Multisystemic Therapy - SAGE Journals - Sage Publications

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The College of New Jersey. Multisystemic Therapy (MST) is a well-validated, evidenced-based treatment for serious clinical problems presented by adolescents.



Multisystemic Therapy: An Empirically Supported, Home-Based Family Therapy Approach Ashli J. Sheidow Medical University of South Carolina Mark S. Woodford The College of New Jersey

Multisystemic Therapy (MST) is a well-validated, evidenced-based treatment for serious clinical problems presented by adolescents and their families. Across randomized clinical trials, MST has been effective in reducing out-of-home placements, delinquent behavior, substance use, and psychiatric symptomatology compared to services currently available in the community. This article is an introduction to the MST approach and outlines key clinical features, describes the theoretical underpinnings, and discusses the empirical support for MST’s effectiveness with a variety of serious clinical issues. Keywords: home-based; family therapy; multisystemic; empirically supported


n the current state of mental health services, treatment providers are increasingly being asked to be accountable for their work (Sexton, Whiston, Bleuer, & Walz, 1997). In a climate of accountability, treatment approaches with compelling empirical support are of high value, as funding agencies and other administrative and governing bodies are expecting to see results from their investments. Likewise, family counselors working with children and adolescents with serious emotional and behavioral problems are not immune to this climate of accountability. Fortunately, a body of process and outcome research has been developed over the last decade highlighting familybased approaches (Alexander, Robbins, & Sexton, 2000). One specific family-based approach that has focused on provider accountability is Multisystemic Therapy (MST). MST follows a family preservation model (Henggeler, Melton,

Authors’ Note: Preparation of this manuscript was supported by grants from the National Institute of Mental Health (MH51852 and MH59138). The authors thank Dr. Scott W. Henggeler for his comments on an earlier draft.

Smith, Schoenwald, & Hanley, 1993) and has strong empirical support for effective treatment of youth with serious problems who are at imminent risk of out-of-home placement (Borduin, 1999; Borduin et al., 1995; Kazdin & Weisz, 1998). The multisystemic treatment model was first introduced in the early 1980s as a “family-ecological systems approach” (Henggeler, 1982; cited in Henggeler & Borduin, 1990). MST has a clearly defined and empirically grounded treatment theory and has proven short- and long-term effectiveness through rigorous scientific evaluations. For example, by 1990, three controlled outcome studies using MST supported the efficacy of this approach (Henggeler et al., 1986; Henggeler & Borduin, 1990), and a text by Henggeler and Borduin (1990) aptly introduced MST to the field of family therapy. During the 1990s, a large body of empirical research developed as randomized clinical trials were conducted using MST with various clinical issues, and by 1998, a clinical treatment manual was published that fully described the MST approach (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998; see also Henggeler, Schoenwald, Rowland, & Cunningham, 2002). This article is intended to provide a brief introduction to MST for family counselors who are working with children and adolescents with serious emotional and behavioral problems and are not yet familiar with this empirically supported approach. The theoretical underpinnings of MST will be outlined as a backdrop for the key clinical features. In addition, the research base supporting MST’s effectiveness with a variety of clinical issues will be discussed. Readers are referred elsewhere (e.g., Chamberlain & Rosicky, 1995; Henggeler & Sheidow, 2002; Mihalic, Irwin, Elliott, Fagan, & Hansen, 2001; Sexton & Alexander, 2002) for comparisons of MST to other ecological, evidence-based treatment models for adolescent problems.

THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 11 No. 3, July 2003 DOI: 10.1177/1066480703251889 © 2003 Sage Publications





THEORETICAL UNDERPINNING AND CLINICAL FEATURES The phrase “family-ecological systems approach” that was first used as a descriptor for MST speaks to two of the primary theoretical underpinnings of this approach: (a) Bronfenbrenner’s (1979) social-ecological theory of behavior and (b) family systems theory. Both theoretical perspectives focus a practitioner’s attention on systemic thinking. Bronfenbrenner’s ecological model places the individual and an individual’s behavior patterns as being part of and shaped by larger systems of influence. These systems extend out from one’s family to include peer groups, school systems, and neighborhoods. Family systems theory, and systemic thinking in general, should not be conceptually unfamiliar to family counselors who have been trained from a family systems perspective, particularly if one works from such pragmatic approaches as strategic and structural family therapy. Therefore, at a base theoretical level, the systemic aspects of the MST approach may already “fit” with the perspectives of many practicing family counselors. This systemic perspective informs every aspect of assessment and treatment. MST clinicians evaluate all facets of a youth’s and family’s ecology (i.e., the various systems with which the youth and family interact). This effort aims to identify indigenous resources that can support and maintain treatment change. MST emphasizes the strengths of family members and the family’s ecology. Family members are viewed as full collaborators in the treatment process, with treatment goals set primarily by the family members. Services are individualized and comprehensive to meet the multiple, systemic needs of the youth and their families and are designed to empower caregivers and families rather than relying on therapists to bring about change. However, MST treatment teams (consisting of an MST supervisor and three to four MST therapists) clearly hold themselves accountable for achieving treatment outcomes, monitoring and problem-solving around barriers to achieving these outcomes. Through adequate resources and support, treatment teams maintain a positive, “can-do” mission, an indispensable attribute when treating challenging, multidetermined youth problems. MST employs a home-based model of service delivery that targets children and adolescents with serious clinical problems, primarily those who are at-risk for out-of-home placements. Services are intensive and are provided in the natural ecology of the family (i.e., in their home, school, and community vs. standard outpatient or inpatient treatment) and at a time that is convenient for the families, greatly decreasing barriers to service delivery. The intensity of treatment, the use of empirically valid techniques, and the close monitoring of progress result in services that are time-limited (average of about 4 months). Clinicians are available for the families on an on-call basis (24 hours per day, 7 days per week) and maintain low caseloads (four to six families per cli-

nician), enabling clinicians to effectively establish treatment alliance and monitor and produce goal achievement in a timely fashion. Clinicians provide evidence-based interventions within the MST framework. The following nine treatment principles guide the clinical interventions of MST therapists (Henggeler et al., 1998): 1. Finding the Fit. The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic context. 2. Positive and Strength Focused. Therapeutic contacts emphasize the positive and use systemic strengths as levers for change. 3. Increasing Responsibility. Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members. 4. Present-Focused, Action-Oriented, and Well-Defined. Interventions are present-focused and action-oriented, targeting specific and well-defined problems. 5. Targeting Sequences. Interventions target sequences of behavior within or between multiple systems that maintain the identified problems. 6. Developmentally Appropriate. Interventions are developmentally appropriate and fit the developmental needs of the youth. 7. Continuous Effort. Interventions are designed to require daily or weekly effort by family members. 8. Evaluation and Accountability. Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes. 9. Generalization. Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.

With the systemic perspective in mind, MST clinicians seek to target specific interventions, grounded in scientific evidence, that can be focused on addressing known risk factors and/or building protective factors within the systemic context (Henggeler et al., 1998), that is, “within and between the multiple systems in which family members are embedded” (Borduin, 1999, p. 242). This means targeting interventions for the individual child or adolescent and his or her family, peer group, school setting, and perhaps even neighborhood and community, if targeting that system would effect positive change in the identified problem behaviors (e.g., if marital conflict is impeding adequate parental monitoring, then marital therapy may be provided by the MST clinician). A case study will be used to illustrate the clinical features of the MST approach. CASE STUDY Consider the case of “Tommy,” a 12-year-old, Caucasian male from a lower- to middle-class family who was referred

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to an MST-based treatment program to prevent out of home placement. He had six previous hospitalizations for a variety of diagnoses from several psychiatrists ranging from bipolar disorder to conduct and oppositional defiant disorder. Tommy was enrolled in a special education classroom and had reached the limit in terms of absences from school for the year. He lived with his mother, grandparents, and older sister and had been hospitalized primarily for violent and aggressive behavior towards his family members. Tommy, his mother, and his sister moved in with his maternal grandparents after his father was killed by police in a gun battle. Within the family system, Tommy was seen as the “bad seed” that the family believed would soon be entering the juvenile justice system “if things didn’t change.” Physically, Tommy had grown to a size that posed a physical threat to his family. Prior to the last hospitalization, his grandfather was able to physically restrain Tommy when Tommy exhibited such behaviors as chasing his mother and sister with a knife and threatening to break furniture and other household items. However, his grandfather was growing increasingly distressed with this role and stated that he was “not going to be the warden anymore.” At the time of the referral to the MST treatment team, the police had not yet been called during Tommy’s violent episodes for fear that “he would only get worse” if he entered the juvenile court system and lived out the family designation of the “bad seed.” Outpatient individual and family therapy after the previous hospitalizations had not produced changes in Tommy’s behavior or prevented rehospitalization, and the family insurance policy would no longer pay for inpatient services. The family felt desperate and had lost hope that any form of “treatment” would help. They were on the brink of involving the police and the courts, despite their reservations with this matter. The outpatient family counselor who had worked with Tommy’s family made the referral for Multisystemic Therapy (MST). He was concerned that the family would not seek further assistance through the available outpatient communitybased services. Funding for the case was being provided through the local community services board. MST is delivered in a treatment team format. Thus, a clinician working within a team of three to four masters-level clinicians is assigned to each case. Advanced masters-level, or doctoral-level clinicians who have been trained to provide MST supervision (Henggeler & Schoenwald, 1998) closely supervise the team of clinicians. Adherence to this format helps to assure treatment fidelity and improve the chances for positive outcomes (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Henggeler, Pickrel, & Brondino, 1999; Schoenwald, Henggeler, Brondino, & Rowland, 2000). MST treatment adherence also helps to continue to build a clinical research base as case outcomes can be documented, furthering the role of accountability of the treatment team to the clients, their families, and the funding sources.

Following the nine treatment principles, an intervention with Tommy’s family began with an assessment in the home to identify both the problem areas and the strengths of the various systems within which Tommy and his family were embedded, such as the school system (speaking with Tommy’s special education teacher, school counselor, or principal), the neighborhood (spending time observing Tommy at the neighborhood park or recreation center), and evaluating community resources that might be helpful in treatment. The MST clinician looks for “levers” for change and areas for intervention within the multiple systems (Henggeler et al., 1998). In Tommy’s case, during the assessment process, several examples of positive levers and areas for change were discovered that could be incorporated into the treatment plan. For example, it was apparent that there were times when Tommy’s family had reinforced his staying home from school by giving him more attention (whether positive or negative) and by allowing him to stay in the family den watching movies “provided that he behaved himself.” At school, the MST clinician found out that Tommy had excelled in science and had in the past year worked harder to attend a field trip to the local science museum. Additionally, through a discussion with his mother about Tommy’s past positive behaviors, a possible community resource was discovered. At one time, Tommy was an avid swimmer. Yet the option of joining the local swim club had not been discussed within the family despite the fact that several years ago Tommy had expressed interest in joining the local swim team. It was assumed by the family that Tommy “would never be able to behave himself” at the swimming events. Systemic assessments and treatment plans are possible because MST services are delivered in the client’s context (home, school, and community). As connections are made with key players in the system, the groundwork is laid for developing present-focused, action-oriented, systemic interventions that are developmentally appropriate. To help implement the treatment plan, the MST clinicians remain available 24 hours per day, 7 days per week, for the family and, as stated in the nine treatment principles, target interventions that “promote responsible behavior and decrease irresponsible behavior among family members” (Henggeler & Borduin, 1990, p. 126). Even though there is an emphasis on increasing responsibility within the family, the MST treatment team accepts the responsibility for keeping the family engaged in treatment (Borduin, 1999), and therapists are taught to “never give up” on engaging a family. The treatment team meets for weekly supervision to review and evaluate cases from multiple perspectives to increase the probability for successful clinical outcomes. In addition, adherence to the MST model is routinely evaluated through caregiver, supervisor, and therapist report questionnaires, and an MST expert consultant provides direction to promote treatment fidelity and corresponding client outcomes (e.g., short- and long-term youth and family outcomes; see Henggeler et al., 1997; Henggeler, Pickrel



et al., 1999; Huey, Henggeler, Brondino, & Pickrel, 2000; Schoenwald, Henggeler, et al., 2000). In the present case, part of the MST therapist’s role in treatment was to empower Tommy’s mother to appropriately address the various ecological systems (family, school, and community) that were involved in Tommy’s life. Preparatory work (developing scripts, generating alternative scenarios, role-playing, etc.) prior to her contacts with the other key players in the intervention enabled Tommy’s mother to gain a level of confidence in her ability to be a lever for change within systems in which she had previously felt powerless. Following the MST treatment model, the treatment plan included a structural intervention at the family level by encouraging Tommy’s mother to take on more power within the system and to parent Tommy actively by setting limits more effectively (using behavioral parent training and assertiveness training). For example, even though Tommy’s grandparents wanted Tommy’s mother to be more assertive as a parent, in the past they had intervened when things appeared to be “getting out of hand,” which undermined her power in the home. Through a family intervention, Tommy’s mother was able to thank her parents for their continued support and to explain to them that she was taking steps to be more assertive and responsible for Tommy’s parenting—something that the grandparents had been asking her to do. After first role-playing such a meeting with the MST therapist, she was able to explain her difficult position to the grandparents, discuss the interventions that she would be implementing over the next few days and weeks, and ask for the grandparents’ emotional support, as they needed to present a united front in the home. In addition, Tommy’s mother met with the special education teacher and engaged him in the treatment plan. Through discussions between Tommy’s mother, his teacher, and the MST therapist, a behavioral plan was developed and implemented that included a contingency plan and reward system for Tommy’s good behavior. Using a point system that rewarded good attendance and appropriate behavior, Tommy was able to gain points and attend an upcoming class fieldtrip to the Smithsonian. In addition, if Tommy’s behavior and attendance continued to improve (including good behavior on the fieldtrip), then he would be rewarded by being allowed to join the local swim club in the summer. The MST therapist and Tommy’s mother also worked with his school counselor and discussed the treatment plan that was being implemented. The school counselor was able to help Tommy to find a mentor within the school system who could serve as a role model for appropriate social behavior at school. Through these endeavors, Tommy saw a visible united front at each level of his ecological system. A key intervention occurred in the home as the MST treatment team helped Tommy’s mother “lay down the law” in terms of his attendance at school. Tommy, his mother, and the MST therapist jointly discussed the expectations and consequences concerning Tommy’s school attendance. When

Tommy next refused to get ready for school, an MST clinician arrived at the family’s home at 7:00 a.m. to reinforce the mother’s stance as she systematically bagged up all of Tommy’s toys, CDs, radio, and so on. She put all of his belongings in small bags and placed them in a locked shed in the back yard. Tommy was told that he could retrieve his belongings over time —one bag per day for each day that he attended school. He was not allowed out of his empty room during school hours if he refused to attend school. His room essentially became a bare cell with a bed for him to stay in during school hours. Tommy rebelled for two days, but his mother and the entire family (and schoolteacher and administrators) knew about and supported the intervention. Once Tommy began attending school, his mother and teacher explained the point system to him, and he learned relatively quickly that his appropriate behavior resulted in positive consequences. There were minor setbacks during the weeks that followed the key intervention described above. For example, Tommy verbally assaulted his mother in front of his grandfather, and his grandfather responded with the previous pattern of acting as the primary caregiver. This challenged the recent structural shift of Tommy’s mother providing the primary parenting role and subsequent disciplinary actions. The argument between Tommy and his grandfather escalated into a crisis situation, whereby the grandfather chased Tommy out of the home and poured a bucket of water on him. Tommy fled the house and hid in a nearby wooded area until police found him and brought him home. The MST treatment team met with the family and determined the sequence of actions that led up to the power struggle. After role-plays with Tommy’s mother, she was able to confront her father about her needs as Tommy’s primary caregiver and to establish appropriate disciplinary action as a natural consequence of Tommy’s acting out behavior. A contingency plan was also established and outlined by Tommy’s mother to prevent similar situations from escalating into crises again. The MST treatment team concluded services at 6 months following a reduction in acting out behaviors in the home and a pattern of regular attendance at school. At the termination of MST services, outpatient family therapy was resumed with initial consultation from the MST treatment team to serve as a follow-up and maintenance of treatment goals. At the oneyear follow-up, Tommy had advanced a grade in school, and Tommy’s mother had moved her family into a separate residence. To date, Tommy has had no involvement with the legal system. CLINICAL OUTCOMES A hallmark of MST is its theoretical underpinnings. The origins of MST as a treatment developed through empirically grounded theory have continued through rigorous scientific

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reviewed programs that aim to reduce evaluations of treatment outcome. Rancrime (Aos, Phipps, Barnoski, & Lieb, domized clinical trials have supported the 2001). They placed the highest level of efficacy of MST as a treatment for youth confidence in the findings of MST studies, who are at imminent risk for out-of-home Although the noting that some studies had been carried placement (e.g., incarceration, residential out by researchers other than the developtreatment, or psychiatric hospitalization). implementation of ers and denoting some studies as “real Unlike many treatment studies, MST studworld” based on study design. This group ies have typically been completed in field MST may appear concluded that, at an average cost of settings and maintained few exclusion cri$5,000 per family, MST had an average teria, strengthening support for treatment difficult to some effect size of -.31 and produced more than effectiveness. Reviewers in the areas of $30,000 in system savings per youth. This juvenile justice (e.g., Elliott, 1998; practitioners and figure reached well over $100,000 when Farrington & Welsh, 1999; Tate, Reppucci, costs to crime victims were included in the & Mulvey, 1995; U.S. Public Health Seradministrators, it formula. Research on MST continues, with vice, 2001), substance abuse (e.g., Center approximately 12 randomized trials of for Substance Abuse Prevention, 2001; has proven to be a MST currently in progress in North AmerMcBride, VanderWaal, Terry, & VanBuren, ica and Europe, several of which are large 1999; National Institute on Drug Abuse, highly effective multisite studies. 1999; Stanton & Shadish, 1997), and children’s mental health (e.g., Burns, approach for Hoagwood, & Mrazek, 1999; Kazdin & CONCLUSIONS Weisz, 1998; U.S. Department of Health achieving positive MST has proven to be a less expensive and Human Services [Surgeon General’s and more effective alternative for youth Office], 1999) have noted the promise of youth outcomes. with serious clinical problems at imminent MST or described the model as an exemr i s k f or out - of - hom e p l a c e m e n t plary practice. (Henggeler et al., 1998; Henggeler et al., Published MST outcome studies have 2002). This is especially compelling given included trials with inner-city delinquents the high cost for out-of-home placements such as psychiatric (Henggeler et al., 1986), violent and chronic juvenile offendhospitalization and juvenile incarceration and in light of the ers (Borduin et al., 1995; Henggeler et al., 1993; Henggeler et increased rates of recidivism for some youth alternatives al., 1997; Henggeler, Melton, & Smith, 1992), substance (e.g., juvenile boot camps, “scared straight” programs) comabusing or dependent juvenile offenders with high rates of pared to services as usual (Aos et al., 2001). These main psychiatric comorbidity (Brown, Henggeler, Schoenwald, gauges of accountability are increasingly important for youth Brondino, & Pickrel, 1999; Henggeler, Pickrel, et al., 1999; services. Schoenwald, Ward, Henggeler, Pickrel, & Patel, 1996), As a treatment with strong empirical support, MST has youths presenting psychiatric emergencies (i.e., suicidal, met stringent criteria for effectiveness, including obtaining homicidal, psychotic; Henggeler, Rowland, et al., 1999; positive outcome compared to services as usual in randomSchoenwald, Ward, Henggeler, & Rowland, 2000), maltreatized controlled trials, having empirical support from multiple ing families (Brunk, Henggeler, & Whelan, 1987), and juvestudies and studies conducted in “real world” settings, and nile sexual offenders (Borduin, Henggeler, Blaske, & Stein, being well specified through treatment manuals so that others 1990). Recent studies have achieved 97% to 98% rates of can replicate the treatment methods. MST has rigorous scientreatment completion. Clinically, outcomes have been consistific evidence supporting its usefulness for treating severe tently in favor of MST compared to control groups and problems in youth (Kazdin & Weisz, 1998). include improved family relations and functioning, increased MST treatment is guided by nine core principles, some of school attendance, decreased adolescent psychiatric sympwhich are common to other treatment approaches in counseltoms, decreased adolescent substance use, and decreased ing. Clinicians using MST maintain an ecological conceptulong-term rates of re-arrest. As an example, when compared alization of cases and plan treatment to effect change systemito control groups, reductions in rates of re-arrest have ranged cally. Treatment emphasizes caregivers as the key to from 25% to 70% across studies. successful change rather than relying on individual treatment Re-arrest rates, as well as out-of-home placement rates, with the youth. MST clinicians also maintain a continuous are crucial indicators for providers. In comparison to control focus on clearly defined treatment outcome goals throughout groups, MST has produced decreased rates of days in out-oftreatment and integrate evidence-based interventions within home placement ranging from 47% to 64%. Outside researchers at the Washington State Institute on Public Policy the MST framework.



The MST approach also has a primary aim of removing barriers to service access, including utilizing a home-based model of service delivery and providing clinicians with resources (e.g., thorough training, low caseloads, supervisory and peer support, outcome-based discharge criteria, etc.) that allow them to successfully engage and maintain families in treatment. The approach also places accountability for engagement and successful treatment outcome on the treatment provider and utilizes a quality assurance system to support treatment fidelity and corresponding outcomes. Although the implementation of MST may appear difficult to some practitioners and administrators, it has proven to be a highly effective approach for achieving positive youth outcomes. Indeed, licensed MST programs are currently operating in 27 states and 7 nations. With clearly specified treatment (Henggeler et al., 1998; Henggeler et al., 2002) and supervision (Henggeler & Schoenwald, 1998) manuals, MST is an effective approach that can be successfully replicated in community settings.

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Ashli J. Sheidow is an assistant professor in the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina. Her research interests focus on the development, prevention, and treatment of adolescent psychopathology and juvenile delinquency from an ecological perspective, with a concentration in quantitative methods. Mark S. Woodford is an assistant professor of counselor education at The College of New Jersey. His research interests are in the fields of substance abuse and family counseling.

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