Multi-Systemic Therapy by wuyunqing


									Young People at risk of developing ASPD:
 the use of multi-systemic therapy as an
   early intervention within the family

                       Dr Simone Fox
          Chartered Clinical & Forensic Psychologist
            MST Supervisor Merton & Kingston

                      Dr Juliette Wait
               Chartered Clinical Psychologist
                 MST Supervisor Reading

                        PD Congress
                    19th November 2009
          Aims of Presentation
   To think about Personality Disorder from
    an adolescent perspective
   To develop an understanding of the risk
    factors in the development of antisocial PD
   An overview of MST and how it addresses
    these risk factors
               Group Exercise
   In pairs identify one risk and one
    protective factors for the onset of
    behavioural problems in adolescence;
       Individual
       Family
       School
       Peer group
       Community
   Feedback on flipchart
                         Risk & Protective Factors
Context      Risk Factors                                                   Protective Factors
Individual      Low verbal skills                                             Intelligence
                Favourable attitudes towards ASB                              Being first born
                Psychiatric symptomatology                                    Easy temperament
                Cognitive bias to attribute hostile intentions to others      Conventional attitudes
                                                                               Problem-solving skills

Family          Lack of monitoring                                            Attachment to parents
                Ineffective discipline                                        Supportive family environment
                Harsh and inconsistent discipline                             Marital harmony
                Low warmth
                High conflict
                Parental difficulties e.g. drug abuse, psychiatric
                 conditions, criminality

Peer            Association with deviant peers                                Bonding with pro-social peers
                Poor relationship skills
                Low association with pro-social peers

School          Low achievement                                               Commitment to schooling
                Dropout                                                       Good school-home links
                Low commitment to education                                   Good relationship with teacher(s)
                Aspects of school – e.g. weak structure & chaotic

Community       High mobility                                                 Ongoing involvement in community activities
                Low community support                                         Strong indigenous support network
                High disorganisation
                Criminal subculture
    Delinquency is a Complex Behaviour

   Common findings of 50+ years of
    research: delinquency and drug use are
    determined by multiple risk factors:
       Family (low monitoring, high conflict, etc.)
       Peer group (law-breaking peers, etc.)
       School (dropout, low achievement, etc.)
       Community ( supports,  transiency, etc.)
       Individual (low verbal and social skills, etc.)
Causal Models of Delinquency and
           Drug Use
Condensed Longitudinal Model
                                  Prior Delinquent
      Family                          Behavior
   Low Parental Monitoring
   Low Affection
   High Conflict
                             Delinquent             Delinquent
                               Peers                 Behavior


   Low School Involvement
   Poor Academic Performance          Elliott, Huizinga & Ageton
       Theoretical Assumptions
Based on Bronfenbrenner, Haley and Minuchin
    Children and adolescents live in a social
     ecology of interconnected systems that impact
     their behaviors in direct and indirect ways
    These influences act in both directions
     (they are reciprocal and bi-directional)
Ecological Model

      Implications for Effective
    The research on delinquency and substance
    use suggests that, to be most effective,
    services should be:
   Comprehensive and have the capacity to
    address all of the relevant risk factors present
    for each youth and family
   Individualised to the strengths and needs of
    each youth and family
   Delivered in the naturally occurring systems
    and be implemented in “ecologically valid”
               What is MST?
 Intensive, goal oriented and time limited
 Community-based, family-driven

 Targets the multiple causes of anti-social and
  criminal behaviour in young people
 Highly structured clinical supervision and quality
  assurance processes
 Strong track record of client engagement,
  retention and satisfaction
    Who is the target population for MST?
   Family and key participants in the environment of young
   MST “client” is the entire ecology of the young person -
    family, peers, school, community
   Age range 11-17 years
   High risk of out-of-home placement
    eg. care, custody, residential school
   Placement risk due to their behaviour
    at home / school / in the community
   May be involved with the criminal justice system
                   What is MST?
   Focus is on families as the solution
   Focus on empowering the caregivers / parents to solve
    current and future problems
   Parents are full collaborators in planning and delivering
   Assumption - Children’s behaviour is strongly influenced
    by their families, friends and communities (and vice
   Works in partnership with a combination of systems
    (parents, family, peers, school and community) to
    address risk factors
               How does MST work?
   Assessing and understanding the factors contributing to
    identified problems
   Having clear goals to work towards
   Prioritising key factors and interventions
   Interventions based on techniques that have strong
    evidence base:
   Behaviour therapy
   Parent management training
   Cognitive behavior therapy
   Pragmatic family therapies
   Pharmacological interventions (e.g., for ADHD)

   Supporting the parent/carer in devising strategies to
    target factors contributing to the young person’s
    How is MST implemented?
 Single therapist works intensively with 4 families
  at a time
 Meetings at least 2-3 times a week

 Community and home based

 Out-of-hours service run by the team which is
  available to families 24 hours a day, 7 days a
 Team has 3-4 therapists and clinical supervisor

 Involvement typically ranges from 3 to 5 months
    How is MST implemented?
 Team provides the family with a single point of
 MST team deliver all treatment

 Typically no services are referred outside the
  MST team
 Never ending focus on engagement and
  alignment with the primary caregiver and other
  key stakeholders – addressing barriers
 MST team must be able to have a lead role in
  clinical decision making for each case
MST Quality Assurance System
 Team comprised of range of professionals
  – multi-disciplinary/multi-agency
 Structured training – orientation and regular
 Frequent professional development planning

 Weekly clinical supervision and case review

 Weekly consultation with consultant in USA

 Research validated adherence process – for
  therapists and supervisor
                 What’s different?

      Traditional models                           MST
       Individual (family)                 Ecological
       Clinic-based                        Home-based
       Fixed times                         Flexible/24 hour
       High caseloads –                    Low caseloads –
        less intensive                       3x weekly +
       Open-ended                          Fixed goal-driven
       Supervision                         Quality assurance
NB Not better, just different approach to address a different need
      Why does it need to be different?

   Multi-determined nature of serious antisocial
   Risk factors span the ecology in which the child
    is embedded
   Families with complex problems struggle to
    access traditional services
   High costs of antisocial behaviour –
    incarceration, placement, victimisation
   Therapist adherence predicts outcome
   Kazdin A. E., & Weisz, J. R. (1998). Identifying
    and developing empirically supported child and
    adolescent treatments. Journal of Consulting
    and Clinical Psychology, 66, 19-36.
   Henggeler, S. W., Schoenwald, S. K., Borduin,
    C. M., Rowland, M. D., & Cunningham, P. B.
    (2009). Multisystemic treatment of antisocial
    behaviour in children and adolescents – 2nd
    edition. New York: Guildford Press.

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