Multisystemic Therapy Using evidence based practice to prevent

Multisystemic Therapy: Using evidence based practice to prevent young people becoming Looked After Away from Home. Nicola Hornsby MST Programme Manager, Consultant Clinical Psychologist 16 th May 2013

Overview • Service context for the delivery of MST, use elsewhere in UK and worldwide • How does MST work? • Fife’s experience of using the model to target young people at risk of being looked after way from home

What is “MST”? • Community‐based, time‐limited, intensive intervention for antisocial behavior in young people • Focus is on empowering parents to solve current and future problems • MST “client” is the entire ecology of the youth ‐ family, peers, school, neighbourhood • Highly structured clinical supervision and quality assurance processes

MST: 30+ Years of Evidencebase • 26 published outcome, transportability and benchmarking studies including 20 randomised trials – 11 with serious juvenile offenders ‐ 7 independent studies • Large-scale independent RCT: START trial (9 joint LA/NHS sites in England) 700 families now recruited. Due to report first outcome data May 2014. Majority of referrals from Social Care and also Youth Offending Services

Safeguarding Children across Services: Messages from Research (Ward and Davies 2011) concluded- • ‘Although practitioners claim to be using evidence‐based interventions, audit and research into actual practice in the field have shown that, despite their stated intentions, this is generally not the case. ’

Where is MST Being Used? • Scotland – 5 teams • England N Ireland – 33 teams • International nationwide infrastructures – Norway and Netherlands • Teams in Australia, Belgium, Canada, Denmark, Iceland, New Zealand, Sweden, Switzerland Chile • Over 34 states in the U. S. including some statewide infrastructures

Rapid expansion in MST in England over last 6 years, including approx 16 teams in the last year • Continuing cross government support for MST from Department for Education, Dept of Health, Youth Justice Board and Cabinet Office • National Institute for Clinical Excellence recommendation MST for 12 ‐ 17 year olds with serious conduct problems • Recognition of need for suite of evidence based programmes and for MST teams to be integrated into wider service redesign for local authorities and health partners • Df. E funding for ‘Intensive Interventions for children in care and on the edge of care and custody’ offers new opportunities for MST development alongside other evidence based programmes such as FFT and MTF

MST Adaptation Sites MST-PSB (Problem Sexual Behaviour) • The Brandon Centre, London • Bedford Borough, Central Bedfordshire, Cambridgeshire and Peterborough • Sheffield MST-Contingency Management for Substance Misuse (CM) • Brandon Centre, London • Cambridgeshire MST-CAN (Child Abuse and Neglect) • Cambridgeshire • London Borough of Greenwich and Oxleas MH Foundation Trust • Leeds MST-FIT (Families in Transition) Df. E

2013 Scottish Policy Context • GIRFEC – MST fits well with 10 core components, values and principles and National Practice model • National Parenting Strategy • Early Years Task Force exploring the potential for a national roll out of evidence based parenting programmes on a population basis • Family Nurse Partnerships ‐ EBP government commitment to ensure its availability across Scotland for teenage parents

MST Theoretical Underpinnings Based on Social Ecological Theory of Uri Bronfenbrenner • 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)

Social Ecological Model Community Provider Agency School Neighbourhood Peers Extended Family Caregiver Family Members CHILD Siblings

MST Theory of Change Peers MST Improved Family Functioning School Community Reduced Antisocial Behavior and Improved Functioning

MST Assumptions • Families can live successfully without formal, statutory services • Change can occur quickly • Professional treatment providers should be accountable for achieving outcomes

How is MST Implemented? Intervention strategies: MST draws from research ‐based treatment techniques • Behaviour therapy • Parent management training • Cognitive behavior therapy • Pragmatic family therapies ‐ Structural Family Therapy ‐ Strategic Family Therapy

How is MST Implemented? (Cont. ) • Single Practitioner working intensively with 4 to 6 families at a time • Team of 3 to 4 Practitioner plus a supervisor • 24 hr/ 7 day/ week team availability: on call system • 3 to 5 months is the typical intervention time (4 months on average across cases) • Work is done in the community, home, school, neighbourhood: removes barriers to service access

How is MST Implemented? (Cont. ) • MST staff deliver all intervention where possible –few services are referred outside the MST team • Never‐ending focus on engagement and alignment with primary caregiver and other key stakeholders (e. g. education, social work, police) • MST staff must be able to have a “lead” role, ensuring services are individualized to strengths and needs of each youth/family • Continuous focus on outcomes and fidelity to the model

Core Elements of MST Key Points: • MST Quality Assurance System • MST Treatment Principles • MST Analytic Process

MST QA/QI Overview PIR Program Implementation Review and other reports Input/feedback via internet-based data collection Training/support, including MST manuals/materials Output to – Organization, Program Stakeholders and MST Coach Organizational Context MST Coach MST Expert/ Consultant MST Supervisor CAM Consultant Adherence Measure Output to – MST Coach MST Therapist SAM Supervisor Adherence Measure Output to – MST Expert Youth/ Family TAM Therapist Adherence Measure Output to – MST Supervisor and MST Expert

9 Principles of MST Intervention Design and Implementation 1. 2. 3. 4. 5. 6. 7. 8. 9. Finding the Fit Positive and Strength Focused Increasing Responsibility Present-focused, Action-Oriented & Well-Defined Targeting Sequences Developmentally Appropriate Continuous Effort Evaluation & Accountability Generalisation

MST Analytical Process Referral Behavior Desired Outcomes of Family and Other Key Participants Overarching Goals Environment of Alignment and Engagement of Family and Key Participants MST Conceptualisation of “Fit” Re-evaluate Prioritise Assessment of Advances & Barriers to Intervention Effectiveness Measure Intervention Implementation Intermediary Goals Do Intervention Development

MST in Fife § Team 1 established in September 2009 § Team 2 established August 2011 § 2 x MST Supervisors (one also the Programme Manager) § 1 MST Business Support Officer (collecting quality assurance data, performance data and admin)

Goals for MST in Fife • Reduce rates of offending; • Increase time in education & employment; and • Keep young people out of care.

MST Referral Criteria in Fife • 11‐ 17 year olds with serious behaviour problems occurring at home, school and/or in the community • Who have a caregiver willing to support them at home; AND • They are at risk of being accommodated as a result of these behaviours.

Fife Performance Data • Total number of cases served to date: 201 • 49% Female 51% Male • Overall Average Adherence score (TAM): 0. 73 (threshold= 0. 61) • 77% of young people had TAM above threshold • Average length of involvement: 138 days

Risk of Becoming Accommodated at Referral (n=201) This amounts to 86% of cases rated as at least a ‘high risk’ of becoming accommodated.

Fife MST Caseload at Referral (n=201) 70% At Home 17% Returned Home with MST Support 9% With New Caregivers 4% Adopted Children Only 21% In Education* / Employment

Fife Instrumental Outcomes Closed Cases 84% 85% 82% 85% 79% with parenting skills necessary to handle future problems with improved family relations Percent with improved network of supports with success in educational/vocational setting of youth involved with prosocial peers/activities where changes have been sustained

Percentage of Young People Remaining at Home and in Education at Case Closure and Follow Up At Home In Education*/Employment Case Closure n=172 91% 73% 6 Month Follow Up n=139 89% 71% 12 Month Follow Up n=102 85% 71% 18 Month Follow Up n=54 87% 70%

Offending Rates – Clients Closed for at Least 6 Months (n=140) 42. 1% decrease in the average monthly rate of offending when comparing pre MST to post MST.

Offending Data • There was a 47. 3% reduction in total number of charges when comparing the 6 month periods pre and post MST (from 281 to 148, n=140)

Outcomes according to whether young people at home versus brought home/moved to new caregiver at point of referral Young People at Home at Referral Young People Brought Home / New Caregiver at Referral At Home at Case Closure 94. 4% (n=126) 1 Homeless 80. 4% (n=46) 1 Homeless At Home at 6 Month Follow Up 92. 5% (n=106) 1 Homeless 78. 8% (n=33) 3 Homeless At Home at 12 Month Follow Up 86. 7% (n=83) 1 Homeless 72. 2% (n=18) 2 Homeless At Home at 18 Month Follow Up 93. 2% (n=44) 60. 0% (n=10)

What have we learned? • It is possible to replicate and implement evidence based treatment programmes from other countries. It requires wide stakeholder support, one “Champion” is essential but not enough • We can offer children, young people and families with serious behavioural problems more effective treatment in their communities. • Quality assurance is an essential component for successful implementation of evidence based practice • Resist the pressure to stretch the model and apply it to groups that it’s not been developed for/or that you don’t have the adaptation for. • MST is an effective intervention process for a specific client group not a magic bullet to solve purchased placement overspends, it can be used as part of an overall strategy that addresses the complexity of need in the Looked After population. • Can MST contribute to the development of systemic practice within mainstream services? A sign of successful integration?

Further Learning Points Organisational change: MST requires very different ways of working: • for the team around the child, • seeing the carer as the key agent of change, • a 24/7 on call service - clarity about roles and responsibilities • the importance of model fidelity for achieving the outcomes -staff need to understand how evidence-based interventions work differently to standard practice Understanding local needs: • the profile of the looked after children population and those on the edge of care needs to be analysed in terms of current and future requirements, costs, current services (social work, youth justice, education, health). • thinking about who should receive a specific intervention and ensuring a sufficient flow of referrals to sustain a programme. The cost implications must be calculated realistically: frame as cost-avoidance rather than cost-savings: • Must understand costs and benefits across all services, over short, medium and longer term