Total therapy

New projects that endeavour to support families with the most complex needs have proliferated over the past decade. But identifying interventions that are proven to make that life-transforming difference is the Holy Grail, all the more so given the government’s current focus on targeting the most troubled families across the country. Inevitably, the price tag attached to such interventions makes the need for a solid evidence base a key consideration.

This is perhaps why one model in particular is accumulating a powerful following across the UK after seeing considerable success in the US. Multisystemic therapy (MST) works with young people and families in their homes to tackle antisocial behaviours and strengthen the ability of parents and carers to reduce problems in the long term.

Extensive research in the US has revealed that among a range of positive outcomes, MST can lead to a reduction in the need for young people to enter care or custody, resulting in a significant return on investment.

So it is perhaps unsurprising that at a time of heightened focus on targeting resources effectively, a programme with proven outcomes is catching on fast in this country.

MST seeks to engage young people displaying challenging behaviours and whose parents feel their child is out of control. It can, for instance, target young people kept in medium-stay hospital placements due to behavioural problems; those who are at breaking point with their families and are at risk of entering the care system; or those who are persistently getting on the wrong side of the law.

Root of the problem
Ultimately, it aims to dig down to the origins of the behaviour, which means practitioners work with parents, teachers and peers in the settings in which young people exist, most commonly the home. Even if the young person is reluctant to engage with the work, therapists find that by equipping carers with the tools to tackle difficult behaviour, changes can be made.

The Brandon Centre, which offers counselling and psychotherapy for young people, began the first randomised controlled trial of MST in the UK in 2003, with Camden and Haringey youth offending services. This meant that young people in serious trouble with the law were identified for intervention, with some going through a programme of MST. The outcomes for this group were monitored against others receiving regular services through youth offending teams.

Geoffrey Baruch, director at the Brandon Centre, recalls that other interventions used at the time did not always get the results desired by the centre. “We were seeing from our work with young people presenting with antisocial behaviour that other types of help were not delivering improvements,” he says. “For most of these interventions, the young person had to come to the centre and that meant that even if we were achieving some change, there was nothing to sustain it for long enough.

“Up to this point, there had not been a trial of MST in the UK. Because there had been some significant changes in the quality and level of services for young offenders through the innovation of the Youth Justice Board, one couldn’t assume that MST would be any better than what was on offer. That led me to decide that we should evaluate it as a trial with Camden and Haringey youth offending teams.”

The University College London evaluation of the trial, published at the end of last year, revealed a significant reduction in non-violent offending among the young people, particularly at 18 months after they had completed the programme. However, only 108 families were monitored, 56 of whom had gone through the MST programme, so other positive trends identified were not deemed statistically significant because of the relatively small numbers involved.

“Apart from the outcomes, the main benefits for the families was the 24 hours-a-day, seven-days-a-week availability of the therapist,” explains Baruch. “The parents found the level of engagement and intensity extremely helpful. They had been through a number of different services, so they were quite cynical as to whether another one would be of any help. They found the strategies that the therapist would introduce them to very helpful; feeling more in control of their child and seeing improvement in the family relationship.”

He believes this initial small-scale study has helped boost the use of MST across the country. The trial has also helped the Brandon Centre secure a contract to deliver MST across the boroughs of Camden and Enfield. “I think MST has a permanent future in this country as part of the menu of services that are available, replacing some that are less cost-effective,” Baruch says. “But what has to be worked out carefully is where to target it.”

A wider evaluation is under way to gain a more comprehensive picture of the outcomes of MST. The Department of Health asked councils to bid for funding to deliver MST and, in 2007, 10 successful bids began establishing the model (see Leeds case study). Alongside this, it commissioned UCL, Leeds University and the University of Cambridge to conduct the biggest study of family intervention in the UK named Systemic Therapy for At Risk Teens (Start), due to report in 2014.

Professor David Cottrell, dean of medicine and professor of child & adolescent psychiatry at the Leeds Institute of Health Sciences, is a principal investigator on the Start programme. He is cautious about making conclusions before the completion of the study, but is convinced MST produces significant savings.

“When you first look at it, MST can seem quite expensive, because case workers have caseloads of only four to eight families and work with them intensively out of normal hours and under careful supervision,” he says. “But actually you have only got to stop one child from going into care or prison and you can save huge amounts of money.”

The pilot authorities receive training from the US originators of the programme and there is ongoing supervision and monitoring. There are two networks, one in the north and one in the south of England, allowing the pilot sites to share best practice and discuss challenges.

“The evidence shows that if you don’t stick to the programme it doesn’t work so well, so the originators did not want their invention to get a bad name,” Cottrell says. “So it can only be used on licence and has to be paid for. What you get for your licence is a lot of training and support and a lot of ongoing checking to see it is sticking to the original method.”

The Start programme is near to its goal of recruiting 750 families to evaluate once they have completed the MST programme, making it the biggest evaluation of a non-drug treatment for emotional and behavioural problems among children. But why is it necessary to spend such a large amount on another trial in the UK?

“In the US, the programme was shown to save between $50,000 and $100,000 per case over time, from a reduction in the need for additional support at school; and fewer young people going through the youth justice system, foster care and children’s homes; or therapeutic resources in the health service,” says Cottrell.

“But the studies compare MST with usual services and there is not the same degree of public health or primary care provision as in the UK. In many parts of the US, services for the disorganised families that MST works with are pretty poor. Therefore, when you offer something very good and compare it with very little, it is hardly surprising that it works.

Positive results expected
“Despite criticism, we have some very good services in this country working in very integrated ways. I am sure MST in the UK will give us the same positive results as in the US, but it remains possible that MST will not be cost-effective, which is why we are doing the research. My hunch is the gap won’t be quite as big as in the US, but it will still be significant.”

Cottrell warns that for MST to be successful in the UK, services need to work much closer together, so savings reaped are shared across services.

“Sometimes the people with the skills to deliver MST are in one service such as child and adolescent mental health, but the savings will be made elsewhere, say in youth justice,” he explains. “So you do need services working together wrapped around the child with an element of pooled budgets.”

Dr Jenny Taylor, consultant clinical psychologist and MST team manager in Hackney, one of the areas that tested MST between 2007 and 2010, is certain the programme has yielded positive results. “Hackney is a borough with considerable social deprivation, with difficulties of young people entering care and custody,” she explains. “In Hackney, the particular focus was on young people at risk of entering custody.”

Taylor says that the completion rates for the programme reveal that families are more responsive to MST than other forms of intervention, with 80 per cent of the 85 families involved finishing the entire course.

“Families have one worker rather than multiple workers. With eight different agencies, the families aren’t clear who is who, they are just seeing everyone asking them the same questions and placing demands on them rather than supporting them,” she explains. “The focus of MST is on supporting them at times that suit them and looking at the whole family rather than looking at the young person.”

But while Taylor is in no doubt that the programme is making a significant difference, she still fears for the future. “As with the other trial sites, we were funded for four years, but there wasn’t any agreement as to what would happen afterwards,” she explains. Luckily for Hackney’s MST team, the authority was able to bid for further funding under the Youth Justice Board pathfinder programme, which is exploring how local authorities can reduce the number of nights young people spend in custody.

Along with six other authorities, Hackney has formed the North & East London partnership, which is using MST as one of its main methods. “It is a vote of confidence from Hackney and the other boroughs that they wanted to use MST as their main clinical component,” she says. But given the pathfinder is for only two years, Taylor says pressure on budgets might not make MST a viable option for all authorities.

One area that is in the process of securing the funds to run MST is Essex, which has approved the model of social impact bonds following a feasibility study with Social Finance Ltd. It will work with 170 children and aim to reduce care numbers by 90. It is also hoping to save £4 for every £1 spent.

While results of the national evaluation of MST are awaited and authorities decide whether to develop their own MST teams or expand existing resources, it is clear that MST has captured the government’s attention. The recent announcement of £6m towards developing intensive therapies for families is in part being used to fund MST services. If the evidence reveals results that match those in other parts of the world, it will be difficult for both local and central government to ignore a programme proven to change young lives.


MST – at a glance

What is multisystemic therapy (MST)?
MST is an intensive intervention that targets the multiple causes of behaviour in young people considered to be at risk of going into custody as a result of antisocial behaviour or those likely to be taken into care. It was developed in the US at the Medical University of South Carolina’s Family Services Research Center in the late 1970s and brings together best practice from a range of interventions.

What are the requirements of the programme?
MST is a licensed programme, which must stick to strict guidelines. The intervention is used to work with young people aged from 11 to 17. It does not work with young people who are living independently; those who have suicidal or psychotic behaviours; adolescent sexual offenders; or those with autism. However, it is used to address behaviour in young people such as truancy, aggressive or criminal behaviour, drug and alcohol problems, running away or self-harm.
Case workers are only allowed to take on four to eight cases at any one time.

What makes MST different?
MST is based on the premise that a young person’s behaviour is embedded in many systems, including at home, in school and the community. Therapists work with parents or carers and other major influences in a young person’s life to examine the factors that lie behind the young person’s behaviour.
It is a home-based intervention that has goals attached to it, and is limited to last between three and five months. MST clinicians are on call 24 hours a day.

What have been the results?
US studies found reductions in long-term rates of reoffending and placing children in care or custody. They also found significant improvements in family functioning and decreased mental health problems. Research from Washington State Institute for Public Policy estimated $5.27 is saved for every $1 invested.

In the UK, the Brandon Centre’s trial compared the outcomes of 56 families who went through MST with 52 who were targeted through standard youth offending team activity. Both showed a reduction in offending, but the MST model significantly reduced the likelihood of non-violent offending during an 18-month follow-up period.



Leeds City Council commits to multisystemic therapy

Leeds was one of several councils that successfully bid to trial multisystemic therapy in 2007 under a pilot programme led by the Department of Health.

Tom Bowerman, MST programme manager at Leeds City Council, says the authority was keen to try a new evidence-based programme to tackle a range of challenges including high numbers of children in care.

The pilot kicked off in 2008 at the same time as a city-wide referral process was established, involving a multiagency panel referring the most complex cases to MST workers. Bowerman says these were “cases where progress wasn’t being made, cases where agencies had been involved for some time and things seemed to be stuck or deteriorating”.

“When it started, the MST team was quite small so would only work with 16 to 20 families at any one time,” he explains. “We wanted to make sure that we targeted the families that needed the intervention most.”

For Bowerman, the main aim of MST is to give parents and carers the tools to sustain changes beyond the life of the programme.

“It would be easy for us to take the children to school and their attendance would improve, but our task is to help parents do things differently so school attendance can improve and is sustained after we are gone,” he says. “It is a service that is adaptable to the family’s needs, so we work flexible hours, weekends, evenings, and we have a person on call 24/7.”

The Leeds trial is part of the national evaluation programme Systemic Therapy For At Risk Teens (Start). While the programme will not report until 2014, Bowerman believes it is already possible to see results. He says that despite working with some of the most hard-to-reach families, 96 per cent have completed the programme.

“We are not going to have success with every young person, but we expect a significant number to live at home when we finish working with them; their school attendance and attainment improves; they will be involved in more positive activities; and reduce or manage their drug or alcohol problems.”

Bowerman also hails the fact that the programme reaches the whole family. “We might be focused on a 14-year-old who is displaying difficult behaviours, but there might also be an eight-year-old and six-year-old in the household who aren’t,” he says. “Because the parent is doing things differently, the benefits they see for their older child are going to make changes to those subsequent children.”

Although the Leeds pilot finished this year, the council has agreed to continue funding the programme. “We have now moved from having one pilot team to having three mainstream MST teams,” explains Bowerman. “We would expect to work with between 120 and 150 families a year. At a time when a lot of services are being reduced, this shows the level of support we have at senior level and the impact we feel it is having on young people and families.”

The authority won MST team of the year last year at the international Whatever It Takes awards out of 480 teams across 12 countries.



Multisystemic therapy in the UK