Multisystemic Family Therapy
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- Abigail Stanley
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1 Multisystemic Family Therapy
2 New Generations of Family Therapy 1) Not just family: wider systems 2) Emphases family strengths 3) Pays attention to research 4) Tracks outcome
3 n Help parents design effective interventions
4 Main Agent of Change Caregivers Example: Uses family strengths: love of child, social support Overcome stressors: parental substance abuse, stress, hopelessness Increase caregiver effectiveness
5 Genogram Father s parents live in Puerto Rico and write but do not visit Ricardo & brother Jose emigrated 5 years ago 38 Jose F Ricardo History of arrest 36 M Mia 16 Rick ADHD
6 Assessment n Background Information Form Genogram Reasons for referral: Problems Frequency Intensity Duration Impact n Meets with stakeholders: Family, teachers, probation officers, etc.
7 Assessment Strengths & Needs Assessment In each system: family, school, etc
8 Research on MST Mechanisms of Change High therapist adherence MST (Henggeler et al., 2009)
9 Research on MST Mechanisms of Change Improved family Functioning & Parental monitoring High therapist adherence MST (Henggeler et al., 2009)
10 Research on MST Mechanisms of Change Improved family Functioning & Parental monitoring High therapist adherence MST Decreased association with delinquent peers (Henggeler et al., 2009)
11 MST Mechanisms of Change Improved family Functioning & Parental monitoring High therapist adherence MST Decreased association with delinquent peers Decreased delinquent behavior (Henggeler et al., 2009)
12 Referral behavior MST Analytic Process
13 Referral Behaviors Behavior Frequency Intensity Duration Marijuana Use 3 4 times a week 1 2 blunts shared with 2 peers Truancy 2 3 times a week Skips entire day Aggression fights with peers Father-son conflict both are verbally aggressive Two incidents Client had stitches, black eye 1 2 times a week Both scream, youth uses rude language; lasts 1 2 minutes Approx. 16 months Started last school year (12 mos. ago) Incidents were 3 and 8 mos. Ago (Henggler, 2009)
14 Referral behavior Desired outcomes of family MST Analytic Process
15 Desired Outcomes Participant Rick Goal Get off probation Get dad to stop nagging Ricardo (father) Mia Jose (Uncle) Probation officer Rick go to school Rick get a job Rick make him proud Rick do good Rick stop getting in trouble Rick stop fighting Rick stay away from bad kids Rick stop smoking dope Rick stay in school Rick stop using drugs Rick stop fighting (Henggler, 2009)
16 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals
17 Overarching Goals School - No unexcused absences No disruptive behavior Passing grades Marijuana Stop No fighting Father and son reduced conflict (Henggeler, 2009)
18 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Fit
19 Fit Circles Marijuana Use
20 Fit Circles Poor impulse control Marijuana Use
21 Fit Circles Poor impulse control Marijuana Use Mom s drug history drugs normalized
22 Fit Circles Poor impulse control Marijuana Use Mom s drug history drugs normalized Family conflict
23 Fit Circles Poor impulse control Marijuana Use Mom s drug history drugs normalized Family conflict Poor parental supervision
24 Fit Circles Poor impulse control Marijuana Use Mom s drug history drugs normalized Drug-using peers Family conflict Poor parental supervision
25 Fit Circles Insufficient structure too much down time Poor impulse control Marijuana Use Mom s drug history drugs normalized Drug-using peers Poor parental supervision Family conflict
26 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Fit Prioritize Intermediary Goals
27 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Fit Prioritize Intermediary Goals Intervention development
28 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Fit Prioritize Intermediary Goals
29 Intermediary Goals Therapist & father attend IEP meeting Strategize approaching teachers Develop school report card for teachers All teachers agree to complete card Set another meeting Father to collect urine for drug screen Father and teen to try three strategies when conflict arises Cousin J to take teen to job interview Review peer sheet with father
30 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Fit Prioritize Intermediary Goals Intervention implementation Do Intervention development
31 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Re-evaluate Assessment Fit Prioritize Intermediary Goals Measure Intervention implementation Do Intervention development
32 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Re-evaluate Assessment Fit Prioritize Intermediary Goals Measure Intervention implementation Do Intervention development
33 Weekly Review n Overarching Goals School - No unexcused absences No disruptive behavior Passing grades Marijuana Stop No fighting Father and son reduced conflict (Henggeler, 2009)
34 Weekly Review 1) Therapist describes overarching goals 2) Therapist lists previous intermediary goals & whether met in last week 3) Therapist lists barriers to intermediary goals experienced in last week 4) Explains advances on gains in last week 5) Revise fit with new info 6) Therapist states new intermediary goals (Henggeler, 2009)
35 Previous Intermediary Goals Therapist & father attend IEP meeting Strategize approaching teachers Develop school report card for teachers All teachers agree to complete card Set another meeting Father to collect urine for drug screen Father and teen to try three strategies when conflict arises Cousin J to take teen to job interview Review peer sheet with father Met Partially No Met Met Met Met Partial Partial Partial Not Not
36 Barriers 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
37 Advances 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
38 Reassessment of Fit between Problems & Intermediary Goals
39 Teen left school early 2 x Reassessment of Fit between Problems & Intermediary Goals
40 Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Teen left school early 2 x
41 Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Teen left school early 2 x Left with 2 peers went to house of one unsupervised
42 Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised
43 Teen: Why should I try? I m going to fail anyway. Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised
44 Teen: Why should I try? I m going to fail anyway. Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised Unable to use conflict resolution plan
45 Teen: Why should I try? I m going to fail anyway. Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised Father thinking teen trying to make him mad felt hopeless Unable to use conflict resolution plan
46 Teen: Why should I try? I m going to fail anyway. Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised Father thinking teen trying to make him mad felt hopeless Unable to use conflict resolution plan Father s anger makes teen feel he s winning
47 Teen: Why should I try? I m going to fail anyway. Behavior plan for home/school link not in place no consequences Reassessment of Fit between Problems & Intermediary Goals Left after PE, before English easy to escape Teen left school early 2 x Left with 2 peers went to house of one unsupervised Father thinking teen trying to make him mad felt hopeless Father uses intolerant tone; teen disrespectful Unable to use conflict resolution plan Father s anger makes teen feel he s winning
48 Referral behavior Desired outcomes of family MST Analytic Process Overarching goals Re-evaluate Assessment Fit Prioritize Intermediary Goals Measure Intervention implementation Do Intervention development
49 New 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 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 conflict Ask father/son why not follow through on conflict plan Shift roles in role play Thought replacement when father discouraged Pizza for family to facilitate engagement Therapist to collect random urine drug screen this week (Henggeler, 2009)
50 Clinical Implications n Address caregiver functioning n Empower families to address teen problems n Must deal with delinquent peer issue n Improve school or vocational performance n Develop indigenous support system (Henggeler et al., 2009)
51 Prime Features n Never give up on families n Failed interventions are team s responsibility
52 Engaging Multi-problem Families n Empathy n Spending nonclinical time with family n Cognitive assists Father as child n Warmth n Flexibility n Reframing
53 Therapist Attitude to Families Don t n Blame families n Ignore families n Label families n Give up on families (Henggeler et al., 2009)
54 Reframing 1) Echo family s point of view I know you think your baby is crying because she knows you had a bad day and she s just trying to upset you. 2) Offer an alternative Lots of babies get gas sometimes. I ve heard a lot of moms say their babies are fussy right after they eat. 3) Check to see family s response. Do you think that might be part of what s going on?
55 Nonclinical Strategies n Family Photos n Food n Helping with practical needs n 5 minute sessions
56 Dimensions of Family Relations n Warmth n Control
57 Parenting Style Warmth Control n Authoritative High High n Authoritarian Low High n Permissive High Low n Neglectful Low Low
58 Authoritative n Responsive to reasonable needs n Maturity demands appropriate to development n Clear expectations school performance
59 Authoritarian n Directive and over-controlling n Require unquestioning obedience n Severe punishment, sometimes physical n Directive teaching style n No child participation in decisions
60 Permissive n Little structure and discipline n Few demands for mature behavior n Tolerate antisocial behavior n Warm and responsive, but not demanding
61 Neglectful n Little discipline or affection n Little concern or interest in parenting n Are not responsive to child s needs n Do not expect responsible behavior
62 Therapist Attitude to Families Don t n Blame families n Ignore families n Label families n Give up on families (Henggeler et al., 2009)
63 Outcome Studies Study Henggeler et al., 1986 N = 57 Brunk et al., 1987 N = 33 Henggeler et al., 1991 Henggeler et al., 1992 N = 84 Population Comparison Follow -Up Delinquents Maltreating Families Serious juvenile offenders Violent & chronic juvenile offenders Diversion Services Behavioral Parent Training Individual counseling; community services Community services Post-tx Post-tx MST Outcomes Family relations Behavior problems Association with delinq. peers Parent-child relations 3 yrs Alcohol and drug use Drug-related arrests 59 weeks Family relations Peer relations Recidivism (43%) Out of home placement (64%)
64 Outcome Studies - Recent Study Population Comparison Follow- Up Stambaugh et al., 2007 N = 267 Henggeler et al., 2006 N = 161 Timmons- Mitchell et al., (2006) N = 93 Rowland et al., 2007 N = 31 Serious emotional disturbance Substance abusing teens in drug court Juvenile offenders at imminent risk of placement Serious emotional disturbance MST Outcomes Wraparound 18 mo. Symptoms Out-of-home placement (54%) 4 Tx conditions including family court with usual services Usual community services Hawaii s intensive Continuum of Care 12 mo. Post entry Substance abuse 18 mo. Youth function Substance use Rearrests (37%) 6 mo. Post entry Symptoms Minor crimes Days out of home (68%)
65 Outcome Studies- Sexual Offenders Study Population Comparison Follow- Up MST Outcomes Borduin et al 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%)
66 Outcome Studies Sex Offenders Study Letournea u et al., in press Population Comparison Follow- Up Juvenile sex offenders Usual sexoffender specific tx 12 mos post-tx MST Outcomes Sexual behavior problems Delinquency, substance abuse & externalizing symptoms Out-of-home placements
67 34 Studies of MST 33 Showed Decreases: n Symptoms n Rearrests Factors Studied n Substance abuse n Out-of-home placements n Sexual behavior problems n Externalizing symptoms n Sexual crime recidivism (Henggeler, 2009)
68 34 Studies of MST 33 Showed Decreases Factors Studied: n Inpatient admissions n Medical charges & direct care costs n Attempted suicide n Violent crime n Association with delinquent peers n Ssychiatric symptomatology (Henggeler, 2009)
69 34 Studies of MST 33 Showed Increases: Factors Studied: n Improved family relations n Improved parent-child interactions n Improved peer relations n Increased school attendance n Higher consumer satisfaction n Improved academic performance n Increased social competence
70 34 Studies of MST 33 Showed Increases: Factors Studied: n Blood glucose testing n Metabolic control n Youth functioning
71 1 Study (Sundell et al., 2008) Compared to child welfare services in Sweden No outcomes favoring either tx Low treatment fidelity
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