Multisystemic Therapy: How It Works, Cost, & What to Expect

What Is Multisystemic Therapy?

Multisystemic therapy (MST) is an intense, community-based, family-involved psychotherapy model for people under 18 who have had serious legal involvement as well as potential substance use issues. It’s provided over the course of four to five months, multiple times a week; a team is available at all times in case of crises. MST focuses on the underage individual’s environments and risk areas in school and the community, as well as with friends and family.^1,2

The MST Theory of Change

MST theory of change is largely based on Bronfenbrenner’s ecological systems model, which expands on some of the basic concepts of family systems theory. It posits that behavior change is influenced directly and indirectly by the interplay of multiple systems that the individual comes from such as family, peers, school, and their community. All these factors can play a huge role in causing, maintaining, and changing negative behaviors.

How Does MST Work?

MST applies treatment in many areas of the adolescent’s life, especially in their supportive environment. For this to be possible, it has a number of primary concepts to help apply lessons and increase the individual’s and the family’s strengths.

The four core concepts of MST are:

1. Identify the “fit:” This requires an evaluation to clarify the connection or “fit” between the identified behaviors and how they play out in different environments. It focuses on what maintains certain continued behaviors.³
2. Concentrate on strengths and increase responsibility: It is important for the treatment team to concentrate on and identify strengths and positive behaviors to encourage good change and coping mechanisms. This helps increase the individual’s (and the family’s) accountability and reduce irresponsible behaviors.³
3. Focus on the present, clearly identify issues, and take action: This helps the team and the family engage in interventions with automatic feedback, actively work on goals, and measure progress without focusing on the past.³
4. Making effort, evaluating the treatment, and encouraging continued application: Due to the intense nature of MST, it is important that challenges are continuously engaged in the individual’s life to encourage their commitment. Further, it supports continuous re-assessment of techniques or goals to ensure they are effective and can be carried into day-to-day life once treatment is over.³

What’s the Goal of MST?

The goal of MST is to reduce unhealthy behaviors and keep underage individuals out of legal involvement within their environment.² This requires the treatment team to identify difficulties and evaluate how these difficulties connect and “fit” within multiple environments.⁴ MST validates appropriate social behavior and attempts to reduce unhealthy behaviors in the family as well.²

While the overarching goal of MST is to complete structured therapy, specific goals regarding certain behaviors or interactions in the client’s environment are set by a main therapist, a team of MST professionals, their supervisor, and the family.

Who Is MST For?

MST can help increase problem-solving and prosocial behaviors in adolescents who present with aggressive, antisocial, or serious criminal behaviors, like fighting, verbal or physical aggression, and serious legal charges. It’s also used to treat teens who make frequent suicidal or homicidal threats or experience substance use issues.¹

However, MST is not only applicable to underage individuals; it is frequently used with parents or guardians in the family unit. It helps address difficulties with mood and anger management, possible substance abuse issues, and other obstacles to efficient parenting skills, such as parents’ mental health issues or high stress situations.¹

What Is MST Treatment Like?

MST is an intensive, brief therapy program that uses specific strategies and techniques that are tailored according to the “fit” of factors driving the problem behavior. Interventions are closely monitored for efficacy and modified as needed.

Here is what to expect during multisystemic therapy:⁵

Behavior Therapy

A key component of MST is conceptualizing concerns affecting the adolescent, the family, and other broader aspects of their environment that are contributing to the behavior problems. Then, different behavioral interventions are devised to help reduce the frequency and severity of troublesome conduct by targeting them and de-escalating difficult situations within the setting where these behaviors occur. MST therapists also work with the family’s strengths to promote positive coping strategies, reduce negative behaviors, and reinforce more adaptive behavioral patterns.

Parent Management Training

Another MST area of focus is improving parental efficacy by empowering caregivers with the knowledge to build the necessary skills to manage the adolescent’s current and future behavioral issues. For example, parents are encouraged to get involved with their teen’s academics and extracurriculars, peer group, etc. Similarly, they are coached on ways to improve their parenting practices, discipline strategies, and family interactions. Ultimately, parent training can mitigate the risk-factors linked to antisocial behavior and assist the family unit to work through potential life obstacles that may arise along the way.

CBT

Cognitive-behavioral therapy (CBT) is often integrated within the MST model to increase prosocial attitudes and skills, reducing other individually based problems for parents and youth. Depending on the issues the person is having, different CBT techniques will be employed, like cognitive restructuring and journaling.

Pragmatic Family Therapy

One of the goals of MST treatment is to improve family functioning so caregivers can address the multiple factors known to be related to delinquency across the key systems in which the young person is embedded. Structural and strategic family therapy techniques are incorporated into the MST program, which can help the family increase accountability and problem-solving skills. This intervention also fosters the use of strengths within the young person’s system to facilitate change, foster responsible behavior, and decrease careless behavior among family members.

24/7 availability

The MST treatment program is designed to have an on-call therapist seven days a week, 24-hours a day. Each MST professional carries a small caseload consisting of about four to six families and works jointly as a team with other staff members. Because of this, the MST treatment team has the flexibility to assist families at times that are convenient for them, provide effective crisis management, and offer high standards of direct care to each family.

Short Treatment Timeline

Although there isn’t an established specific length of service for MST-based care, the average treatment timeline is often brief. MST typically occurs throughout the course of approximately 3-5 months. Therapist-family contacts can take place as often as necessary, but on average professionals meet with youth and families two times per week at home, school, and/or other appropriate settings.

tential evidence-based treatments for families, including multisystemic therapy. By 1996, MST Services was established as the major organization for training, developing, assessing, and ensuring quality adherence with MST.

Examples of Multisystemic Therapy

Multisystemic therapy can be applied in a variety of situations involving adolescents, their families, and outside environments. Examples indicate the level of intensity, extensive involvement, behavior and safety planning, and coordination between the team, family unit, potential legal professionals, and outside support.

Here are three examples of MST:

1. James: Increased Dangerous Behaviors & Missing School

14-year-old James’ parents express concern about his affiliation with known gang members, an increase in dangerous behaviors (carrying weapons and stealing), going missing for periods of time, and increased fighting and aggression at home and school. His teachers note isolation and minimal attendance. His parents want him to be monitored outside of the home before he receives more serious legal consequences or hurts himself or someone else. In addition to requesting potential residential care, James is monitored in an alternative school due to previous legal involvement.

When the MST therapist and team become involved, they address the parents’ approaches to behaviors, identifying how poor communication (explosive arguments and conversations) and physical discipline are not necessarily helpful in reducing risky behaviors. They identify sequencing patterns to help parents understand how interactions can become so explosive, validating the parents to recognize their feelings and help James do the same. The team also works with James and the family on communication and a behavior response plan, as well as providing crisis support for when situations escalate at school, with friends, and at home.

Over time, James shows a decrease in risky behaviors, increased social support in school, significantly less interactions with juvenile detention, and ultimately, a reduction in involvement with CPS for the family.

2. Kayla: Substance Misuse & Dealing Drug

Kayla, a 16-year-old, presents with daily substance use, dealing drugs in the neighborhood and at school, running away frequently, and engaging in behaviors of physical and verbal aggression at home, school, and in the community. She also faces charges of criminal damage, assault, and carrying weapons. She recently ran away prior to referral and was found five days later at a significantly older man’s apartment; he was also a sex offender. Due to these behaviors, her parents request that Kayla be placed out-of-home due to risk to self and others.

The MST team sets a safety plan, requiring Kayla to pass daily dorm and item searches for substances and weapons. In the case of Kayla running away again or missing curfew, the plan includes expectations to bring her home. Another plan is placed with support from the neighborhood and teachers at school to increase her attendance and reduce her chances of buying or dealing drugs.

Next, the MST team requires drug testing. Kayla earns rewards if the tests are negative and consequences if they’re positive. The team applies sequencing to help Kayla and her supporters understand and monitor what was influencing her substance use, help her increase insight to triggers, and ultimately reduce these triggers. Ultimately, Kayla is able to return home, increase communication, and significantly reduce any criminal or aggressive behaviors.

3. Chris: Sexual Assault

Chris, a 13-year-old, receives two charges of rape against his youngest sibling, Anna. In addition, Chris’s teachers express concern about sexual communication between Chris and his classmates, including invitations to come to his house. The court refers him to treatment and requires the Problem Sexual Behaviors program (MST-PSB). He is placed at another family member’s house to ensure no contact with Anna.

The MST-PSB team initiates a safety plan that allows all involved professionals, including his parents, guardians, and Anna’s therapist to explore any concerns and behavioral assessments moving forward. Chris’s therapist meets with him individually as well as with his parents and guardians. MST staff is able to assess and walk his family through supportive care. They also help guide conversations between Chris and his guardians about what happened, ensuring to highlight the “fit,” or connection between the behaviors and what influenced them.

Chris is able to write an apology letter and meet with his sister (with her therapist’s approval) for the first time since the assault. This gives Chris, his family, and outside supporters the opportunity to gain more insight into the reasons he engaged in these behaviors. It also encourages productive conversations between Chris and his family members about Chris’ negative perspectives of women due to the domestic violence he witnessed between his parents. This allows further productive discussions about appropriate sexual behaviors. Upon completion of MST-PSB, Chris is able to move back in with his father, separate from his mother and Anna, reduce his sexual behaviors, and visit his sister regularly.

How to Find a Multisystemic Therapist

If the adolescent has already referred to some type of family therapy or program due to previous legal involvement or concerning behavior, communicate with your legal counsel or Child Protective Services to see if the court might consider MST. You can also check with the residential program or institution (if the individual is already placed out-of-home).

If the individual isn’t in a program yet, check the MST services site to assess their eligibility and find contact information for services in your area. You could also contact your local children’s hospital or treatment programs, especially if the adolescent has already been seen there. A therapist, psychiatrist, or primary care doctor should also be able to provide information or referral.

Who Is Able to Offer Multisystemic Therapy?

An MST team is typically made up of a supervisor, two to four therapists (all on the on-call team), and an outside team manager to call for emergencies. All of these people must have been trained to provide MST services by the leading company at the time.⁸ People who provide MST are also required to have obtained a master’s degree in counseling or social work.

Key Questions to Ask a Multisystemic Therapist When Considering

During an already difficult time, considering intensive therapy can make things feel even more stressful; however, it can be helpful to ask questions to be able to make the best decision for the family.

Here are some questions to ask before beginning multisystemic therapy:⁷

• What is multisystemic therapy and how can it help me?
• How often will you be seeing our family and where?
• How can I reach you in the middle of a crisis?
• Where can you meet our family if, for example, our child is at school?
• Are there other types of MST that may be more appropriate for our family?
• How much will MST services charge to treat me and my family?
• What are your measurements of success in regards to treating families and what do these success rates look like?

How Much Does Multisystemic Therapy Cost?

Research on cost of MST is rooted in underage individuals being insured by Medicaid, which covers potential hospitalizations, physical health care, dental care, and other mental health services in addition to MST. One study noted that costs were about $5,500 per family.⁶ Medicaid funding remains imperative, and grants are available for families who are not eligible for Medicaid.^6,7

What to Expect at the First Appointment

The first session of multisystemic therapy will require the attendance of the team supervisor, the main therapist, and all family members, including the adolescent. The session will generally begin with paperwork regarding consent, limitations of confidentiality, and general rules, such as hours of contact and how the team works.

After this, there may be some assessments and a guided discussion of the issues that have led to the family and individual pursuing MST. Then the supervisor and therapist will likely set a crisis plan, including crisis contacts. They may begin discussions of a behavior plan and begin to set boundaries for how sessions will occur, who will attend, how information will be shared, and the expectations they have.^7,9

Is Multisystemic Therapy Effective?

Many studies on multisystemic therapy have shown evidence of significant changes in the underage individual’s aggressive behavior, legal offenses, and interpersonal relationships.

Here are three different studies regarding the effectiveness of MST:

• Henggeler and colleagues (1992) reported a randomized control trial study of MST in South Carolina with underage offenders who were treated with either a) general care or b) MST. After 59 weeks, results indicated that the MST group had roughly half the re-arrests as the general care group, a significant decrease in recidivism and time spent in juvenile detention facilities. Only 20% had been incarcerated compared to 68% of the general care group. In addition, the MST group indicated increased connection with their families as well as decreased aggression with their friends.³
• Timmons-Mitchell and colleagues (2006) reported a study of the implications of MST on recidivism and underage individuals’ abilities to function 6 months after treatment. Results noted that the MST group’s recidivism rate was 86.7% compared to general care, there were significantly less re-arrests and more improvements on children’s measurements in six areas. It also improved functioning in school and work compared to general care. However, they did match the general care group on substance abuse with no significant differences.³
• Sheidow, Bradford, Henggeler, Rowland, et al. (2004) completed a randomized clinical trial that compared Medicaid charges following hospitalization for those being treated with a) general care or b) MST. Medicaid charges for those in the MST group indicated a savings of $1,617 per individual, although this did change to $400 per individual after a year.⁶

Criticisms of MST

After evaluations, only 5% of underage individuals with serious offenses receive evidence-based treatment like MST. While there are not many criticisms of the treatment, researchers in 2004 noted that Medicaid savings for each youth went down significantly by the end of the year, from $1,617 to $400. This research, however, didn’t assess for changes in re-arrest or measure aggressive behavior; it only measured interactions with care teams or hospitalizations.⁶

How Is MST Different From Other Family Therapy Options?

While multisystemic therapy has much evidence supporting it with a few criticisms, there are other treatment options for families. MST differs in a number of ways from these different treatments, including functional family therapy (FFT).

The initial difference between MST and FFT is in the population they treat. FFT focuses on underage individuals who are high-risk (i.e., gang correlation, abuse history, or substance abuse background) but have committed less serious crimes. MST, on the other hand, treats underage individuals who may end up incarcerated; they are typically repeat violent offenders.^7,11

Another difference between MST and FFT includes the amount of contact between families and therapists. In MST, therapists are on-call 24/7 for crises, will spend as long as needed during sessions, and may initially start out with almost daily contact. Over four to six months, there may be 60 or more hours of contact. In FFT, total time of family-therapist contact ranges between about 25 to 30 hours of contact.^7,11

History of MST

Multisystemic therapy began in the 1970s with Dr. Scott Henggeler and his graduate student, Dr. Borduin, at Memphis State University. There were minimal effective treatments for serious underage individuals’ behavior outside of mental health hospitalizations and “scared straight” tactics.

While working with inner-city and continuous underage offenders, Henggeler noted an ignorance of risk factors for criminal behavior, realizing that many services didn’t engage families in treatment either. Using Bronfenbrenner’s social ecological theory of human nature, they aimed to empower the families and address the individual’s behavior as well as the risk factors in their environments.¹²

The Family Services Research Center was built in 1992 to explore, develop, validate, and publish potential evidence-based treatments for families, including multisystemic therapy. By 1996, MST Services was established as the major organization for training, developing, assessing, and ensuring quality adherence with MST.