Des Moines 3.30.11 #3 Multi Systemic Family Therapy

8/7/2019 Des Moines 3.30.11 #3 Multi Systemic Family Therapy

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Multisystemic Family TherapyMultisystemic Family Therapy

Theory of Social EcologyTheory of Social Ecology

MultiMulti--determined nature of human behavior determined nature of human behavior

Ecological validityEcological validity

Reciprocal Nature of Human InteractionReciprocal Nature of Human Interaction

((Bonfenbrenner¶sBonfenbrenner¶s 1979)1979)



MultiMulti--determined nature of determined nature of

human behavior human behavior

FamilyFamily

Peer Peer

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 Delinquency

Within Systems & BetweenWithin Systems & Between

SystemsSystems Within systemsWithin systems

Lax parental supervisionLax parental supervision

Association with delinquent peers Association 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 f unctioning real worldUnderstand youth f unctioning real world

HomeHome

ClassroomClassroomCommunityCommunity

First hand sourcesFirst hand sources

Caregivers, siblings, teachers, coachesCaregivers, siblings, teachers, coaches



Reciprocal NatureReciprocal 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

ParentParent ± ± easier to do him/herself 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, socialUses family strengths: love of child, socialsupportsupport

Overcome stressors: parental substanceOvercome stressors: parental substanceabuse, stress, hopelessnessabuse, stress, hopelessness

Increase caregiver effectivenessIncrease caregiver effectiveness



ExampleExample

Help parents design effective interventionsHelp parents design effective interventions



Research on MST MechanismsResearch on MST Mechanisms

of Changeof Change

High therapist

adherence

MST

Improved family

Functioning &

Parental monitoring

Decreased

association with

delinquent peers

Decreased

delinquent

behavior

(Henggeler et al., 2009)



Therapist Attitude to FamiliesTherapist Attitude to Families

Don¶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)





Home Based ModelHome Based Model

24 hour, 7 day a week availability24 hour, 7 day a week availability



Training and SupervisionTraining and Supervision

5 day initial orientation5 day initial orientation

Majority of learningMajority of learning ± ± working with familiesworking with families

and supervision by onand supervision by on--site s

upervisor andsite supervisor andoff off--site consultantsite consultant

Weekly meeting with s

upervisor who

uses

Weekly meeting with s

upervisor who

usesa protocol for reviewing casesa protocol for reviewing cases

Weekly disc

ussion with cons

ultant

Weekly disc

ussion with cons

ultant



Referral

behavior Referral

behavior MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

Fit

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

Fit

Intermediary

Goals

Prioritize

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

Fit

Intermediary

Goals

Prioritize

Intervention

development

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

Fit

Intermediary

Goals

Prioritize

Intervention

development

Intervention

implementation

Do

MST Analytic

Process



Referral

behavior Referral

behavior

Desired

outcomes of

family

Overarching

goals

Fit

Intermediary

Goals

Prioritize

Intervention

development

Intervention

implementation

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: ProblemsFrequencyFrequency

IntensityIntensity

DurationDurationImpactImpact

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

Tr uancy 2 ± 3 times a week Skips entireday Started lastschool year (12

mos. ago)

Aggression ±

fights with peers

Two incidents Client had

stitches, black

eye

Incidents were 3

and 8 mos. Ago

Father-sonconflict ± both are

verbally

aggressive

1 ± 2 times a week Both scream,youth uses

r ude language;

lasts 1 ± 2

minutes

(Henggler, 2009)



Desired OutcomesDesired Outcomes

Participant Goal

Rick Get off probation

Get dad to stop nagging

Ricardo (father) Rick go to schoolRick get a job

Rick make him proud

Mia Rick do good

Rick stop getting in trouble

Rick stop fighting

Jose (Uncle) Rick stay away from bad kidsRick stop smoking dope

Probation officer Rick stay in school

Rick stop using dr ugs

Rick stop fighting

(Henggler, 2009)



System Strengths & WeaknessesSystem Strengths & Weaknesses

Systemic Strengths Systemic Weaknesses

Individual:

Athletic ± likes baseball

Social ± leader

Wants a job

Impulsive

Verbally & physically aggressive

Failing classes

Thinks can¶t stop mariju

anaFamily:

Father committed to son

Sister well-behaved

Uncle supportive

Father authoritarian

Father & son high conflict

Father history of arrest

Mother dr ug use

Mother goneSchool:

Willing to work with teen as long as he

tries to improve

Has a baseball team

PE teacher/coach interested

Negative peers are at school

Low supervision in free time

School negative to family

Teen may not be sports eligible

School not in contact with father



System Strengths & WeaknessesSystem Strengths & Weaknesses

Systemic Strengths Systemic Weaknesses

Peers:

Positive friends 2 years ago still go to

school

One friend has job

Cousin

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 skip

Most friends use marijuana & alcohol

2 friends in fights

Community:

Recreation center in neighborhood

Little sister goes to churchLady next door potential support for father

High crime neighborhood

High unemploymentMany youth on street corner



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 goalsTherapist lists barriers to intermediary goalsexperienced in last weekexperienced in last week

4)4) Explains advances on gains in last weekExplains advances on gains in last week

5)5) Revise ³fit´ with new infoRevise ³fit´ with new info

6)6) Therapist states new intermediary goalsTherapist states new intermediary goals

(Henggeler, 2009)(Henggeler, 2009)



Weekly ReviewWeekly Review

Overarching GoalsOverarching Goals

SchoolSchool -- No unexcused absencesNo unexcused absences

No disr uptive behavior No disr uptive behavior Passing gradesPassing grades

MarijuanaMarijuana ± ± StopStop

No fightingNo fightingFather and sonFather and son ± ± reduced conflictreduced conflict




Previous Intermediary GoalsPrevious Intermediary Goals

Met Partially No

Therapist & father attend IEP meeting

Strategize approaching teachers

Develop school report card for teachers

All teachers agree to complete card

Set another meeting

Met

Met

Met

Met

Partial

Father to collect urine for dr ug 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 disrespectf ul 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 conflictresolution

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

oneunsupervised Father thinking

teen trying to

make him mad ±

felt hopeless

Father¶s anger

makes teen feel

he¶s winning

Father uses

intolerant

tone; teen

disrespectf ul

Reassessment of Fit

between Problems &

Intermediary Goals



Marijuana Use

Fit Circles

Insufficientstr ucture ±

too much

down time

Poor impulse

control

Mom¶s dr ug

history ± dr ugs

normalized

Dr ug-using

peers

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 card

See if teachers comply with plan

See if father able to follow through with conseq

uences

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 conflict

Ask father/son why not follow through on conflict plan

Shift roles in role playThought replacement when father discouraged

Pizza for family to facilitate engagement

Therapist to collect random urine dr ug 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 onWeekly on--site supervisionsite supervision

Weekly consultationWeekly consultation



Engaging MultiEngaging Multi--problem Familiesproblem Families

EmpathyEmpathy

Spending nonclinical time with familySpending nonclinical time with family

Cognitive assistsCognitive assistsFather as childFather as child

WarmthWarmth

FlexibilityFlexibility ReframingReframing



ReframingReframing

1) Echo family¶s point of view1) Echo family¶s point of view³I know you think your baby is crying³I know you think your baby is crying

because she knows you had a bad daybecause she knows you had a bad day

and she¶s just trying to upset you.´and she¶s just trying to upset you.´

2) Offer an alternative2) Offer an alternative

³Lots of babies get gas sometimes.³Lots 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 f ussy right after they eat.´babies are f ussy right after they eat.´

3) Check to see family¶s response.3) Check to see family¶s response.

³Do you think that might be part of ³Do you think that might be part of

what¶s oin on?´what¶s oin on?´



Nonclinical StrategiesNonclinical Strategies

Family PhotosFamily Photos

FoodFood

Helping with practical needsHelping with practical needs

5 minute sessions5 minute sessions



Dimensions of Family RelationsDimensions of Family Relations

WarmthWarmth

ControlControl



Parenting StyleParenting Style

WarmthWarmth ControlControl

Authoritative Authoritative HighHigh HighHigh

Authoritarian Authoritarian LowLow HighHigh

PermissivePermissive HighHigh LowLow

Neglectf ulNeglectf ul LowLow LowLow



AuthoritativeAuthoritative

Responsive to reasonable needsResponsive to reasonable needs

Maturity demands appropriate to developmentMaturity demands appropriate to development

Clear expectationsClear expectations ± ± school performanceschool performance



AuthoritarianAuthoritarian

Directive and over Directive and over--controllingcontrolling

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



PermissivePermissive

Little str ucture and disciplineLittle str ucture and discipline

Few demands for mature behavior Few demands for mature behavior

Tolerate antisocial behavior Tolerate 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 needs Are not responsive to child¶s needs

Do not expect responsible behavior Do not expect responsible behavior



Outcome StudiesOutcome Studies

Study Population Comparison Follow

-Up

MST Outcomes

Henggeler

et al., 1986

N = 57

Delinquents Diversion

Services

Post-tx Family relations

Behavior problems

Association with delinq. peers

Br unk et al.,1987

N = 33

MaltreatingFamilies

BehavioralParent

Training

Post-tx Parent-child relations

Henggeler

et al., 1991

Serious

juvenile

offenders

Individual

counseling;

community

services

3 yrs Alcohol and dr ug use

Dr ug-related arrests

Henggeler

et al., 1992

N = 84

Violent &

chronic

juvenile

offenders

Community

services

59

weeks

Family relations

Peer relations

Recidivism (43%)

Out of home placement (64%)



Outcome StudiesOutcome Studies -- RecentRecent

Study Population Comparison Follow-

Up

MST Outcomes

Stambaugh

et al., 2007

N = 267

Serious

emotional

disturbance

Wraparound 18 mo. Symptoms

Out-of-home

placement (54%)

Henggeler

et al., 2006N = 161

Substance

abusingteens in dr ug

court

4 Tx

conditionsincluding

family court

with usual

services

12 mo.

Postentry

Substance abuse

Timmons-

Mitchell etal., (2006)

N = 93

Juvenile

offenders atimminent risk

of placement

Usual

communityservices

18 mo. Youth f unction

Substance useRearrests (37%)

Rowland et

al., 2007

N = 31

Serious

emotional

disturbance

Hawaii¶s

intensive

Continuum

of Care

6 mo.

Post

entry

Symptoms

Minor crimes

Days out of home

(68%)



Outcome StudiesOutcome Studies-- Sexual OffendersSexual Offenders


Up

MST Outcomes

Borduin

et al.

1990

N = 16

Adolescent

sex

offenders

Individual

counseling

3 yrs Sexual offending

Other criminal offending

Borduin &

Schaeffer

(2001) N

= 48

Prelim

Adolescent

sex

offenders

Usual

community

services

9 yrs Behavior problems & symptoms

Family relations

Peer relations

Academic performance

Borduin &

Schaeffer,

in press

Full

Caregiver distress

Recidivism for sex crimes (83%)

Recidivism for other crimes

(50%)

Days incarcerated (80%)



Outcome StudiesOutcome Studies ± ± Sex OffendersSex Offenders


Up

MST Outcomes

Letournea

u 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 Studied

SymptomsSymptoms

RearrestsRearrests

Substance abuseSubstance abuse

OutOut--of of--home placementshome placements

Sexual behavior problemsSexual behavior problems

Externalizing symptomsExternalizing symptoms

Sexual crime recidivismSexual crime recidivism




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 costs

Attempted suicide Attempted suicide

Violent crimeViolent crime Association with delinquent peers Association with delinquent peers

SsychiatricSsychiatric symptomatologysymptomatology





33 Showed Increases:33 Showed Increases:


Improved family relationsImproved family relationsImproved parentImproved parent--child interactionschild interactions

Improved peer relationsImproved peer relations

Increased school attendanceIncreased school attendanceHigher consumer satisfactionHigher consumer satisfaction

Improved academic performanceImproved academic performance

Increased social competenceIncreased social competence




33 Showed Increases:33 Showed Increases:


Blood glucose testingBlood glucose testing

Metabolic controlMetabolic control

Youth f unctioningYouth f unctioning



1 Study1 Study

((SundellSundell et al., 2008)et al., 2008)

Compared to child welfare services inCompared to child welfare services in

SwedenSweden

No outcomes favoring either No outcomes favoring either txtx

Low treatment fidelityLow treatment fidelity

Des Moines 3.30.11 #3 Multi Systemic Family Therapy

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