttest, the MST group saw an improvement over the same period. Additionally, the treatment group reported significantly lower peer aggression than the comparison group at the posttest. All other measures were not significant.
Arrests and Seriousness of Offenses
Survival analysis by Borduin and colleagues (1995) showed significant differences between treatment and comparison groups 4 years after the end of their probation: 71.4 percent of the individual therapy (IT) comparison group participants were arrested at least once, compared to 26.1 percent of MST participants. Further analysis showed that the number of arrests of the recidivists was significantly lower for the MST treatment group: intervention group recidivists were arrested on average 1.71 times, compared to 5.43 times in the comparison IT group.
The researchers additionally explored the severity of the crimes committed by study participants. They found that the recidivists of the MST group had also been arrested for significantly less-serious crimes and significantly fewer violent crimes than IT recidivists.
There were significant differences between mother and father psychiatric symptomatology between treatment conditions from pre- to posttest: MST families reported a significant decrease in the symptoms they presented, while these levels did not change (or increased) in the IT sample. MST mothers also reported significantly less problem adolescent behavior than those in the comparison group. Additionally, significant differences were found between the intervention and comparison group in family cohesion and adaptability, which increased in the MST group pre- to posttest but decreased in the IT group. No significant differences were found in peer relations measures.
At the 18-month posttreatment follow-up of the Timmons–Mitchell and colleagues (2006) study, the 66.7 percent recidivism rate for the MST group was found to be significantly lower than the 86.7 percent rate for the treatment-as-usual (TAU) group. MST participants were also arrested and arraigned for new charges significantly fewer times (on average 1.44 times) compared to the TAU group (2.29 times). Binary logistic regression showed youths in the TAU group were 3.2 times more likely to be arrested than the MST group. While survival analysis revealed significant differences in recidivism between treatment groups, no significant differences were found between groups on the time until first arrest.
Both interventions improved youth functioning over time, with MST scoring significantly better on four of the six subscale areas examined. At the 6-month follow-up, the MST group showed significantly better school and work functioning than the TAU group. At posttest and 6-month follow-up, significant differences were found for the home subscale of adolescent functioning. Mean differences between the groups were significantly different at all points in time for the community scale. Further, the moods and emotions subscale showed significantly lower results for MST at 6 months. A significant trend was found in the substance use scale over time but not between groups, indicating that the MST group did not show better substance use outcomes than the comparison group.