Kicking the habit: How MST is helping young people give up drugs

At 15, Jodie* was spending a lot of her time smoking cannabis with friends. She was drinking heavily too, and refusing to go to school.

When the family was offered an intervention called multisystemic therapy (MST), she was reluctant at first. But MST therapist Katie Vincent won her round and started an intensive programme involving both Jodie and her parents.

As part of the treatment, Vincent set up a reward system, administered by Jodie's parents. They carried out a drugs screening test every week on a urine sample Jodie provided and she was rewarded each time the test showed she had not smoked cannabis that week. She could spend the "points" she earned on items such as phone credit, iTunes vouchers and cinema and bowling trips.

"We did a lot of work looking at the situations, people, places, times of day and feelings that reinforced her drug use," says Vincent. "We also did role play on drug refusal skills. Some kids come up with things they can say to their friends like 'I'm being urine-tested so I can't' or you can just build up their confidence so that they can say 'No, I just don't fancy it today'."

Jodie started to enjoy the process. "Her parents were really motivated and that makes a massive difference," says Vincent. "The parents are the ones who are going to be around when the programme finishes."

More young people across the UK are benefiting from this type of treatment, which is currently used mainly to tackle serious antisocial behaviour.

MST includes elements of behavioural, cognitive and family therapy and helps parents develop skills to manage their children's difficult behaviour. The therapist works intensively with the young person, their family and other people in their lives such as teachers.

Meetings take place in the young person's own home. If necessary, the therapist visits every day at first, reducing to two or three times a week as the situation stabilises. The MST service is on hand round the clock so parents can get help in a crisis. The therapist also liaises with social workers, police and youth offending team workers, where they are involved.

The MST service in Cambridgeshire, which worked with Jodie and her family, is one of the longest-established in the UK and the first to use the approach to specifically tackle substance misuse.

This includes the "contingency management" system of rewards and sanctions, which was particularly effective in Jodie's case.

At the end of the five-month programme she had stopped smoking cannabis and was attending school regularly. Her relationship with her parents had also improved and she no longer felt the need to be with her friends all the time.

Cambridgeshire's programme director is consultant clinical psychologist Brigitte Squire, who set up the MST service in 2001 as part of an ISSP (intensive supervision and surveillance project) run by the county's youth offending service.

In 2003, the team began accepting referrals from social care, eventually moving out of the youth offending service when new government funding for MST became available in 2007/08.

This meant they could receive direct referrals from the youth offending team, social care and child and adolescent mental health services.

The service is now run jointly by Cambridgeshire County Council and Cambridgeshire and Peterborough NHS Foundation Trust with the council employing the MST workers and the trust employing both Squire and team supervisor James Fowler.

The team of four MST therapists sees a total of around 30 families a year. In around half the cases, substance misuse is the main problem. Most of the young people are heavy users of cannabis and many are taking other substances as well, including so-called legal highs.

Because of the intensive nature of MST, each therapist has a caseload of just four families at a time. There is a lot of travelling involved as Cambridgeshire covers such a wide area.

"We always have families waiting for our service," says Fowler. "Families with the greatest level of need take priority - so some families will never be seen."

Recognition of the benefits of offering incentives has seen other teams around the UK now being trained to use the contingency management system trialled in Cambridgeshire.

A "clean" urine screening test earns the young person points or rewards at three different levels. At Level 1, a young person can earn a £5 voucher, to be spent online, each week. Further into the treatment at Level 2, this doubles to £10, reflecting the difficulty of staying off drugs as time goes on. At Level 3, the value doubles again.

If the child fails the test, they not only forfeit the reward that week but they also go back to Level 1 and face a consequence – for example, they lose access to their most valued privilege, such as using the internet.

The MST service makes a maximum contribution of vouchers worth £150 and parents are asked to match this if they can. So young people can potentially earn vouchers worth up to £300 over the course of the programme - a powerful incentive.

This is a sobriety programme so young people only earn rewards if they have not used drugs at all – refusing to take a test counts as a failed test.

The beauty of the testing regime is that it is clear, says Fowler, whose background is in forensic psychology.

"This can work better than some more easy-going models because there's no endless debate with parents about whether they have been using drugs or not," he explains.

The idea is that by the end of the programme "sobriety is its own reward" although some parents continue the rewards if they can afford it. Families can ask for one or two follow-up visits.

In standard MST, the young person's compliance is helpful but not necessary. With contingency management the young person must have a real desire to change for it to work.

"However, we can still work with parents using contingency management to nudge the young person in the direction of engagement," says Fowler.

Sometimes the motivation comes when a teenager realises they are on the verge of a custodial sentence.

Other elements include motivational interviewing, which encourages the young person to think about the consequences of their behaviour and how their life might improve by changing it.

Together with the young person and parents, therapists also do an "ABC assessment". They analyse the antecedents of the problem behaviour - what leads up to it, the behaviour itself, and the consequences. This helps both the young person and parents understand what is influencing the behaviour.

The process can be difficult for some parents, who may not realise their own behaviour can be a trigger. For example, parents' "nagging" or anger may mean a child simply wants to get out of the house. They are then more likely to bump into friends and go on to use drugs.

Therapists help parents improve their communication skills with their children and to interact with them more positively. Some parents feel detached from their child by the time they reach the MST service because they are so worn down by the child's difficult behaviour, but therapists help them rebuild bonds as they see their child hitting the targets and are able to praise him or her.

During the team's supervision session, therapists Charlotte Armitage, Anna Mayes and Sharon Noble discuss some of their ongoing cases with Fowler. A key aim of the team is to keep children and young people at home with their families rather than see them go into care or custody. But that does not look likely in one case, where they talk about a mother who is refusing to have her son in the house any longer.

A second case involves a boy who has just been excluded from school. "How much training did we give the school staff about a behaviour plan?" asks Fowler. "Let's show the school what we have to offer. They should lean on us more in times of need. In the best relationships I've had with schools there has been a key person in the school and the school rings me when the kid is kicking off."

Every MST team has a consultant to oversee its work and ensure it sticks to the MST treatment model. The Cambridgeshire team has a weekly transatlantic conference call with Phillippe Cunningham, a Professor in the Department of Psychiatry and Behavioural Sciences at the Medical University of South Carolina, who has been involved in MST since its early days. Every three months Cunningham flies from the US to spend some time supporting and training the Cambridgeshire team and the MST team at the Brandon Centre in London.

MST is constantly evolving and changing, says Fowler. "Every young person has unique problems," he says. "You never stop learning."

*Name changed.

Multisystemic therapy – The basics

What is multisystemic therapy (MST)?

An intensive family-based intervention, lasting three to five months. It is generally used for serious antisocial or delinquent behaviour in young people. There are also specialised approaches to tackle substance misuse and problematic sexual behaviour.

Who is it for?

Children and young people aged 12 to 17 who are living at home but are at risk of being placed into residential care or custody due to their behaviour.

How does it work?

It is a holistic approach that draws on a range of methods including cognitive, behaviour and family therapy. The therapist analyses the environment around the child to work out what is driving the problem behaviour and to resolve or eliminate these drivers.

Where was it developed?

MST has its origins in the US in the 1970s when Dr Scott Henggeler started working with antisocial adolescents. In 1992 the Family Services Research Centre at the Medical University of South Carolina was formed to develop treatments for this group and carry out clinical trials. MST had good outcomes and MST Services, a university-licensed organisation, was set up in 1996. It now grants licenses to MST programmes in the US and 15 countries around the world to ensure they adhere closely to the treatment principles.

Who can be an MST therapist?

MST therapists often have backgrounds in psychology, youth offending, social work and working with families. They undergo a week-long training course when they join an MST team and there is ongoing training and supervision.

How is MST used for substance misuse?

In the UK, a specific new approach called "contingency management" has begun to be used as part of MST when substance misuse is the main issue. It involves weekly drug screening tests on urine samples provided by young participants. Children earn rewards for "clean" urine tests while failing the test means losing privileges or treats.

Contingency management was originally developed in the US for older people with serious drug problems, in the context of a drug treatment service. As part of the MST model, it is used within families, implemented by parents rather than drugs workers.

Multisystemic therapy in the UK

Over the past 15 years, MST has become an established form of treatment in the UK and is one of the approaches recommended by the National Institute for Health and Care Excellence to tackle problem behaviour in young people.

"MST is for where problems have got quite severe and, a bit like family therapy, tries to get to the nub of what needs to be changed and how you bring that change about," explains Professor Dame Sue Bailey, chair of the Children and Young People's Mental Health Coalition.

Three core MST UK sites - Cambridgeshire, the Brandon Centre in London and Extern in Belfast - have been running since 2001.

There are now more than 35 teams in England, Scotland and Northern Ireland, with more in the process of setting up. However, some have closed down due to lack of funding.

The roll-out of MST in the UK is now being spearheaded by the National Implementation Service. Staffed by personnel from NHS England, the Institute of Psychiatry and the South London & Maudsley NHS Foundation Trust, it supports new and established MST teams.

Results from international research have shown MST has reduced long-term re-arrest rates, out-of-home placements, substance misuse and mental health problems.

In 2011, the first randomised controlled trial of MST in the UK found the approach to be more effective than usual services in reducing offending and improving family relationships for young people referred to the Brandon Centre from two youth offending services in London.

A major UK research study, funded jointly by the Department of Health and Department for Education is currently looking at outcomes from MST across nine sites in the UK. Results from the Start (Systemic Therapy for At Risk Teens) programme will be published this year.

"MST has got some of the things you would expect would make it work, in that practitioners have small caseloads, close supervision from the leader of the team and consultant supervision," says Professor Bailey.

It is not cheap but, as Professor Bailey points out, "any good psychological therapy that is delivered robustly will not be inexpensive".

According to a 2011 DfE report, MST on average costs £7,000 to £9,000 per intervention. Meanwhile, the cost of running an MST team, which usually consists of a supervisor and three or four therapists, is about £350,000 per year.

However, the average cost per child/family is significantly lower than the average yearly cost for mainstream foster care at about £35,000, or residential care at up to £160,000.

In 2007/08 the government provided funding to set up some MST teams as part of the Start trial. There was a small amount of additional funding from 2011 to 2014 for training and set-up as part of the DfE intensive interventions programme for children in care and on the edge of care.

There is a wide variation in ongoing funding arrangements, explains Cathy James, programme lead at MST UK, which is part of the National Implementation Service and is allied to the treatment's originators in the US.

"The majority of sites are now funded by local commissioning, mostly from children's services, but clinical commissioning groups are partnership funders in many areas," she explains.

Providers include mental health trusts and voluntary organisations while many services are joint schemes between mental health and children's services. Some teams are linked with youth offending services but still take referrals from children's services and child and adolescent mental health services, says James. "It's a service that's really everybody's business," she stresses.

In Essex two teams are funded by social impact bonds, and this option is being explored in other areas.