Multisystemic Therapy for Emerging Adults (MST-EA)

· MST-EA was designed for young people aged 17-26 at the highest risk for negative outcomes – those with multiple co-occurring problems and extensive systems involvement.

· MST-EA is an adaptation of standard MST, an evidence-based treatment with decades of research supporting its effectiveness with juvenile justice populations.

· MST-EA has been tested thus far with young adults with justice involvement and co-occurring behavioral health disorders (e.g., mood, anxiety, psychotic, trauma-related, and/or substance use disorders).

· Referrals have included juvenile and adult justice system-involved clients, youth aging out of foster care, prison re-entry populations, as well as young adults in supported housing programs.

GOALS OF MST-EA

· Reduce criminal behaviors and recidivism

· Treat behavioral health conditions including:

o Mood Disorders (including Bipolar Disorder)

o Anxiety Disorders (including PTSD and other trauma-related symptoms)

o Psychotic Disorders (including Schizophrenia)

o Substance Use Disorders

· Develop an effective social network (a “family of choice”) for adulthood

· Target housing and independent living skills

· Target education and career goals

· Reduce interpersonal conflict and maintain client and social network safety

· Coordinate medical and psychiatric care

· If applicable, teach parenting skills

MST-EA defines the primary case-specific treatment goals as “Overarching Goals.” Overarching Goals are individualized to each client and are designed to:

· refer directly to the referral/target behavior,

· incorporate the desired outcomes of the emerging adult and other key participants in the young person’s life, and

· be objective, so an outside observer can easily determine whether or not the goal has been met.

TREATMENT DESCRIPTION

MST-EA addresses factors that are the most likely causes of offending and behavioral health problems in emerging adults. MST-EA directly supports the developmentally appropriate life goals (e.g., education, employment, housing) of emerging adults and also helps them build an effective social network, while retaining the underlying principles, processes, and service delivery model of standard MST. With the MST-EA treatment model:

· The emerging adult collaborates with the therapist in designing the treatment plan that will be carried out over approximately 6-12 months depending on client needs.

· The therapist and emerging adult have contact multiple times per week in-person and by phone.

· The emerging adult is an active participant in each stage of treatment.

· Evidence-based interventions (cognitive behavioral therapy, behavioral interventions, motivational interviewing, affective education) are used to address treatment needs.

· Extensive skill building also occurs to address the array of issues associated with the emerging adult’s mental health symptoms, antisocial behavior, and other problems.

· Treatment targets are achieved through changing how emerging adults function in their natural settings (home, school, community), leveraging the emerging adult’s strengths, pulling in positive natural supports, and developing the emerging adult’s skills and resources to overcome barriers to success.

· In addition, psychiatric and physical health professionals are engaged by the MST-EA therapist to coordinate effective health care.

MST-EA Safety Planning and Emergency Response

· Therapists are available 24/7 to emerging adults and their social network to address emergencies and remove barriers to treatment.

· An initial safety assessment is completed with every client, based on the evidence base for risk factors in this population.

· Thorough safety plans are developed as needed and a Safety Support Person(s) is identified for each client.

· Therapists on the MST-EA team rotate on-call coverage so that crises can be defused or avoided, although in-person crisis support is provided when needed.

The Role of the MST-EA Coach

· MST-EA also includes paraprofessional “coaches” who help teach concrete life skills and engage clients in prosocial activities.

· Coaches engage clients in skills training and recreational activities once or twice a week.

· Skills training areas are directly related to the goals of the client's treatment plan, and may include behavior management skills, communication skills, coping skills, problem solving, educational or vocational skills.

ROLE OF FAMILY & NATURAL SUPPORTS IN TREATMENT

· MST-EA clients can be living on their own, with family or friends, in foster care, or in group homes. Emerging adults are guided to identify their values and social network (“family of choice”), with those values guiding all elements of treatment and the social network being actively engaged.

· The emerging adult is the focus of MST-EA. Thus, family or caregiver involvement is not required. However, involvement of family or other supports is strongly recommended, and all efforts are made to identify such supports and include them in treatment.

Eligibility Criteria

The eligibility criteria for MST-EA are as follows:

· Individual must be between the ages of 17 and 26

· Individual must have:

o Justice Involvement: criminal activity or jail/detention/prison in the past 18 months (more than simple probation violation) and/or

o A current behavioral health condition:

Mental illness other than or in addition to ADHD, Conduct Disorder, or ODD
Substance use disorder

· Individual must have stable housing or plan to achieve stable housing (see below)

In addition, eligible individuals may demonstrate any of the following:

· Physical aggression

· School problems: truancy, suspensions, and/or expulsions

· A trauma/abuse history

· Eligibility for adult mental health services

Exclusion Criteria

· CANNOT be actively suicidal, homicidal, or psychotic at the time of referral; that is, those who pose an urgent risk and need hospitalization/inpatient treatment prior to safely living in the community. These referrals can be re-considered when release/discharge from hospitalization/inpatient treatment is approaching.

· NO EVIDENCE of stable housing or plan for stable housing in the community. Group homes, foster home, and supervised living can be accepted. Cannot currently be homeless, in a shelter, or couch surfing without a primary address where sessions can be conducted; or in a hospital, locked residential unit, or in detention.

· CANNOT have a significant history or a pattern of problem sexual behaviors.

· CANNOT have Autism, Pervasive Developmental Disorders, or Intellectual Disability that would prevent or limit the effect of psycho-therapeutic treatments.

· CANNOT have pending charges at referral that are likely to require incarceration that would interfere with treatment completion. These referrals can be re-considered when release/discharge from incarceration is approaching.

Provider Requirements

MST-EA is typically delivered by a team of practitioners employed by mental health and/or substance abuse provider organizations. MST-EA providers must have the ability to deliver services in various settings, such as homes, schools, group homes, etc. Organizations that deliver MST-EA also must provide phone and in-person (as needed) crisis response on a 24-hours-a-day, 7 days a week, 365 days a year basis, to individuals who are receiving this service.

Staffing Requirements

This service model includes at a minimum 1 full-time Master’s level supervisor and 2-4 full-time Master’s level therapists. MST-EA therapists carry a maximum caseload of 4 emerging adult clients. Supervisors do not carry cases. However, Supervisors can provide short-term coverage for cases during staff vacation times and/or in the event of staff turnover.

In addition, the MST-EA team typically includes 4-5 paraprofessional coaches. The caseload for coaches varies based on client needs and coach availability.

Service Type and Setting

MST-EA is a direct and indirect service where the therapist provides direct intervention and also arranges, coordinates, and monitors services on behalf of the emerging adult. MST-EA services are provided in a range of community settings. MST-EA also includes telephone time with the individual and collateral contact with persons who assist in meeting the client’s individualized treatment goals.

Quality Assurance Procedures

To ensure high fidelity to the model, provider agencies participate in the following quality assurance procedures:

· Trainings by expert consultant:

o Initial in-person 6-day training for therapists and supervisor (conducted onsite at provider agency for new teams)

o Bi-annual in-person booster trainings for therapists and supervisor (conducted onsite at provider agency)

o Weekly case consultation provided by phone to therapists and supervisor

o Additional in-person and phone/web-based supervisor training (as needed)

· Quantitative Data:

o Therapy session audiotape submitted monthly by each therapist and coded by an external expert for implementation of Motivational Interviewing techniques

o Supervision session audiotape submitted monthly and coded by an external expert

o Client completion of Therapist Adherence Measure for Emerging Adults (TAM-EA) and Coach Adherence Measure (CoachAM) every two months (administered by the expert consultant, with assistance from provider agency as needed)

· On-site clinical supervisor:

o Weekly review of structured paperwork

o Weekly supervision sessions

o Monthly review of therapist session audiotapes and field observations

o Training and weekly supervision with coaches

o Completion of MST-EA Clinician Development Plan process

Discharge Criteria

The determination to discharge an emerging adult from MST-EA is based upon evidence of intervention effectiveness as evaluated from multiple perspectives (e.g. client, social network/family members, school, probation officer) indicating that:

• a majority of the Overarching Goals for the case have been met and sustained;

• the EA has few significant behavioral health and justice-related problems;

• the EA can effectively manage any recurring problems and function reasonably well for at least 3 to 4 consecutive weeks;

• the EA is making reasonable educational/vocational efforts;

• the EA is involved with prosocial peers and is not involved with, or is minimally involved with problem peers; and

• the therapist and supervisor feel the EA has the knowledge, skills, resources, and support needed to handle subsequent problems.

Discharge from MST-EA may also occur when few of the Overarching Goals have been met, but despite consistent and repeated efforts by the therapist and supervisor to overcome the barriers to further success, the treatment has reached a point of diminishing returns for the additional time invested.

PUBLISHED OUTCOMES

Aside from the extensive data supporting standard MST for youth with antisocial behavior, support for MST-EA comes from an open trial conducted by the investigators and clinical data collected by the community-based MST-EA program. This NIH-funded work focused on evaluating MST-EA for young people with justice involvement and behavioral health conditions. Outcomes are summarized in two peer-reviewed publications1,2 and demonstrate:

· Significant reductions in criminal charges and mental health symptoms

· Significant reductions in deviant peer involvement

· Reduced substance use

· Reduced placement in out-of-home settings

· Improved rates of employment

¹Davis, M., Sheidow, A. J., & McCart, M. R. (2015). Reducing recidivism and symptoms in emerging adults with serious mental health conditions and justice system involvement. Journal of Behavioral Health and Services Research, 42, 172-190.

²Sheidow, A. J., McCart, M. R., & Davis, M. (2016). Multisystemic therapy for emerging adults (MST-EA) with serious mental illness and justice involvement. Cognitive and Behavioral Practice, 23, 356-367.