Program Profile: Multisystemic Therapy-Psychiatric

This is a program that addresses externalizing symptoms, suicidal behaviors, and family relations, while allowing youth with serious behavioral and psychiatric problems to avoid an inpatient setting and spend more time in school and at home. The program is rated Promising. Overall, findings were mixed. Youth who participated in treatment showed statistically significant reductions in suicide attempts, but not suicidal ideation, compared with control group youth, at the 1-year follow up.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

The overriding goal of Multisystemic Therapy (MST) is to keep adolescents who have exhibited serious clinical problems (e.g., drug use, violence, severe criminal behavior) at home, in school, and out of trouble. Multisystemic Therapy–Psychiatric (MST–P) adapts the principles of MST by treating youths with psychiatric problems within their home environment and intervening in the systems, family, and care-giving environment. Treatment aims to reduce the risk of self-harm (including suicide), depression, and anxiety as well as externalizing symptoms such as drug use and criminal behavior among youths at risk of out-of-home placement due to serious behavioral problems with co-occurring mental health symptoms.

Program Components

MST typically uses a home-based model of service delivery to reduce barriers preventing families from accessing services. Therapists have small caseloads (four to five families); work as a team; are available 24 hours a day, 7 days a week; and provide services at times convenient to the family. The average treatment occurs over roughly 6 months, with multiple therapist–family contacts occurring each week. MST therapists concentrate on empowering parents and improving their effectiveness by identifying strengths and developing natural support systems (e.g., extended family, neighbors, friends, church members) and removing barriers (e.g., parental substance use, high stress, poor relationships between partners). Specific treatment techniques used to facilitate these gains are integrated from a variety of therapies, including behavioral, cognitive–behavioral, and pragmatic family therapies. In the family–therapist collaboration, the family takes the lead in setting treatment goals and the therapist helps them to accomplish their goals.

MST principles are adopted for the treatment of youths suffering psychiatric crises by developing strategies to reduce the risk of self-harm to suicidal youth, including:

• Standardized safety assessment of the home with ecologically-based safety planning process
• Developing a safety plan with the family to eliminate potential self-harm risks
• Containing and observing youths
• Distancing the patient from deviant peers and other activities that trigger self-harm
• Empowering responsible adults in the immediate environment to enhance structure and surveillance in the environment

MST–P also uses various strategies to address serious psychiatric illnesses in the youth and/or caregiver:

• Psychiatrist(s) integrated into the clinical team
• Integration of evidence-based psychiatric interventions for youth and family members
• Therapists trained to assess youth and family members for psychiatric problems and coordinate care with team psychiatrist

Key Personnel

MST–P is an intensive program with daily contact for a 3- to 6-month duration with therapists who have relatively low caseloads (generally, four to six families). MST–P requires therapists with special MST training, as well as a fulltime crisis case worker and a part-time child psychiatrist. Special training is given: intensive safety training associated with suicidal, homicidal, or psychotic behaviors in youths; training to recognize and treat psychiatric problems in the child and caregivers; and substance use intervention where caregivers have alcohol and drug problems.

Program Theory

Systems and social ecological theories form the theoretical foundation of MST. As a family-based home intervention, MST identifies the practical issues which impact a patient’s recovery, within the patient’s immediate environment (Huey et al. 2004).

Study

The study by Huey and colleagues (2004) was a randomized trial comparing the treatment of youths admitted to psychiatric emergency services. The study recruited 156 families presenting suicidal ideation, planning or attempted suicide, homicidal ideation or behavior, psychosis, or threats of harm to themselves or others, who were approved for emergency psychiatric hospitalization at the Medical University of South Carolina. To be included in the study, youths needed to be between the ages of 10 and 17, receiving Medicaid or without health insurance, residing in a noninstitutional environment, and not presenting autism. The youths in the sample were 65 percent male and were an average age of 12.9 years. Sixty-five percent were African American, and 33 percent were white. Thirty-one percent lived in two-parent households with at least one biological parent. Fifty-one percent lived in single-parent households with a biological or adoptive parent, and 18 percent lived with someone other than their biological or adoptive parents.

The families were randomized into a psychiatric hospitalization comparison condition (n=78) or a Multisystemic Therapy–Psychiatric (MST–P) condition (n=78). Measures were taken at a baseline, a posttreatment point of 4 months (on average), and at a 1-year follow-up. Instruments were used to measure suicide attempts (reported both by the caregiver and the youths), hopelessness, parental control, depressive affect, and suicidal ideation. The instruments included the Youth Risk Behavior Survey (to assess youth self-rated suicide attempts), the Child Behavior Checklist Checklist (to assess caregiver-rated youth suicide attempts), the Family Friends and Self Scale, and the Brief Symptom Inventory. During treatment, 44 percent of the MST–P group was admitted for psychiatric hospitalization because of an emergency that could not be treated in the community. While they were hospitalized, care was taken to keep them separated from the regular inpatient population.

The study used generalized linear mixed-model analysis to estimate the treatment effects. These models tested for both linear and quadratic effects. Subsequent analysis examined the moderator effects of the sample’s age, gender, and ethnicity. The researchers conducted subgroup analyses on age, gender, and ethnicity.

More information on Multisystemic Therapy–Psychiatric Care can be found on the program’s website: http://www.mstservices.com/mst-psych

Subgroup Analysis

Huey and colleagues (2004) conducted subgroup analyses on age, gender, and ethnicity at the 1-year follow up. In regard to age, preadolescents (ages 9–12) in the control group showed a statistically significant greater likelihood of attempting suicide than preadolescents in the Multisystemic Therapy–Psychiatric group. Conversely adolescents between the ages of 13 and 17 in the Multisystemic Therapy–Psychiatric group were slightly more likely to attempt suicide, compared with control group adolescents. In regard to gender, females in the control group showed a statistically significant greater likelihood of attempting suicide, compared with females in the Multisystemic Therapy–Psychiatric group; however, there were no significant differences between groups for males. The researchers did not find significant differences between groups in regard to ethnicity.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Henggeler, Scott W., Melisa D. Rowland, Colleen A. Halliday–Boykins, Ashli J. Sheidow, David M. Ward, Jeff Randall, Susan G. Pickrel, Phillippe B. Cunningham, and James Edwards. 2003. “One-Year Follow-Up of Multisystemic Therapy as an Alternative to the Hospitalization of Youths in Psychiatric Crisis.” Journal of the American Academy of Child and Adolescent Psychiatry 42(5):543–51.

Henggeler, Scott W., Melisa D. Rowland, J. Randall, David M. Ward, Susan G. Pickrel, Phillippe B. Cunningham, S.L. Miller, James Edwards, J.J. Zealberg, L.D. Hand, and Alberto B. Santos. 1999. “Home-Based Multisystemic Therapy as an Alternative to the Hospitalization of Youths in Psychiatric Crisis: Clinical Outcomes.” Journal of the American Academy of Child and Adolescent Psychiatry 38(11):1331–39.

Rowland, Melisa D., Colleen A. Halliday–Boykins, Scott W. Henggeler, Phillippe B. Cunningham, Terry G. Lee, Markus J.P. Kruesi, and Steven B. Shapiro. 2005. “A Randomized Trial of Multisystemic Therapy With Hawaii’s Felix Class Youths.” Journal of Emotional and Behavioral Disorders 13(1):13–23. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating.)

Schoenwald, Sonja K., David M. Ward, Scott W. Henggeler, and Melisa D. Rowland. 2000. “Multisystemic Therapy Versus Hospitalization for Crisis Stabilization of Youth: Placement Outcomes 4 Months Postreferral.” Mental Health Services Research 2(1):3–12.