Multisystemic Therapy (MST) - Detailed Report

Delinquent or antisocial youth who are 12 to 17 years old and may also meet the following criteria:

• Youth at Imminent risk of out-of-home placement due to criminal offenses.
• Physical aggression at home, at school, or in the community.
• Verbal aggression, verbal threats of harm to others.
• Substance abuse in the context of problems listed above.

Programs will need to exclude:

• Youth living independently or youth for whom a primary caregiver cannot be identified despite extensive efforts to locate all extended family, adult friends, and other potential surrogate caregivers.
• Youth referred primarily due to concerns related to suicidal, homicidal, or psychotic behaviors.
• Youth referred primarily for problem sexual behavior. MST–Problem Sexual Behavior (MST-PSB), however, is an adaptation of MST that is available for youth with externalizing, delinquent behaviors, including aggressive (e.g., sexual assault, rape) and non-aggressive (e.g., molestation of younger children) sexual offenses.
• Youth with pervasive developmental delays.

Intervention Context

• Services are provided in the family’s home or other places convenient to them and at times convenient to the family.
• Services are intensive, with intervention sessions being conducted from once per week to daily.
• A 24 hour/7 day/week on-call schedule is utilized to provide round-the-clock availability of clinical services for families.

Therapists and Supervisors

• MST staff members work on a clinical team of 2-4 therapists and a supervisor.
• MST therapists are Masters-prepared (clinical-degreed) professionals.
• MST clinical supervisors must be at least 50% part-time and may supervise 1-2 teams only.
• MST clinical supervisors are, at minimum, highly skilled Master's-prepared clinicians with training in behavioral and cognitive behavioral therapies and pragmatic family therapies (i.e., Structural Family Therapy and Strategic Family Therapy).

Application of the Intervention

• Interventions are developed using an analytical model that guides the therapist to assess factors that are driving the key clinical problems, and then in designing interventions that are applied to these driving factors or “fit factors.”
• All intervention techniques are evidence-based or evidence-informed.
• Each therapist carries a maximum caseload of 6 families and case length ranges from 3 to 5 months.

Clinical Supervision

• The MST clinical supervisor conducts on-site weekly team clinical supervision, facilitates the weekly MST telephone consultation, and is available for individual clinical supervision for crises.

Program Monitoring and Use of Data

• Agencies collect data as specified by MST Services, and all data are sent to the MST Institute (MSTI) which is charged with keeping the national database system.
• MSTI data reports are used to assess and guide program implementation.
• Agencies use these reports to monitor and assure fidelity to the MST model.

Agency

• The agency must have community support for sustainability.
• With the buy-in of other organizations and agencies, MST is able to “take the lead” for clinical decision-making on each case.  
• Stakeholders in the overall MST program have responsibility for initiating these collaborative relationships with other organizations and agencies while MST staff sustain them through ongoing, case-specific collaboration.

Multisystemic Therapy (MST) is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. For more information on the rating of a "1 - Well-Supported by Research Evidence," please see the Scientific Rating Scale.

Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stein, R. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 35, 105-114.

Type of Study: Randomized controlled trial
Number of participants: 16
Population:

Age Range: 14 years on average
Race/Ethnicity: 62.5% White, 37.5% African American
Status (e.g., foster care, CW) Adolescent sexual offenders referred by juvenile court personnel.

Location/Institution: Columbia, Missouri; University of Missouri
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study compared the efficacy of MST and individual therapy (IT) in the outpatient treatment of adolescent sexual offenders. Sixteen adolescent sexual offenders were randomly assigned to either MST or IT conditions. Youths in the MST and IT conditions received an average of 37 and 45 hours of treatment, respectively. Recidivism data were collected on all subjects at an approximately 3-year follow up. Compared to youth who received IT, those in the MST condition showed significantly lower rates of re-arrest for sexual offending and other criminal offending. The most evident limitation of this study was the small sample size, which would warrant a replication with a larger sample size.
Length of post-intervention follow-up: 3 years.

Henggeler, S. W., Melton, G. B., & Smith, L. A. (1992). Family preservation using Multisystemic Therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology, 60, 953-961.

Type of Study: Randomized controlled trial
Number of participants: 84
Population:

Age Range: 15.2 years on average.
Race/Ethnicity: 56% African American, 42% White, 2% Hispanic-American
Status (e.g., foster care, CW) Violent and juvenile criminal offenders referred by the Department of Juvenile Justice

Location/Institution: Simpsonville, SC; SC Department of Mental Health
Summary: (To include comparison groups, outcomes, measures, notable limitations) Multisystemic Therapy (MST) delivered through a community health center was compared to usual services delivered by the Department of Juvenile Justice in the treatment of 84 serious juvenile offenders and their families. Offenders were assigned randomly to treatment conditions. Pretreatment and posttreatment assessment batteries evaluated family relations (as measured by the Family Adaptability and Cohesion Evaluation Scales), peer relations (as evaluated by the Missouri Peer Relations Inventory), behavioral symptomology and social competence (as measured by the Revised Behavior Problem Checklist), criminal offending based on self-reports, and arrest/incarceration records through 59 weeks post-referral. In comparison with youth who received usual juvenile justice services (high rates of incarceration), youths who received MST showed improved family cohesion, improved peer relations, decreased recidivism (43%), and decreased incarceration (64%).
Length of post-intervention follow-up: 59 weeks; a subsequent publication provided a 2.4 year follow-up with outcomes favoring the MST condition.

Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M., et al. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63(4), 569-578.

Type of Study: Randomized controlled trial
Number of participants: 176
Population:

Age Range: 14.8 years on average
Race/Ethnicity: 70% White, 30% African American
Status (e.g., foster care, CW) Adolescent offenders referred by juvenile court personnel.

Location/Institution: Missouri
Summary: (To include comparison groups, outcomes, measures, notable limitations) Youth were randomly assigned to receive MST or individual therapy (IT). Participants and family members were assessed prior to treatment and approximately one week after treatment using the same measurement procedure. A follow-up using police and court records was conducted for 4 years after completion of treatment. Outcome measures included self-reports on the Symptom Checklist—90 and the Revised Behavior Problem Checklist. Family functioning was assessed with the Family Adaptability and Cohesion Evaluation Scales (FACES-II), and observers evaluated family interactions using the Unrevealed Differences Questionnaire. Finally, peer relations, through parent and teacher perceptions, were evaluated with the Missouri Peer Relations Inventory. Post-treatment measures found improved parent-reported psychiatric symptoms, levels of behavior problems, and observed family functioning for the MST group, while the IT group reported increased problems in these areas. By the end of the 4-year observation, 71.4% of the IT youth had been arrested compared with 26.1% of the MST group. The MST group also had significantly fewer arrests for violent crimes. Limitations include lack of expected improvement on participants’ peer relations. Therapists in the MST condition may also have differed in motivational factors from those in the IT condition.
Length of post-intervention follow-up: 4 years.

Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65, 821-833.

Type of Study: Randomized controlled trial
Number of participants: 155
Population:

Age Range: 15.2 years on average.
Race/Ethnicity: 19.4% White, 80.6% African American
Status (e.g., foster care, CW): Violent and juvenile criminal offenders youth referred to the study by juvenile court personnel.

Location/Institution: Orangeburg and Spartanburg, SC; Medical University of South Carolina
Summary: (To include comparison groups, outcomes, measures, notable limitations) The effects of MST in treating violent and chronic juvenile offenders and their families in the absence of certain aspects of the MST quality assurance protocol were examined. Across 2 public sector mental health sites, 155 youths and their families were randomly assigned to MST versus usual juvenile justice probation services with high rates of incarceration. Youth emotional adjustment and adolescent behavior problems were measured by the Global Severity Index of the Brief Symptom Inventory. Criminal activity was measured by the Self-Report Delinquency Scale as well as Department of Juvenile Justice arrest records. Family relations were measured by the Family Adaptability and Cohesion Evaluation Scales and peer relations were measured by the Missouri Peer Relations Inventory. MST decreased adolescent externalizing and internalizing symptoms at post treatment, decreased incarceration by 47% at a 1.7-year follow-up and decreased recidivism (26%, nonsignificant). Analysis of parent, adolescent, and therapist reports of MST treatment adherence (as measured by the MST Treatment Adherence Measure) indicated that outcomes were substantially better in cases where MST treatment fidelity was high.
Length of post-intervention follow-up: 1.7 years.

Henggeler, S. W., Pickrel, S. G., & Brondino, M. J. (1999). Multisystemic treatment of substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research, 1, 171-184.

Type of Study: Randomized controlled trial
Number of participants: 118
Population:

Age Range: 15.7 years on average
Race/Ethnicity: 50% Black, 47% White, 1% Asian, 1% indicating some Hispanic ethnicity, and 1% Native American
Status (e.g., foster care, CW): Substance abusing and substance dependent delinquents youth referred to the study by juvenile court personnel.

Location/Institution: Charleston, South Carolina; Medical University of South Carolina
Summary: (To include comparison groups, outcomes, measures, notable limitations) The effectiveness and transportability of MST were examined in a study that included 118 juvenile offenders meeting the Diagnostic and Statistical Manual, Third Edition, Revised (DSM-III-R) criteria for substance abuse or dependence and their families. Participants were randomly assigned to receive MST versus usual community services. Outcome measures assessed drug use (as measured by the Personal Experience Inventory and urine drug screens), criminal activity (measured by the Self-Report Delinquency Scale as well as Department of Juvenile Justice arrest records), and days in out-of-home placement at post treatment and at a 6-month post-treatment follow-up. Also, treatment adherence (as measured by the MST Treatment Adherence Measure) was examined from multiple perspectives. Results showed a reduction in drug use, decreased days in out-of-home placement (50%), and decreased recidivism (26%, nonsignificant). Treatment adherence was linked with long-term outcomes, and analyses suggested that the modest results of MST were due, at least in part, to difficulty in transporting this complex treatment model from the direct control of its developers. Increased emphasis on quality assurance mechanisms to enhance treatment fidelity may help overcome barriers to transportability.
Length of post-intervention follow-up: 1 year; a 4-year follow-up was subsequently published with results favoring the MST condition.

Ogden, T., & Halliday-Boykins, C. A. (2004). Multisystemic treatment of antisocial adolescents in Norway: Replication of clinical outcomes outside of the US. Child and Adolescent Mental Health, 9, 77-83.

Type of Study: Randomized controlled trial
Number of participants: 100
Population:

Age Range: 14.9 years on average
Race/Ethnicity: 95% Norwegian
Status (e.g., foster care, CW): Norwegian youth with serious antisocial behavior referred for treatment

Location/Institution: Multiple sites in Norway
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study examined the degree to which MST outcomes in the U.S. could be replicated in Norway for youth with serious behavior problems. As such, a randomized trial of MST was conducted by an independent team of investigators. Participants were 100 seriously antisocial youths in Norway who were randomly assigned to MST or Child Welfare Services (CS) treatment conditions. Outcome measures included the Child Behavior Checklist, Self-Report Delinquency Scale, Social Competence with Peers Questionnaire, Social Skills Rating System, the Family Adaptability and Cohesion Evaluation Scales-III, and the Family Satisfaction Survey. Data were gathered from youths, parents, and teachers pre and post-treatment. MST was more effective than CS at reducing youth internalizing and externalizing behaviors and out-of-home placements, as well as increasing youth social competence and family satisfaction with treatment.
Length of post-intervention follow-up: 6 months post-recruitment; a 2-year follow-up was published subsequently, with results favoring the MST condition.

Henggeler, S. W., Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B., & Chapman, J. E., (2006). Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 34(4), 658-670.

Type of Study: Randomized controlled trial
Number of participants: 161
Population:

Age Range: 15.2 years on average
Race/Ethnicity: 67% White, 31% African American, 2% Biracial
Status (e.g., foster care, CW): Substance abusing and substance dependent juvenile offenders referred to the study by juvenile justice authorities

Location/Institution: Charleston SC, Medical University of South Carolina
Summary: (To include comparison groups, outcomes, measures, notable limitations) Over a 1-year period, a four treatment condition randomized design evaluated the outcomes for family court with usual services, drug court with usual services, drug court with MST, and drug court with MST enhanced with contingency management for adolescent substance use (as measured by self report and urine screens) , criminal behavior (as measured by the Self-Report Delinquency Scale and arrest records), symptomatology (as measured by the Child Behavior Checklist), and days in out-of-home placement (as documented in criminal justice records). In general, results showed MST enhanced substance use outcomes and drug court was more effective than family court at decreasing self-reported substance use and criminal activity. Possibly due to the greatly increased surveillance of youths in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in re-arrest or incarceration. Limitations included the relatively short follow-up.
Length of post-intervention follow-up: 12 months post-recruitment.

Timmons-Mitchell, J., Bender, M. B., Kishna, M. A., & Mitchell, C. C. (2006). An independent effectiveness trial of multisystemic therapy with juvenile justice youth. Journal of Clinical Child and Adolescent Psychology, 35(2), 227-236.

Type of Study: Randomized controlled trial
Number of participants: 93
Population:

Age Range: 15.1 years on average.
Race/Ethnicity: 15.5% African American, 77.5% European American, 4.2% American Hispanic, and 2.8% biracial.
Status (e.g., foster care, CW) Youth who had appeared before a family court

Location/Institution: Midwestern U.S.
Summary: (To include comparison groups, outcomes, measures, notable limitations) Families were randomly assigned to MST or to treatment as usual (TAU). In their introduction, the authors note that this study is unusual in that it does not involve the original MST developers and was conducted in a more naturalistic setting than some previous trials. Youth functioning was measured using the Child and Adolescent Functional Assessment Scale (CAFAS), which focuses on school/work, home, community, behavior towards others, emotions, self-harming and risky behavior and thinking. Youth recidivism was also measure using family court records. The MST group showed a significantly lower recidivism rate. Both groups showed functional improvements, with MST showing particular improvements in the areas of home, school and community. Limitations include relatively little information about services used in the TAU condition. Available information suggested that use of services was low by families in the TAU group.
Length of post-intervention follow-up: 6 months.

Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of multisystemic therapy with juvenile sexual offenders: Effects on youth social ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77(1), 26-37.

Type of Study: Randomized controlled trial
Number of participants: 48 families
Population:

Age Range: 14 years on average
Race/Ethnicity: 72.9% White, 27.1% Black, 2.1% HispanicStatus (e.g., foster care, CW) Youth referred to the study by juvenile court personnel.

Location/Institution: Midwestern U.S.
Summary: (To include comparison groups, outcomes, measures, notable limitations) Youth were included in the study if the reason for their arrest included a serious sexual offense and if they had subsequently been referred for sexual offender counseling. Participants were randomly assigned to receive MST or usual community services (UCS). Measures of individual adjustment include the Global Severity Index of the Brief Symptom Inventory and the Revised Behavior Problem Checklist. Family relations were assessed with the Family Adaptability and Cohesion Scale (FACES-II) and peer relations with the Missouri Peer Relations Inventory. Researchers also measured self-report of delinquent behavior and arrests and incarcerations. Improvement was shown for the MST group in individual adjustment, family and peer relations, with comparable decreases over time for the comparison group. MST recipients also have 84% fewer arrests for sexual crimes and 70% fewer arrests of other crimes. Limitations include lack of randomization of therapists to treatments and lack of data about possible crimes committed in other states.
Length of post-intervention follow-up: 8.9 years on average (arrest and incarceration data only).

Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E., et al. (2009). Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23(1), 89-102.

Type of Study: Randomized controlled trial
Number of participants: 127 youth
Population:

Age Range: 11-17 years
Race/Ethnicity: 54% Black, 44% White, with 31% indicating some Hispanic ethnicity.
Status (e.g., foster care, CW):
Youth referred by the County State’s Attorney after being charged with a sexual offense.

Location/Institution: Not given.
Summary: (To include comparison groups, outcomes, measures, notable limitations) Youth recommended for sexual offender treatment were randomly assigned to receive either MST or treatment as usual (TAU), specific to juvenile sexual offenders. Outcome measures assessed problem sexual behavior using the Adolescent Sexual Behavior Inventory; substance abuse, using the Personal Experience Inventory; and delinquency, using the National Youth Survey’s self-report delinquency scale. Parents also reported mental health issues using the Child Behavior Checklist (CBCL) and out-of-home placements were monitored. Relative to the TAU group, those receiving MST showed reductions in sexual behavior problems, delinquency, externalizing behaviors on the CBCL, substance use, and out-of-home placements. Limitations include lack of long-term follow-up and lack of adequate validation for self-report measures of criminal sexual behaviors.
Length of post-intervention follow-up: 12 months post-recruitment.

Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic Therapy for antisocial behavior in children and adolescents (2nd ed.). New York: Guilford Press.