COMMENTARY Advantages and Disadvantages of Multisystemic Therapy and Other Evidence-Based Practices for Treating Juvenile Offenders Scott W. Henggeler, PhD ABSTRACT. Evidence-based treatments of criminal behavior in adolescents have demonstrated clear and consistent advantages. In comparison with a variety of traditional services, the evidence-based models have reduced criminal behavior, improved youth and family functioning, and done so at considerable cost savings. On the other hand, implementation of the evidence-based treatments of adolescent criminal behavior requires considerable change in prevailing clinical and administrative practices and may not be fully Medicaid reimbursable in many locales. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.haworthpress.com> 2003 by The Haworth Press, Inc. All rights reserved.] Scott W. Henggeler is Professor of Psychiatry and Behavioral Sciences, Medical University of South Carolina and Director of the Family Services Research Center. Correspondence concerning this article should be addressed to: Scott W. Henggeler, Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite CPP, P.O. Box 250861, Charleston, SC 29425 (E-mail: henggesw@musc.edu). This manuscript was supported by grants DA10079 and DA99008 from the National Institute on Drug Abuse; MH59138, MH51852, and MH60663 from the National Institute of Mental Health; AA122202 from the National Institute on Alcoholism and Alcohol Abuse and the Center for Substance Abuse Treatment, and the Annie E. Casey Foundation. Journal of Forensic Psychology Practice, Vol. 3(4) 2003 http://www.haworthpress.com/store/product.asp?sku=j158 2003 by The Haworth Press, Inc. All rights reserved. 10.1300/J158v03n04_04 53
54 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE KEYWORDS. Multisystemic therapy, evidence-based practices, outcomes, juvenile offenders The purpose of this article is to describe the advantages and disadvantages that multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) and other evidence-based practices have in comparison with traditional mental health services for juvenile offenders. Although MST was developed in the late 1970s, significant funding for MST-related research was not obtained until about 1990. Since that time, approximately $30,000,000 has been committed to MST research, the vast majority of which has been awarded from the National Institutes of Health. This funding has been critical to the validation of the model through several randomized clinical trials with chronic and violent juvenile offenders as well as trials with other challenging clinical populations (e.g., substance abusing juvenile offenders, youths presenting psychiatric emergencies). Currently, findings from eight MST trials including 800 families have been published and approximately 15 others including more than 2,000 families are in progress (Henggeler, Schoenwald, Rowland, & Cunningham, 2002). The success of MST with serious juvenile offenders led to requests from various provider organizations and funders for the transport of MST programs to their communities. Initial efforts at such transport were provided by faculty at the Family Services Research Center, Medical University of South Carolina (MUSC), beginning in 1994. In 1996, these transportability efforts shifted to MST Services, Inc. (mstservices.com), which has the exclusive license for the transport of MST technology and intellectual property through MUSC. Licensed MST programs were transported to approximately 30 states and 7 nations by 2003. These programs serve approximately 2% of the eligible population (i.e., juvenile offenders at imminent risk of placement) annually in the United States. Based on conclusions from the Blueprint Series (Elliott, 1998) and Surgeon General s Report on Youth Violence (U.S. Public Health Service, 2001), two other intervention models have demonstrated efficacy or effectiveness in treating criminal behavior in adolescents. These include Oregon Treatment Foster Care (OTFC, Chamberlain, 1998) and Functional Family Therapy (FFT, Alexander et al., 1998). Together, these models serve, perhaps, an additional 2% of the eligible population. Thus, a reasonable estimate is that about 96% of the eligible population of serious juvenile offenders in the nation is not receiving an evidence-based treatment.
WHY FAVOR EVIDENCE-BASED PRACTICES? The primary advantage of an evidence-based practice, such as MST, can be summarized in three words: outcomes, outcomes, and outcomes. Reduce Criminal Activity By definition, evidence-based practices for juvenile justice populations have demonstrated, through rigorous scientific methods, their capacity to reduce criminal behavior. For example, separate studies have shown the capacity of MST to reduce 4-year rearrest rates by 70% (Borduin et al., 1995) and 2.4-year rearrest rates by 40% (Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993) in samples of violent and chronic juvenile offenders; and MST has significantly reduced violent criminal behavior among substance abusing offenders at 4-year follow-up (Henggeler, Clingempeel, Brondino, & Pickrel, 2002). Improve Youth and Family Functioning As described by Henggeler and Sheidow (2002), the three evidence-based treatments of juvenile offenders (i.e., MST, FFT, and OTFC) have also been successful at improving family relations, increasing school attendance, decreasing substance use, and decreasing youth psychiatric symptomatology. Save Money Commentary 55 Aos and his colleagues (Aos, Phipps, Barnoski, & Lieb, 2001) conducted cost analyses on numerous violence prevention and intervention programs and found MST, FFT, and OTFC to be highly cost effective. For example, MST produced cost savings ranging from about $31,000 to $131,000 per youth served. The lower figure considers savings as a result of decreased rates of felonies and out-of-home placements, while the upper figure also includes reduced crime victim costs. OTHER ADVANTAGES In addition to decreased crime and improved functioning at reduced cost, the evidence-based treatments of adolescent criminal activity have
56 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE several other important advantages in comparison with usual mental health and juvenile justice interventions. Accountability Through Quality Assurance Systems Each of the evidence-based models devotes considerable resources to developing and maintaining program fidelity. Such is generally accomplished through the implementation of rigorous quality assurance systems aimed at optimizing youth outcomes. The quality assurance system for MST includes, for example, well-specified treatment, supervisory, consultation, and administrative components; ongoing training of therapists and supervisors; an Internet feedback system to assess therapist adherence; and intensive and ongoing oversight to track and foster clinical progress for each case. Clearly Operationalized Goals MST and the other evidence-based intervention models incorporate behavioral strategies (e.g., cognitive behavior therapy, behavior therapy) into their intervention protocols. Behavior therapies emphasize the clear operationalization of treatment goals, and these are articulated in ways that are clear to consumers and stakeholders. As noted by Gendreau (1996) for adult offenders, behavioral interventions help to engage stakeholders (e.g., all know the specific goals of treatment) and serve as clear benchmarks for progress. Family- and Community-Based Each of the evidence-based interventions views the development of more functional and adaptive family relations as critical to achieving youth outcomes. Hence, rather than teaching youths to adapt to an institutional structure at a site many miles from their home community, the evidence-based treatments devote considerable resources to helping the parents or caregivers build more prosocial contexts around their children in real world community settings. Such emphases can successfully address the challenging issue of treatment generalization. Target Known Risk Factors Logically, but in contrast with most juvenile justice and mental health interventions, the evidence-based practices explicitly target the key risk
Commentary 57 factors for criminal behavior in adolescents. For example, association with deviant peers is the strongest single predictor of antisocial behavior in adolescents. As such, MST and OTFC treatment protocols explicitly prohibit or minimize such contact. Such clinical emphases contrast starkly with many juvenile justice interventions that place antisocial youths together in groups with other antisocial youths, often for prolonged periods of time. DISADVANTAGES Evidence-based practices are not for everyone. Considerable Change in Clinical and Administrative Practice Is Required The evidence-based practices set clear boundaries on therapist behavior (e.g., no group therapy) and mandate certain organizational processes (e.g., intensive and ongoing supervision) and conditions (e.g., flex time, competitive salary) that might conflict with current approaches. Many highly competent professionals are satisfied with their current work practices and, as such, have little motivation to adopt evidence-based practices. Program Accountability Is Required The evidence-based practices have developed formal structures aimed at enhancing program accountability for engaging families in treatment, providing interventions with high fidelity, and achieving targeted outcomes. Such accountability is rare in the fields of mental health and juvenile justice, and many professionals and administrators are not eager for evaluation. Evidence-Based Practices Are Often Under Funded or not Reimbursable Several essential components (e.g., intensive supervision, teacher consultations, home visits, meetings with juvenile justice authorities) of the evidence-based practices are not reimbursable through Medicaid or private insurers in many areas of the country. Moreover, funding structures often favor institution-based services rather than community-based services. Thus, a provider organization that wants to implement evidence-based practices might not be able to obtain the necessary levels of funding.
58 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE Focus on Youths Presenting Relatively Serious Problems The evidence-based practices are more cost effective for youths that are presenting relatively serious problems and for whom service systems are already devoting considerable resources. Application of these intervention models to youths who may need treatment (e.g., truants), but are not being provided significant services, might add cost to the system. CONCLUSIONS MST and the other evidence-based treatments for adolescent criminal behavior present several advantages that pertain primarily to their capacity to reduce crime, improve the lives of the youths and their families, and provide cost savings at the societal level. On the other hand, these treatments usually represent a significant departure from prevailing practice models in mental health and juvenile justice systems. The degree of penetration of evidence-based practices into the field will depend largely on forces, advocates, and champions outside the domain of evidence-based practices-individuals and groups committed to using evidence-based treatments as vehicles for attaining a more effective juvenile justice system. AUTHOR NOTE Dr. Henggeler has published approximately 200 journal articles, book chapters, and books, is on the editorial boards of nine journals, and has received grants from NIMH, NIDA, NIAAA, OJJDP, The Annie E. Casey Foundation, and others. Dr. Henggeler s research and social policy interests include the development and validation of innovative methods of mental health and substance abuse services for disadvantaged children and their families, efforts for redistributing mental health resources to services that are clinically effective, cost effective, and preserve family integrity; and research on the transport of evidence-based treatments to community settings. REFERENCES Alexander, J., Barton, C., Gordon, D., Grotpeter, J., Hanson, K., Harrison, R., Mears, S., Mihalic, S., Parsons, B., Pugh, C., Schulman, S., Waldron, H., & Sexton, T. (1998). Blueprints for violence prevention, book three: Functional Family Therapy. Boulder, CO: Center for the Study and Prevention of Violence. Aos, S., Phipps, P., Barnoski, R., & Lieb, R. (2001). The comparative costs and benefits of programs to reduce crime, Version 4.0. Olympia, WA: Washington State Institute for Public Policy.
Commentary 59 Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M., & Williams, R. A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63, 569-578. Chamberlain, P. (1998). Family connections: A treatment foster care model for adolescents with delinquency. Eugene, OR: Northwest Media Inc. Elliott, D. S. (1998). Blueprints for violence prevention (Series Ed.). University of Colorado, Center for the Study and Prevention of Violence. Boulder, CO: Blueprints Publications. Gendreau, P. (1996). Offender rehabilitation: What we know and what needs to be done. Criminal Justice and Behavior, 23, 144-161. Henggeler, S. W., Clingempeel, W. G., Brondino, M. J., & Pickrel, S. G. (2002). Four-year follow-up of multisystemic therapy with substance abusing and dependent juvenile offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 868-874. Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K., & Hanley, J. H. (1993). Family preservation using multisystemic treatment: Long-term follow-up to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies, 2, 283-293. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press. Henggeler, S. W., Schoenwald, S. K., Rowland, M. D., & Cunningham, P. B., (2002). Serious emotional disturbance in children and adolescents: Multisystemic therapy. New York: Guilford Press. Henggeler, S. W., & Sheidow, A. J. (2002). Conduct disorder and delinquency. In D. H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 27-51). Alexandria, VA: American Association for Marriage and Family Therapy. U.S. Public Health Service (2001). Youth violence: A report of the Surgeon General. Washington, DC: author.