Multisystemic Therapy in The Netherlands: Implementation and Effectiveness

Multisystemic Therapy (MST) is an intensive home- and community-based treatment
for youth who show
serious, violent and chronic antisocial behavior. Since 2004, MST has been
implemented on a small-scale basis in The Netherlands. From 2006, in order to
ensure availability of a (potentially) successful treatment all over The
Netherlands, a
large-scale implementation of MST will be conducted. The reasons for the choice
of this treatment are
first, its strong theoretical foundation and second, empirical support for its
effectiveness from controlled
clinical trials in the USA. Notwithstanding these positive indications, there
are also reasons for caution. A recently published review by Littell (2005) has
questioned the conclusion that MST is effective by pointing out that
inconsistent and incomplete reports have been published. Also, with few
exceptions, most of the empirical support comes from studies conducted by the
same group of researchers who also developed and implemented MST. There is a
clear need for confirmation of these results by an independent team of
researchers. Even more importantly, due to the differences between the two
countries in social and political climate, organization of mental health
services, availability of
different treatments, type and ethnic background of clients, etc., it is not
known whether the same
positive results will be obtained here. Many of the treatments available for
adolescents who show serious and persistent antisocial behavior have never been
properly evaluated in The Netherlands. Moreover, the poor quality of most
evaluation studies does not allow reliable and valid conclusions. This fact has
been repeatedly emphasized as an important obstacle in development and
refinement of evidence-based interventions. This concerns an evaluation study
in which a new, promising treatment for juvenile delinquents, Multisystemic
Therapy, is compared to Treatment as Usual in The Netherlands.

This project aims to examine the implementation and effectiveness of MST in The
Netherlands.

The aim of Implementation study is to determine the degree to which MST is
implemented as intended at different sites in The Netherlands. Following
questions are asked:
1a. What is the degree of treatment integrity, as perceived by clients
(adolescent and parents), MST
therapist and MST supervisor?
1b. Are all components of multilevel quality assurance system (training,
supervision and consultations by
MST supervisor on the site and by MST consultant) included?
1c. Is the targeted population of MST recruited and retained? What are the
referral paths? What are the
reasons for case discharge/drop-out?
1d. Is treatment integrity affected by organizational and service system
characteristics, client- and
therapist characteristics?

The aim of Effectiveness study is to determine short and long term effects of
MST.
Following questions are asked:
2a. Does MST yield to better outcomes (decrease in recidivism and in rate and
seriousness of antisocial
behavior, increase in adolescent competence, improvement in family relations
and relations with peers)
in chronic juvenile offenders than *treatment as usual* (TAU)?
2b. To what degree is effectiveness of MST affected by treatment integrity,
characteristics of MST
therapists and characteristics of clients?

The aim of the cost-effectiveness study is to gain insight into the balance of
costs and benefits of MST compared to CAU.

The design of Implementation study is a multi-site, non experimental,
one-group-only design. Data will be gathered immediately prior to the beginning
of treatment (T1, pre test assessment), immediately after treatment (T2, post
test assessment) and 6 months after the end of treatment (T3, follow up). The
participants include all (new) MST teams and their clients. These twelve teams
include each 3 to 5 therapists, with a caseload of 4-5 clients per therapist
and an average length of treatment around 5 months. Even when allowing for a
slow start at some of the locations, this means that it will be possible to
obtain data on at least 300 to 350 MST treatments in the course of the present
study (two years of data collection). This sample is large enough to answer our
research question. The information will be collected by the National Monitoring
System to be developed together with researchers involved in the Development
and Implementation Trajectory and researchers evaluating Functional Family
Therapy (FFT).

In order to determine whether MST yields effects superior to the treatment as
usual, a randomized clinical trial will be conducted. Clients will be randomly
assigned into either treatment group (MST group) or control group (*treatment
as usual* group - TAU). Randomisation will take place on the level of the
clients, rather than on team level. Clients will be randomised at referral.
Only those who are randomized to the MST condition will be treated by MST
therapists. Families in the control group (TAU) will not be treated by MST
therapists, but by other therapists (in the same or in the other institutions).
This is consistent with the requirements of MST: the MST therapists focus
exclusively on MST and conduct no other form of therapy. Following the time
schedule of Implementation study, pretest assessment (T1) will take place
before random assignment into groups, posttest assessment (T2) will take place
immediately after treatment (5 months), and follow up (T3) will be conducted 6
months after treatment. In this study only teams who are experienced in the MST
(i.e. who have been involved in MST for longer than a year) will participate,
in order to control for the starting difficulties in using the new treatment
model. This includes about 7 teams of De Viersprong, Jeugdzorg Drenthe, and De
Waag. Most analyses will be carried out on client level. A sample size of 64
per group is sufficient to test differences in outcomes between MST and TAU
groups, assuming .80 power, an alpha of .05 and a medium effect size (Cohen,
1992). In the present study N=100 per group can be easily reached (5 teams, 3-5
therapists per team, case load 3-5 clients, length of treatment around 5
months, two years of data collection).

Multisystemic Therapy (MST)
The MST is based on social ecological and family systems theories, and on
research on the causes and correlates of serious antisocial behavior. It
addresses several key systems in which adolescent is embedded: family, school,
peer group, neighborhood. Intervention strategies include strategic family
therapy, structural family therapy, behavioral parent training, and cognitive
therapies. Treatment is typically delivered for 4 to 6 months and it is
individualized to address specific needs of clients. Therapists are available
24 hrs/day and, 7 days/week. MST uses a home-based model of service delivery
which model helps to overcome barriers to services access and increases family
retention in treatment. In consultation with family members, the therapist
identifies a well-defined set of treatment goals, assigns the tasks required to
accomplish these goals, and monitors the progress in regular family sessions at
least once a week.
Treatment as Usual (TAU)
The adolescents in the control group will receive *treatment as usual*, a
selection of the treatments that are already available for the treatment of
antisocial behaviour, including juvenile justice services, child welfare
services, individual adolescent counseling and home-based social services
(parental counseling). The counseling focuses on personal, family and
school-related issues, which were found to be related to the development and
persistence of antisocial behavior. The exact content of TAU will be decided
upon together with the local referrers.

Filling in questionnaires about parenting and behavior of the child (and
participating in interviews by telephone and for a selected small group
participating in short observations) and about costs related to the treatment
by parents and adolescents is limited in time and costs, and the associated
risk is small. The contribution of therapists (short questionnaires) also is
limited in time and costs, and the associated risk is small. The only risk is
that filling in questionnaires about parenting and the child and about costs
related to the treatment will lead to additional requests for assistance. Since
families receive treatment, we expect minimal adverse effects. Benefit of the
study is being able to provide information that may help improve implementation
of evidence-based treatments in community setting. Second, it will provide the
answer whether a promising approach works on Dutch clients. Finally, by
examining differential effects of MST (for whom and under which circumstances
the MST has best effects) we can provide guidelines for matching clients to the
treatment. We can also determine the cost effectiveness of MST.