Programs that Work
Multisystemic Therapy (MST)
Healthy and Safe Children
Youths not using alcohol, tobacco, or illegal drugs
Children living in a permanent home
Children and youth not engaging in violent behavior or displaying serious conduct problems
Age of Child
Type of Setting
Community-Based Service Provider
Health Care Provider
Type of Service
Type of Outcome Addressed
Substance Use and Dependence
Evidence Level (What does this mean?)
Multisystemic Therapy (MST) is an intensive, family-based treatment approach for improving the antisocial behavior of serious juvenile offenders. MST seeks to reduce youth criminal activity and other kinds of negative behavior (for example, drug abuse) in a cost-effective manner by limiting the need for incarceration or other types of out-of-home placement. Adaptations of MST have also been developed for child abuse and neglect, psychiatric issues, substance abuse, and problem sexual behavior.
Developed in the 1970s by MST Services board director Dr. Scott Henggeler and Dr. Charles Borduin, the MST model is based on the belief that youth behavior is determined by multiple factors, such as youth's social and cognitive development, family relations, peer interactions, and community influences, and that each of these factors can be targeted to promote positive behavioral change. Thus, depending on the youth's individual circumstances, MST treatment may aim to improve a caregiver's discipline practices, decrease the youth's interaction with deviant peers, improve the youth's school performance, or aim to produce other positive results. The MST approach is guided by nine principles:
- Finding the Fit—how youth problems relate to youth's environment
- Focusing on Positives and Strengths—build on strengths currently present in youth's lives
- Increasing Responsibility—promote responsible behavior
- Present-Focused, Action-Oriented and Well-Defined—focus on actions that can happen immediately and have clear outcomes that can be measured
- Targeting Sequences—target the interaction between youth and external influences
- Developmentally Appropriate—appropriate to youth's age and developmental needs
- Continuous Effort—families are expected to show effort on a daily or weekly basis
- Evaluation and Accountability—the MST team is responsible for overcoming barriers to success, and intervention effects are monitored continuously
- Generalization—youth's caregivers are equipped to handle all family issues after intervention ends.
The original version of MST targets juvenile offenders, age 12-17, and their families. The targeted youth are chronic, violent, and/or substance-abusing juvenile offenders at high risk of out-of-home placement. More recently, adaptations of MST have also been developed for youth that have experienced abuse and neglect, psychiatric issues, substance abuse, and problem sexual behavior.
In one study (Henggeler, Melton, and Smith, 1992), 84 serious juvenile offenders and their families were randomly assigned to two groups: One group received MST, and the other received the usual services provided by the local Department of Youth Services. Going into the study, the youths averaged 3.5 previous arrests and 9.5 prior weeks of incarceration. The youths lived in South Carolina; they had an average age of 15.2 years; 77 percent were male; and 56 percent were African-American, 42 percent were white, and 2 percent were Hispanic.
Before the treatment began, both groups completed a battery of tests evaluating family relations, self-reported delinquency, and other items. The same tests were given after treatment, approximately 13 weeks later. Fifty-six out of the original 84 participants completed both tests and were included in the analysis of test results. (A separate analysis determined that rates of dropout from the study did not affect the comparability of the two groups.) Fifty-nine weeks after the start of treatment, researchers examined arrest and incarceration records for all 84 youth to determine whether there were differences between the two groups. Still later, in a follow-up study (Henggeler et al., 1993), researchers analyzed arrest data for the two groups, 2.4 years after initial treatment began.
In another study (Borduin et al., 1995), 176 serious juvenile offenders and their families were randomly assigned to two groups: One group received MST, and the other received individual therapy that mimicked typical community treatment for juvenile offenders in the area. Individual therapy was provided by master's-level therapists and used either a psychodynamic, client-centered, or behavioral approach. All individual therapy focused on the adolescent and ignored the external factors, or "systems," surrounding youth. Going into the study, the youths averaged 4.2 previous arrests. The youths lived in Missouri; they had an average age of 14.8 years; 68 percent were male; and 70 percent were white and 30 percent were African-American.
Each group completed a battery of tests prior to and approximately four months after the treatment. Of the original 176 participants, 126 completed the two sets of tests and were included in the analysis of test results. (A separate analysis determined that attrition from the study did not affect the comparability of the two groups.) Researchers also analyzed arrest data for all youths in the two groups, comparing differences four years after the study began. In a related analysis, the two groups were compared to see whether there were differences in the number of substance-related arrests (Henggeler et al., 1991).
In a four-year follow-up to an earlier study, Henggeler et al. (2002) looked at the long-term effects of MST. The researchers contacted 90 percent (106) of the original 118 study participants, 80 of whom provided information at the four-year follow-up. The study examined criminal behavior, substance abuse, and psychiatric symptoms. Participants completed the Self-Report Delinquency Scale, which measures aggressive and property crimes committed in the past 12 months. The study also looked at law enforcement records for convictions that occurred in the previous 2.5 years. Four years after treatment ended, substance abuse was reported by participants through a scale using established measures from the Young Adult Self-Report, the Addiction Severity Index, and the Youth Risk Behavior Survey. Because self-reported measures may not be reliable by themselves, the study used biological drug tests to supplement the self-reported questionnaire. For these drug tests, the study gathered hair and urine samples from participants at the same time the questionnaires were administered and once again, during the next year. Psychiatric symptoms were measured using the Externalizing and Internalizing scales of the Young Adult Self-Report.
Early studies of MST were conducted by teams that included at least one of the MST program developers in a controlled setting. Timmons-Mitchell et al. (2006) tested the effectiveness of MST when administered in a community setting without direct oversight from a principal developer of the approach, and this study team did not include any program developers. Youth that appeared in a Midwestern family court were randomly assigned to receive either MST or treatment as usual. In this case, treatment as usual was primarily centered on referrals to youth for such services as anger management courses and individual counseling. The study collected baseline information from both groups on the demographic characteristics, criminal history, and scores on the Child and Adolescent Functional Assessment Sale (CAFAS). CAFAS measures youth functioning in several areas, including school, work, community, behavior toward others, and substance abuse. The study collected two more sets of CAFAS scores, once just after completing MST and again six months after treatment ended. Criminal histories of youth were tracked until 18 months after treatment ended. CAFAS scores and criminal histories from the treatment-as-usual group were collected at time intervals approximately equal to those for the MST group.
Key Evaluation Findings
Three related studies of serious juvenile offenders and their families (Henggeler et al., 1991, 1992, and 1993) found the following:
- After 13 weeks of treatment:
- MST youth reported significantly less peer aggression than did non-MST youth.
- MST youth reported significantly lower use of alcohol and marijuana than did non-MST youth.
- MST families showed significantly more family cohesion than did non-MST families.
- Fifty-nine weeks after treatment began:
- Significantly fewer MST participants had been arrested than had non-MST participants (42 percent versus 62 percent).
- MST participants had spent significantly fewer days in incarceration than had non-MST participants. Twenty percent of MST participants had been incarcerated, compared with 68 percent of non-MST participants.
- Significantly fewer MST participants had been arrested than had non-MST participants (42 percent versus 62 percent).
- Almost 2.5 years after treatment began, significantly fewer MST participants had been arrested than had non-MST participants (61 percent versus 80 percent).
- After about four months of treatment, MST families reported significantly greater family cohesion and fewer youth behavior problems than did non-MST families.
- Four years after treatment began:
- Significantly fewer MST youths had been arrested compared with non-MST youths (26 percent versus 71 percent).
- Significantly fewer MST youths had been arrested for substance-related offenses compared with non-MST youths (4 percent versus 16 percent).
- Among the youths that were arrested following treatment, those in the MST group were arrested for significantly fewer serious and violent crimes than were those in the non-MST group.
- MST was equally effective with youths of different genders and ethnic backgrounds.
- Youth that had participated in MST reported fewer aggressive crimes and were convicted of fewer aggressive crimes than the treatment as usual participants.
- MST participants showed significantly higher rates of marijuana abstinence on biological tests, but did not self-report significantly higher abstinence rates.
- Youth that had participated in MST did not show significant reductions in property crimes, cocaine use, or psychiatric symptoms compared to treatment-as-usual participants.
- Immediately after treatment, youth in the MST group showed substantial improvement in school/work, home, community and mood/emotional functioning.
- In the 18 months after treatment, youth participating in MST were three times less likely to be re-arrested and were arrested and arraigned for fewer new offenses.
MST programs are typically housed within public mental health organizations or in private provider organizations that offer mental health services. MST programs typically interact with multiple local agencies (for example, juvenile justice, mental health, and social welfare agencies) as well as with schools and family courts.
Funding for MST may come from a variety of sources, including Medicaid reimbursement, state children's services funding, program-level grants to reduce recidivism, funds diverted as an alternative to out-of-home placements for youth, and state reimbursements to managed care organizations that treat emotionally disturbed youth.
Training and comprehensive program support for MST can be obtained from MST Services or any of the more than 20 MST Network Partner organizations, which are fully certified to deliver MST training. More information about training in MST and MST Network Partner organizations is available at www.mstservices.com.
Books, training materials, and DVDs can be purchased from the MST online store. Prices range from $15 (in 2011 dollars) for a DVD to $115 (in 2011 dollars) for the MST startup kit. While MST does not publish the cost to treat individuals on its website, a review of national research on MST (Aos et al., 1999) found that the average program cost is about $4,500 per MST participant (in 1998 dollars). A more recent study (Sheidow et al., 2004) estimated the average cost to treat one individual for psychiatric problems with MST at about $8,200 (in 2004 dollars).
MST uses techniques from cognitive, behavioral, and family therapies. Each MST treatment plan is designed by an MST-trained team, usually composed of three master's-level counselors and a clinical supervisor. Guided by the nine principles, the team develops a treatment plan in collaboration with the youth's family members; the plan is family-driven rather than therapist-driven. The overall objectives of MST treatment are to empower caregivers with the skills and resources they will need to address the inevitable difficulties associated with raising teenagers, and to empower youths with skills and resources for coping with family, peer, school, and neighborhood problems. Over the course of treatment, MST therapists place developmentally appropriate demands on the youths and family members so that they behave in an increasingly responsible manner.
MST does not have a prescribed or set curriculum.
Staffing and Training
Master's-level therapists, who work for the MST program, provide treatment. Each full-time therapist carries a caseload of four to six families. The therapists are organized into "teams" of two to four; each team of therapists receives on-site supervision, usually by a Ph.D.-level mental health professional. MST therapists are required to track weekly progress and outcomes on each case by completing case paperwork and participating in clinical supervision and MST consultation.
Staff training and program development assistance are provided by MST Services, through licensing agreements with the Medical University of South Carolina and the Family Services Research Center. The core services for program development and training include the following:
- organizational assessment and assistance
- an initial five-day training session
- weekly MST clinical consultations
- quarterly "booster" training sessions
- ongoing monitoring for treatment fidelity and adherence.
Issues to Consider
This program received a "proven" rating. Two rigorous studies found that MST was effective in reducing arrests and incarceration among serious juvenile offenders. Furthermore, positive outcomes were shown to persist for two to four years after treatment began. While the program developer was involved in all the major studies of MST, the research was conducted and reported according to high scientific standards.
Additional research has examined how MST performs with other populations, such as substance-abusing juvenile offenders (Henggeler et al., 1999a) or youths in psychiatric crisis (Henggeler et al., 1999b). Henggeler et al. (1999b) found evidence that a modified form of MST was more effective than hospitalization at reducing externalizing psychiatric symptoms and improving self-esteem. Henggeler et al. (1999a) supplemented traditional MST with psychopharmacological treatment and found this combination was more effective at reducing substance use than non-MST "service as usual." Timmons-Mitchel et al. (2006) also looked at substance use as an outcome possibly affected by MST. Although they found improvement in substance use outcomes, the effect was not statistically significant and it is not clear whether the improvement was due to multisystemic therapy. However, the Timmons-Mitchel et al. (2006) study was not specifically targeting substance-abusing youth, so they may not have had enough of these youth to detect program effects on substance use. These studies suggest that MST may need to be adapted if it is to serve populations with specific needs beyond those of "typical" juvenile offenders.
Other research has investigated MST's effectiveness when delivered under "real-world" conditions, under which study authors did not have control over hiring MST therapists and could not ensure the integrity of treatment delivery (Henggeler et al., 1997). Again, the results were mixed, suggesting that adherence to strict MST protocols (including regular, expert supervision) may be essential to program success. Timmons-Mitchell et al. (2006) found positive effects when MST was delivered in the community without direct oversight from the program developer, but the effects were smaller than those shown in more-controlled studies. These less-favorable studies do not take away from the demonstrated success of MST when delivered under standard protocols and with serious juvenile offenders. Rather, these later studies indicate the difficulties that program implementers may face as they attempt to expand the program.
MST programs operate in 30 states and in 11 countries outside of the United States, including Australia, Canada, Iceland, Norway, New Zealand, England, the Netherlands, Northern Ireland, Sweden, Switzerland, and Denmark. All licensed sites are listed on MST's website: www.mstservices.com.
For further information about program development, treatment model dissemination, and training, contact:
Marshall E. Swenson, MSW, MBA
Manager of Program Development
MST Services, Inc.
710 Johnnie Dodds Blvd., Suite 200
Mt. Pleasant, SC 29464
Tel: 843-856-8226, ext. 215
Melanie Duncan, Ph.D.
Program Development Coordinator
MST Services, Inc.
710 Johnnie Dodds Boulevard, Suite 200
Mt. Pleasant, SC 29464
For further information about research-related issues, contact:
Dr. Scott W. Henggeler
Family Services Research Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
326 Calhoun St.
Charleston, SC 29425-0742
Phone: (843) 876-1800
Fax: (843) 876-1808
Aos, Steve, Polly Phipps, Robert Barnoski, and Roxanne Lieb,
The Comparative Costs and Benefits of Programs to Reduce Crime,
Olympia, Wash.: Washington State Institute for Public Policy, Version 3.0, May 1999. As of March 9, 2011:
Borduin, Charles M., Barton J. Mann, Lynn T. Cone, Scott W. Henggeler, Bethany R. Fucci, David M. Blaske, and Robert A. Williams, "Multisystemic Treatment of Serious Juvenile Offenders: Long-Term Prevention of Criminality and Violence," Journal of Consulting and Clinical Psychology, Vol. 63, No. 4, 1995, pp. 569-578.
Henggeler, Scott W., Charles M. Borduin, Gary B. Melton, B. Mann, Linda A. Smith, J. Hall, Lynn Cone, and Bethany Fucci, "Effects of Multisystemic Therapy on Drug Use and Abuse in Serious Juvenile Offenders: A Progress Report from Two Outcome Studies," Family Dynamics of Addiction Quarterly, Vol. 1, No. 3, 1991, pp. 40-51.
Henggeler, Scott W., Gary B. Melton, and Linda A. Smith, "Family Preservation Using Multisystemic Therapy: An Effective Alternative to Incarcerating Serious Juvenile Offenders," Journal of Consulting and Clinical Psychology, Vol. 60, 1992, pp. 953-961.
Henggeler, Scott W., Gary B. Melton, Linda A. Smith, Sonja K. Schoenwald, and Jerome H. Hanley, "Family Preservation Using Multisystemic Treatment: Long-Term Follow-Up to a Clinical Trial with Serious Juvenile Offenders," Journal of Child and Family Studies, Vol. 2, 1993, pp. 283-293.
Henggeler, Scott W., Gary B. Melton, Michael J. Brondino, David G. Scherer, and Jerome H. Hanley, "Multisystemic Therapy with Violent and Chronic Juvenile Offenders and Their Families: The Role of Treatment Fidelity in Successful Dissemination," Journal of Consulting and Clinical Psychology, Vol. 65, No. 5, 1997, pp. 821-833.
Henggeler, Scott W., Melisa D. Rowland, Jeff Randall, David M. Ward, Susan G. Pickrel, et al., "Home-Based Multisystemic Therapy as an Alternative to the Hospitalization of Youths in Psychiatric Crisis: Clinical Outcomes," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 38, No. 11, pp. 1331-1339, 1999b.
Henggeler, Scott W., Susan G. Pickrel, and Michael J. Brondino, "Multisystemic Treatment of Substance-Abusing and -Dependent Delinquents: Outcomes, Treatment Fidelity, and Transportability," Mental Health Services Research, Vol. 1, No. 3, pp.171-184, 1999a.
Henggeler, Scott W., W. Glenn Clingempeel, Michael J. Brondino, and Susan G. Pickrel, "Four-Year Follow-Up of Multisystemic Therapy with Substance-Abusing and Substance-Dependent Juvenile Offenders," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 41, No. 7, 2002, pp. 868-874.
Sheidow, Ashli J., W. David Bradford, Scott W. Henggeler, Melisa D. Rowland, Colleen Halliday-Boykinds, Sonja K. Schoenwald, and David M. Ward, "Treatment Costs for Youth Receiving Multisystemic Therapy or Hospitalization After a Psychiatric Crisis," Psychiatric Services, Vol. 55, No. 5, 2004, pp. 548-554.
Timmons-Mitchell, Jane, Monica B. Bender, Maureen A. Kishna, and Clare C. Mitchel, "An Independent Effectiveness Trial of Multisystemic Therapy with Juvenile Justice Youth," Journal of Clinical Child and Adolescent Psychology, Vol. 35, No. 2, 2006, pp. 226-236.