• By Dartington SRU
  • Posted on Wednesday 16th May, 2012

A safe landing on the other side of the Atlantic

Multisystemic therapy is a Rolls Royce of evidence-based programs. It features on most lists of “what works,” including the highly regarded Blueprints model programs list. Despite this prestigious position, there has been a question on the lips of service providers in the UK. The results of tests of the program in other countries have not been conclusive: it might work in the US but does it work in the UK? Stephen Butler and colleagues have just published the results of the first UK trial of MST, which indicates that the program travels well across the Atlantic making an impact on re-offending rates.MST is an intensive family and home-based intervention for young people with serious antisocial behavior. It is designed for the most challenging and hard to engage young people and their families, and aims to prevent re-offending and the need for custody (referred to in the US as out-of-home placement). It is widely used outside of the US in countries including the Netherlands, Norway and Sweden, as well as the UK.It is sensible to question whether the program will work in the UK for two reasons. First, the evaluations in the US compare the program to standard practice, which often includes a period in some form of custody. The judgment about whether the program works is a measure of the added impact of the program compared to the alternative. If standard practice in the UK is in any way better or more effective than that in the US, the program might not be worth the additional investment. Second, it is common for programs to have less impact when the developers are less involved. There are several studies of MST in the US when the developer has not been involved and the effectiveness of the program has been significantly reduced. In Butler’s study, MST was provided by therapists working in the normal youth offending environment, with a standard level of training and advice to guide the adoption of the new practice. Furthermore, the program was judged against the usual package of support designed to address personal, family, social, educational and health factors. By most people's standards, this was a robust and fair test of the program.Butler and colleagues set out to determine if MST was more effective in reducing youth offending and the use of custody than standard youth offending practices. It also investigated effects on youth sociality, family function and other potential influences on young people’s behavior, like, for example, parenting skills and parent-child communication.Just over 100 young people were randomly assigned to receive MST or treatment as usual and followed for 18 months. An independent and objective measure of offending was obtained from the Data National Young Offender Information System. Parents and young people completed a battery of measures on anti-social behavior, personality functioning and parenting. The number of offenses committed by both groups, those undergoing MST and the comparison group, decreased significantly, but MST made a greater impact on all types of offenses. The MST group was also more likely to have periods without any offending. At the 18-month follow up, eight per cent of the MST group had offended in the previous six months, compared with 36 per cent of the comparison group.The objective measures of offending were complemented by the views of parents and young people in the MST group, who reported less aggression and delinquency. Parents also reported some improvements in parenting. One curious finding from the study was that there appeared to be no relationship between adherence to MST standards - often described as program fidelity - and offending. Most studies find that the greater the fidelity, the better the outcomes.MST appears to be an effective intervention for young people in the UK offering superior results against standard practice, but it is unclear how it worked. The research team expected to see increased parental supervision, greater family warmth and communication, and a reduction in deviant peer affiliation. They assumed that, in turn, these would lead to the reductions in anti-social behavior and offending, but none of these were apparent when they gathered data six months after the intervention. The program might show delayed effects of the treatment, which could explain why these changes were not immediately apparent. Unfortunately, longer term data were not collected on these factors.Having answered the question of whether this program works in the UK, the next question, which the researchers are currently tackling, is whether these greater gains come at a reasonable price. Once published, this will help policy makers and commissioners decide whether or not there should be widespread investment in this therapy that helps some of our most hard-to-reach and troubled young people.**********Reference:Butler, S., Baruch, G., Hickey, N & Fonagy, P. (2011). A Randomized Controlled Trial of Multisystemic Therapy and a Statutory Therapeutic Intervention for Young Offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 50(12), 1220-1235.

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