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Multisystemic Family TherapyMultisystemic Family Therapy
Theory of Social EcologyTheory of Social Ecology
Multi-determined nature of human behaviorMulti-determined nature of human behavior
Ecological validityEcological validity
Reciprocal Nature of Human InteractionReciprocal Nature of Human Interaction
(Bonfenbrenner’s 1979)(Bonfenbrenner’s 1979)
Multi-determined nature of Multi-determined nature of human behaviorhuman behavior
FamilyFamily
PeerPeer
SchoolSchool
NeighborhoodNeighborhood
Broad View of Contextual InfluencesBroad View of Contextual Influences
E.g., mother’s employer, school boardE.g., mother’s employer, school board
Contributors to DelinquencyContributors to DelinquencyWithin Systems & Between Within Systems & Between
SystemsSystems Within systemsWithin systems
Lax parental supervisionLax parental supervision
Association with delinquent peersAssociation with delinquent peers
Between systemsBetween systems
Lack of caregiver knowledge about friendsLack of caregiver knowledge about friends
Conflict between family and schoolConflict between family and school
(Henggeler et al., 2009)(Henggeler et al., 2009)
Ecological ValidityEcological Validity
Understand youth functioning real worldUnderstand youth functioning real world
HomeHome
ClassroomClassroom
CommunityCommunity
First hand sourcesFirst hand sources
Caregivers, siblings, teachers, Caregivers, siblings, teachers, coachescoaches
Reciprocal Nature Reciprocal Nature of Human Interactionof Human Interaction
Parent asks teen to do choresParent asks teen to do chores
Child complains, argues, does them poorlyChild complains, argues, does them poorly
Parent – easier to do him/herselfParent – easier to do him/herself
Child learns complaining worksChild learns complaining works
Main Agent of ChangeMain Agent of Change
CaregiversCaregivers
Example:Example:
Uses family strengths: love of child, social Uses family strengths: love of child, social supportsupport
Overcome stressors: parental substance Overcome stressors: parental substance abuse, stress, hopelessnessabuse, stress, hopelessness
Increase caregiver effectivenessIncrease caregiver effectiveness
ExampleExample
Help parents design effective interventionsHelp parents design effective interventions
That support prosocial behaviorThat support prosocial behavior
Effective caregiversEffective caregivers
Supportive schoolSupportive school
Involved extended familyInvolved extended family
Support from neighborsSupport from neighbors
New Generations of Family TherapyNew Generations of Family Therapy
1)1) Systemic focusSystemic focus
2)2) Not just family: wider systemsNot just family: wider systems
3)3) Include biological factors: Use of Include biological factors: Use of medicationmedication
4)4) Emphasis on therapeutic allianceEmphasis on therapeutic alliance
(Lebow, 2005)(Lebow, 2005)
New Generations of Family New Generations of Family TherapyTherapy
5)5) Shaping interventions to research on Shaping interventions to research on specific issuesspecific issues
6)6) Sustaining change – engagement in Sustaining change – engagement in sports, prosocial groupssports, prosocial groups
7)7) Emphasizing family strengthsEmphasizing family strengths
8)8) Considering client goalsConsidering client goals
New Generation of Family New Generation of Family TherapyTherapy
9)9) Tracking outcomesTracking outcomes
10)10) Attending to cultureAttending to culture
Prefer therapists from culturePrefer therapists from culture
Research on CausesResearch on Causes
Not amenable to interventionsNot amenable to interventions
Genetic loadingsGenetic loadings
Prenatal exposure to toxinsPrenatal exposure to toxins
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on CausesResearch on Causes
TeenTeen
ADHD, impulsivityADHD, impulsivity
Positive attitudes to delinquencyPositive attitudes to delinquency
Lack of guiltLack of guilt
Negative affectNegative affect
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on CausesResearch on Causes
FamilyFamily
Poor supervisionPoor supervision
Parental substance abuseParental substance abuse
Parental mental health problemsParental mental health problems
Inconsistent or lax disciplineInconsistent or lax discipline
Poor affective relations with teenPoor affective relations with teen
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on CausesResearch on Causes
PeersPeers
Association with drug-using or Association with drug-using or delinquent peersdelinquent peers
Poor relationship with peers, peer rejectionPoor relationship with peers, peer rejection
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on CausesResearch on Causes School levelSchool level
Academic difficulties, low grades, held backAcademic difficulties, low grades, held back
Behavioral problems – truancy, suspensionsBehavioral problems – truancy, suspensions
Negative attitudes towards schoolNegative attitudes towards school
Inflexible school: zero-toleranceInflexible school: zero-tolerance
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on CausesResearch on Causes
NeighborhoodNeighborhood
Availability of weapons & drugsAvailability of weapons & drugs
High environmental and psychosocial High environmental and psychosocial stress (e.g., violence)stress (e.g., violence)
(Henggeler et al., 2009)(Henggeler et al., 2009)
Research on MST Mechanisms Research on MST Mechanisms of Changeof Change
High therapist adherence
MST
Improved familyFunctioning &
Parental monitoring
Decreased association with delinquent peers
Decreased delinquent behavior
(Henggeler et al., 2009)
Clinical ImplicationsClinical Implications Address caregiver functioningAddress caregiver functioning
Empower families to address teen problemsEmpower families to address teen problems
Must deal with delinquent peer issueMust deal with delinquent peer issue
Improve school or vocational performanceImprove school or vocational performance
Develop indigenous support systemDevelop indigenous support system
(Henggeler et al., 2009)(Henggeler et al., 2009)
Therapist Attitude to FamiliesTherapist Attitude to FamiliesDon’tDon’t
Blame familiesBlame families
Ignore familiesIgnore families
Label familiesLabel families
Give up on familiesGive up on families
(Henggeler et al., 2009)(Henggeler et al., 2009)
Basic MST Team StructureBasic MST Team Structure
2 to 4 therapists2 to 4 therapists
SupervisorSupervisor
Each therapist: 4 to 6 familiesEach therapist: 4 to 6 families
Intensive home-and community-based txIntensive home-and community-based tx
3 to 5 months: 60 hours3 to 5 months: 60 hours
Home Based Model Home Based Model
24 hour, 7 day a week availability24 hour, 7 day a week availability
9 Treatment Principles 9 Treatment Principles
1) Finding the fit between problems and the 1) Finding the fit between problems and the systemsystem
Example: therapist developed fit circle Example: therapist developed fit circle hypothesizing roles played by school, hypothesizing roles played by school, caregiver, peer, individual & community caregiver, peer, individual & community factors in development and maintenance factors in development and maintenance of problem behaviorsof problem behaviors
(Henggeler, 2009)(Henggeler, 2009)
Treatment Principles Treatment Principles 2) Positive and strength focused2) Positive and strength focused
Therapeutic contacts should emphasize Therapeutic contacts should emphasize system strengthssystem strengths
Example: Therapist leveraged father’s Example: Therapist leveraged father’s commitment to son and son’s desire for commitment to son and son’s desire for father’s respect to facilitate commitment father’s respect to facilitate commitment to treatmentto treatment
(Henggeler, 2009)(Henggeler, 2009)
Treatment PrinciplesTreatment Principles3) Increasing responsibility3) Increasing responsibility
Interventions designed to increase Interventions designed to increase responsible behavior and decrease responsible behavior and decrease irresponsibleirresponsible
Example: Goals were 1) Increase Example: Goals were 1) Increase attendance at school, stop using drugs, attendance at school, stop using drugs, and comply with father’s rulesand comply with father’s rules
(Henggeler, 2009)(Henggeler, 2009)
Treatment PrinciplesTreatment Principles
4) Present focused, action oriented and 4) Present focused, action oriented and target well-defined problemstarget well-defined problems
Example: Treatment targets that can be Example: Treatment targets that can be measured. Attending school measured by measured. Attending school measured by school records. Stopping drugs confirmed school records. Stopping drugs confirmed by urine tests. Teen’s anger over mother’s by urine tests. Teen’s anger over mother’s abandonment not a treatment target.abandonment not a treatment target.
Treatment PrinciplesTreatment Principles5) Targeting sequences within and between 5) Targeting sequences within and between
multiple systems that maintain problemsmultiple systems that maintain problems
Examples: Poor home-school link Examples: Poor home-school link father/son conflict - ineffective monitoringfather/son conflict - ineffective monitoring
father/school conflict - father avoiding father/school conflict - father avoiding school; school judging fatherschool; school judging father
youth/school conflict – youth insufficiently youth/school conflict – youth insufficiently supervised at school; youth avoided supervised at school; youth avoided schoolschool
(Henggeler, 2009)(Henggeler, 2009)
Treatment PrinciplesTreatment Principles
6) Developmentally appropriate6) Developmentally appropriate
Example: Plan included awards and Example: Plan included awards and consequences appropriate for a teen – access consequences appropriate for a teen – access to music, video games, cell phone use, to music, video games, cell phone use, transportation, and moneytransportation, and money
Treatment PrinciplesTreatment Principles
7) Continuous effort7) Continuous effort
Interventions require daily or weekly effort Interventions require daily or weekly effort by family membersby family members
Example: home/school daily report card; Example: home/school daily report card; home behavioral plans require daily efforthome behavioral plans require daily effort
(Henggeler, 2009)(Henggeler, 2009)
Treatment PrinciplesTreatment Principles
8) Evaluation and accountability8) Evaluation and accountability
Efficacy is evaluated continuously from multiple Efficacy is evaluated continuously from multiple perspectivesperspectives
Example: Monitoring drug use through urine Example: Monitoring drug use through urine screens, school attendance through school screens, school attendance through school records, curfew compliance through father, son, records, curfew compliance through father, son, and probation reportsand probation reports
(Henggeler, 2009)(Henggeler, 2009)
Treatment PrinciplesTreatment Principles9) Generalization9) Generalization
Interventions designed to promote treatment Interventions designed to promote treatment generalization and long-term maintenance of generalization and long-term maintenance of change by empowering family to address change by empowering family to address members’ needs across systemsmembers’ needs across systems
Example: Father learned to communicate with Example: Father learned to communicate with school, better access social supports, obtain school, better access social supports, obtain urine drug screens and develop behavioral urine drug screens and develop behavioral interventionsinterventions (Henggeler, (Henggeler, 2009)2009)
Training and SupervisionTraining and Supervision 5 day initial orientation5 day initial orientation
Majority of learning – working with families Majority of learning – working with families and supervision by on-site supervisor and and supervision by on-site supervisor and off-site consultantoff-site consultant
Weekly meeting with supervisor who uses a Weekly meeting with supervisor who uses a protocol for reviewing casesprotocol for reviewing cases
Weekly discussion with consultantWeekly discussion with consultant
Referral behaviorReferral behavior
Desired outcomes of
family
Overarchinggoals
Fit
MST Analytic Process
Referral behaviorReferral behavior
Desired outcomes of
family
Overarchinggoals
Fit
IntermediaryGoals
Prioritize
MST Analytic Process
Referral behaviorReferral behavior
Desired outcomes of
family
Overarchinggoals
Fit
IntermediaryGoals
Prioritize
Interventiondevelopment
MST Analytic Process
Referral behaviorReferral behavior
Desired outcomes of
family
Overarchinggoals
Fit
IntermediaryGoals
Prioritize
Interventiondevelopment
Interventionimplementation
Do
MST Analytic Process
Referral behaviorReferral behavior
Desired outcomes of
family
Overarchinggoals
Fit
IntermediaryGoals
Prioritize
Interventiondevelopment
Interventionimplementation
Do
Assessment
Measure
Re-evaluate
MST Analytic Process
Prime FeaturesPrime Features
Never give up on familiesNever give up on families
Failed interventions are team’s responsibilityFailed interventions are team’s responsibility
AssessmentAssessment
Background Information FormBackground Information Form
GenogramGenogram
Reasons for referral: ProblemsReasons for referral: Problems
FrequencyFrequency
IntensityIntensity
DurationDuration
Impact Impact Meets with stakeholders: Family, Meets with stakeholders: Family,
teachers, probation officers, etc.teachers, probation officers, etc.
GenogramGenogram
63
3840 FJose Ricardo
History of arrest
59
36 M38
201915 13 16 Rick ADHDMia
Father’s parents live in Puerto Rico and write but do not visit
Ricardo & brother Jose emigrated 5 years ago
AssessmentAssessment
Strengths & Needs AssessmentStrengths & Needs Assessment
In each system: family, school, etc.In each system: family, school, etc. Case SummaryCase Summary
Referral BehaviorsReferral Behaviors
Behavior Frequency Intensity Duration
Marijuana Use 3 – 4 times a week 1 – 2 blunts shared with 2 peers
Approx. 16 months
Truancy 2 – 3 times a week Skips entire day
Started last school year (12 mos. ago)
Aggression – fights with peers
Two incidents Client had stitches, black eye
Incidents were 3 and 8 mos. Ago
Father-son conflict – both are verbally aggressive
1 – 2 times a week Both scream, youth uses rude language; lasts 1 – 2 minutes
(Henggler, 2009)
Desired OutcomesDesired Outcomes
Participant Goal
Rick Get off probationGet dad to stop nagging
Ricardo (father) Rick go to schoolRick get a jobRick make him proud
Mia Rick do goodRick stop getting in troubleRick stop fighting
Jose (Uncle) Rick stay away from bad kidsRick stop smoking dope
Probation officer Rick stay in schoolRick stop using drugsRick stop fighting
(Henggler, 2009)
System Strengths & WeaknessesSystem Strengths & WeaknessesSystemic Strengths Systemic Weaknesses
Individual: Athletic – likes baseballSocial – leaderWants a job
ImpulsiveVerbally & physically aggressiveFailing classesThinks can’t stop marijuana
Family: Father committed to sonSister well-behavedUncle supportive
Father authoritarianFather & son hyigh conflictFather history of arrestMother drug useMother gone
School: Willing to work with teen as long as he tries to improveHas a baseball teamPE teacher/coach interested
Negative peers are at schoolLow supervision in free timeSchool negative to familyTeen may not be sports eligibleSchool not in contact with father
System Strengths & WeaknessesSystem Strengths & WeaknessesSystemic Strengths Systemic Weaknesses
Peers:Positive friends 2 years ago still go to schoolOne friend has jobCousin Joe may be role model – has jobHas one prosocial peer he’d like to spend time with – plays baseball
Most peers are not in school or skipMost friends use marijuana & alcohol2 friends in fights
Community:Recreation center in neighborhoodLittle sister goes to churchLady next door potential support for father
Father authoritarianFather & son hyigh conflictFather history of arrestMother drug useMother gone
Weekly ReviewWeekly Review
1)1) Therapist describes overarching goalsTherapist describes overarching goals
2)2) Therapist lists previous intermediary goals & Therapist lists previous intermediary goals & whether met in last weekwhether met in last week
3)3) Therapist lists barriers to intermediary goals Therapist lists barriers to intermediary goals experienced in last weekexperienced in last week
4)4) Explains advances on gains in last weekExplains advances on gains in last week
5)5) Revise “fit” with new infoRevise “fit” with new info
6)6) Therapist states new intermediary goalsTherapist states new intermediary goals
(Henggeler, 2009) (Henggeler, 2009)
Weekly ReviewWeekly Review
Overarching GoalsOverarching Goals
School - No unexcused absencesSchool - No unexcused absences
No disruptive behaviorNo disruptive behavior
Passing gradesPassing grades
Marijuana – StopMarijuana – Stop
No fightingNo fighting
Father and son – reduced conflictFather and son – reduced conflict
(Henggeler, 2009)(Henggeler, 2009)
Previous Intermediary GoalsPrevious Intermediary GoalsMet Partially No
Therapist & father attend IEP meetingStrategize approaching teachersDevelop school report card for teachersAll teachers agree to complete cardSet another meeting
MetMetMet
MetPartial
Father to collect urine for drug screen Partial
Father and teen to try three strategies when conflict arises Partial
Cousin J to take teen to job interview Not
Review peer sheet with father Not
Barriers to Intermediary GoalsBarriers to Intermediary Goals
English teacher not in IEP conference – teen failing in her class plus behavioral problems – need teacher buy-in on card
Teen left school early 2 days – came out in conference
Father collected urine but unsure how to read results – didn’t call therapist – gave teen privileges as if screen were clean
Teen disrespectful and didn’t follow through with conflict plan
Cousin had to work unexpectedly and couldn’t take teen to job interview
Advances in TreatmentAdvances in Treatment
Coach attended IEP – seemed fond of teen – willing to help
Teachers and father agree on a more vocational track
Teachers seem willing to fill in brief report card each day
Teen set up another time to go with cousin for job interview
Father had neighbor help twice this week – check to see if teen home
Father rewarded son this week for making curfew
Teen: Why should I try? I’m going to fail anyway.
Teen left school
early 2 x
Unable to use conflict resolution
plan
Behavior plan for home/school link not in place – no consequences
Left after PE, before English – easy to escape
Left with 2 peers – went to house of one unsupervised
Father thinking teen trying to make him mad – felt hopeless
Father’s anger makes teen feel he’s winning
Father uses intolerant tone; teen disrespectful
Reassessment of Fit between Problems & Intermediary Goals
Marijuana Use
Fit Circles
Insufficient structure – too much down time
Poor impulse control
Mom’s drug history – drugs normalized
Drug-usingpeers
Poor parental supervision
Family conflict
New Intermediary GoalsNew Intermediary Goals
Therapist to follow-up with English teacher
Therapist to check with father on daily report cardSee if teachers comply with planSee if father able to follow through with consequences
Father to call coach about teen not skipping out after P.E.
Father to call peer’s mom and ask not to allow teen there during school
Work on conflictAsk father/son why not follow through on conflict planShift roles in role playThought replacement when father discouragedPizza for family to facilitate engagement
Therapist to collect random urine drug screen this week
(Henggeler, 2009)
Support for TherapistsSupport for Therapists
Initial 5 day orientation trainingInitial 5 day orientation training
Quarterly booster trainingQuarterly booster training
Weekly on-site supervisionWeekly on-site supervision
Weekly consultationWeekly consultation
Engaging Multi-problem FamiliesEngaging Multi-problem Families
EmpathyEmpathy Spending nonclinical time with familySpending nonclinical time with family Cognitive assistsCognitive assists
Father as childFather as child WarmthWarmth FlexibilityFlexibility ReframingReframing
ReframingReframing1) Echo family’s point of view1) Echo family’s point of view
““I know you think your baby is crying I know you think your baby is crying because she knows you had a bad day because she knows you had a bad day and and she’s just trying to upset you.”she’s just trying to upset you.”
2) Offer an alternative2) Offer an alternative
““Lots of babies get gas sometimes. Lots of babies get gas sometimes. I’ve heard a lot of moms say their I’ve heard a lot of moms say their babies are babies are fussy right after they eat.”fussy right after they eat.”
3) Check to see family’s response.3) Check to see family’s response.
““Do you think that might be part of Do you think that might be part of what’s going on?”what’s going on?”
Nonclinical StrategiesNonclinical Strategies
Family PhotosFamily Photos
FoodFood
Helping with practical needsHelping with practical needs
5 minute sessions5 minute sessions
Parenting StyleParenting Style
WarmthWarmth ControlControl AuthoritativeAuthoritative HighHigh HighHigh
AuthoritarianAuthoritarian LowLow HighHigh
PermissivePermissive HighHigh LowLow
NeglectfulNeglectful LowLow LowLow
AuthoritativeAuthoritative
Responsive to reasonable needsResponsive to reasonable needs
Maturity demands appropriate to developmentMaturity demands appropriate to development
Clear expectations – school performanceClear expectations – school performance
AuthoritarianAuthoritarian
Directive and over-controllingDirective and over-controlling
Require unquestioning obedienceRequire unquestioning obedience
Severe punishment, sometimes physicalSevere punishment, sometimes physical
Directive teaching styleDirective teaching style
No child participation in decisionsNo child participation in decisions
Permissive Permissive
Little structure and disciplineLittle structure and discipline
Few demands for mature behaviorFew demands for mature behavior
Tolerate antisocial behaviorTolerate antisocial behavior
Warm and responsive, but not demandingWarm and responsive, but not demanding
NeglectfulNeglectful
Little discipline or affectionLittle discipline or affection
Little concern or interest in parentingLittle concern or interest in parenting
Are not responsive to child’s needsAre not responsive to child’s needs
Do not expect responsible behaviorDo not expect responsible behavior
Outcome StudiesOutcome Studies
Study Population Comparison Follow-Up
MST Outcomes
Henggeler et al., 1986N = 57
Delinquents DiversionServices
Post-tx Family relations Behavior problems Association with delinq. peers
Brunk et al., 1987N = 33
MaltreatingFamilies
Behavioral ParentTraining
Post-tx Parent-child relations
Henggeler et al., 1991
Serious juvenile offenders
Individual counseling; community services
3 yrs Alcohol and drug use Drug-related arrests
Henggeler et al., 1992N = 84
Violent & chronic juvenile offenders
Community services
59 weeks
Family relations Peer relations Recidivism (43%) Out of home placement (64%)
Outcome Studies - RecentOutcome Studies - RecentStudy Population Comparison Follow-
UpMST Outcomes
Stambaugh et al., 2007N = 267
Serious emotional disturbance
Wraparound 18 mo. Symptoms Out-of-home placement (54%)
Henggeler et al., 2006N = 161
Substance abusing teens in drug court
4 Tx conditions including family court with usual services
12 mo. Post entry
Substance abuse
Timmons-Mitchell et al., (2006)N = 93
Juvenile offenders at imminent risk of placement
Usual community services
18 mo. Youth function Substance use Rearrests (37%)
Rowland et al., 2007N = 31
Serious emotional disturbance
Hawaii’s intensive Continuum of Care
6 mo. Post entry
Symptoms Minor crimes Days out of home (68%)
Outcome Studies- Sexual OffendersOutcome Studies- Sexual OffendersStudy Population Comparison Follow-
UpMST Outcomes
Borduin et al. 1990N = 16
Adolescent sex offenders
Individualcounseling
3 yrs Sexual offending Other criminal offending
Borduin & Schaeffer(2001) N = 48Prelim
Adolescent sex offenders
Usual community services
9 yrs Behavior problems & symptoms Family relations Peer relations Academic performance
Borduin & Schaeffer, in pressFull
Caregiver distress Recidivism for sex crimes (83%) Recidivism for other crimes (50%) Days incarcerated (80%)
Outcome Studies – Sex OffendersOutcome Studies – Sex Offenders
Study Population Comparison Follow-Up
MST Outcomes
Letourneau et al., in press
Juvenile sex offenders
Usual sex-offender specific tx
12 mos post-tx
Sexual behavior problems Delinquency, substance abuse & externalizing symptoms Out-of-home placements
34 Studies of MST34 Studies of MST33 Showed Decreases:33 Showed Decreases:
Factors StudiedFactors StudiedSymptomsSymptomsRearrestsRearrestsSubstance abuseSubstance abuseOut-of-home placementsOut-of-home placementsSexual behavior problemsSexual behavior problemsExternalizing symptomsExternalizing symptomsSexual crime recidivismSexual crime recidivism
(Henggeler, 2009)(Henggeler, 2009)
34 Studies of MST34 Studies of MST
33 Showed Decreases33 Showed Decreases
Factors Studied:Factors Studied:Inpatient admissionsInpatient admissionsMedical charges & direct care costsMedical charges & direct care costsAttempted suicideAttempted suicideViolent crimeViolent crimeAssociation with delinquent peersAssociation with delinquent peersSsychiatric symptomatologySsychiatric symptomatology
(Henggeler, 2009)(Henggeler, 2009)
34 Studies of MST34 Studies of MST33 Showed Increases:33 Showed Increases:
Factors Studied:Factors Studied:
Improved family relationsImproved family relationsImproved parent-child interactionsImproved parent-child interactionsImproved peer relationsImproved peer relationsIncreased school attendanceIncreased school attendanceHigher consumer satisfactionHigher consumer satisfactionImproved academic performanceImproved academic performanceIncreased social competenceIncreased social competence
34 Studies of MST34 Studies of MST
33 Showed Increases:33 Showed Increases:
Factors Studied:Factors Studied:
Blood glucose testingBlood glucose testingMetabolic controlMetabolic controlYouth functioningYouth functioning
1 Study1 Study(Sundell et al., 2008)(Sundell et al., 2008)
Compared to child welfare services in Compared to child welfare services in SwedenSweden
No outcomes favoring either txNo outcomes favoring either tx
Low treatment fidelityLow treatment fidelity