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Multisystemic Therapy for Adolescents

Michaela cribb msn cpnp

Learning Objectives

Describe the driving theories behind Multisystemic Therapy (MST)

Identify the role of MST in treating youth with conduct disorder

Compare the therapeutic techniques of MST to functional family therapy

History of MST

Simply Psychology. (2025, May 6). Bronfenbrenner's Ecological Systems Theory. https://www.simplypsychology.org/bronfenbrenner.html

Public Safety Canada. (2018, January 26). Results of the Multi-Systemic Therapy Program. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rslts-mltsystmc-thrpy-prgrm/index-en.aspx

Based on Bronfenbrenner’s Ecological Systems theory, which states that individuals’ behavior is directly influenced by their environments

Environments include family, friends, school, neighborhood, culture, societal norms, government, media, economic systems, etc. (Simply Psychology, 2025)

Started by Dr. Henggeler in the US in the 1970s when he was asked to work with some of the most “difficult cases” of delinquent youth

By 1996, Multisystemic Therapy had been refined and studied with strong evidence of effectiveness

MST Services was founded by Dr. Henggeler to teach other communities how to implement the therapeutic interventions (Public Safety Canada, 2018)

Major Concepts of MST

Crime Solutions, 2011

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

Target population: adolescents (usually 12-17 years old) with antisocial and externalizing behaviors that have lead to delinquency and incarceration

Theory: these behaviors exist in the context of an environment that involve family, school, peer, and community influences

Therapeutic interventions: therapy is delivered in the youth’s natural environment (home, school, etc.) in order to reduce barriers to care access, and to allow the therapist to work with the adolescent and the primary influencers of the youth’s behavior

Complexity MST is relatively simple in concept, though somewhat complex in its application.

The concepts of:

meeting the youth where they are,

identifying environmental and personal factors that influence behavior, and

working towards modifying those factors

The application of:

intensive therapy (many scheduled hours/week)

availability of a therapist 24/7

therapists working with few families (typically 4-6) at a time, and

working with many individuals from the patient’s circle of contacts

are complex.

are straightforward.

Scope of Theory

The scope of the theory is quite broad and truly could be infinite if its parameters were not constrained by financial and power limitations

For example, therapists do not have unlimited resources to provide tutors, provide rental assistance to allow families to move to neighborhoods with lower rates of violent crime, etc.

Therapists are similarly unlikely to be able to make policy changes or work with governmental officials to change factors that affect social drivers of health while also providing MST services to patients and families

Usefulness of Theory

The theoretical underpinnings of MST make this theory extremely useful when resources are provided.

Because it is an intensive care model, it does require significant community financial buy-in, availability of a team of therapists and other partners (law enforcement, school personnel, SW, DHS, etc.) to succeed.

Techniques for Use MST is driven by 9 core principles

Principle 1: Finding the fit

The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.

Principle 2: Focusing on positives and strengths

Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.

Principle 3: Increasing responsibility

Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members.

Principle 4: Present focused, action oriented and well-defined

Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.

Principle 5: Targeting sequences

Interventions should target sequences of behavior within or between multiple systems that maintain the identified problems.

Principle 6: Developmentally appropriate

Interventions should be developmentally appropriate and fit the developmental needs of the youth.

Principle 7: Continuous effort

Interventions should be designed to require daily or weekly effort by family members.

Principle 8: Evaluation and accountability

Intervention efficacy is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes.

Principle 9: Generalization

Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.

Zajac K, Randall J, Swenson CC., 2015.

Zajac K, Randall J, Swenson CC. Multisystemic Therapy for Externalizing Youth. Child Adolesc Psychiatr Clin N Am. 2015 Jul;24(3):601-16. doi: 10.1016/j.chc.2015.02.007. Epub 2015 Mar 29. PMID: 26092742; PMCID: PMC4475575.

Techniques for Use

Zajac K, Randall J, Swenson CC., 2015.

MST is an intensive family- and community-based model of therapeutic intervention.

Therapy is conducted in the patient’s home, school, and/or community environment.

Sessions occur several times per week over a 4-6 month period.

Therapists are available to families 24/7 so that real-time challenges can be addressed and solutions can be brought forward.

Techniques for Use (continued)

Zajac K, Randall J, Swenson CC., 2015.

Therapists work to identify problem behaviors, discover the “drivers” of the behavior, and work with the youth and family to address those drivers 1

For example, peer group relationships are targeted if the patient typically surrounds him/herself with peers who demonstrate similarly delinquent or externalizing behaviors

Parents are helped and encouraged to improve their parenting skills and relationship with the youth, and to have more influence in the youth’s life. This often means addressing parental mental health problems, SUDs, intellectual disabilities, poor parenting skills, etc.

School teachers and administrators are also encouraged to take an active interest in the at-risk youth, so that school/patient relationship and investment can be strengthened

Evidence-based Literature

https://pilotfeasibilitystudies.biomedcentral.com/counter/pdf/10.1186/s40814-023-01409-9.pdf

https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst#0-0

https://crimesolutions.ojp.gov/ratedpractices/psychosocial-interventions-antisocial-behavior-juveniles#2-0

Long-term effects of prevention and treatment on youth antisocial behavior: A meta-analysis

Lifespan Issues

Crime Solutions, 2011

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

MST has been specifically developed for use with adolescents (typically 12-17 years of age) and their families

This type of therapy requires participation of the child and/or adolescent’s primary support circle (including extended family).

This includes addressing mental health conditions and SUDs in adult caregivers

Cultural Variations

A meta-analysis showed that some broad populations (girls and ethnic minorities) responded somewhat more favorably to this type of intervention, but the studies were relatively small and more information is needed to determine who would benefit most from this intervention (Sawyer, A., Bourdiun, C., and Dopp, A., 2018)

It would be reasonable to predict that community members who mistrust law enforcement and social services personnel (immigrants, communities of color) would be less willing to invite court-mandated therapists into their homes and communities.

However, I did not come across any studies directly addressing the issue of trust as a measured data point

Sawyer, A., Borduin, C., & Dopp, A. (2018). Long-term effects of prevention and treatment on youth antisocial behavior: A meta-analysis. American Journal of Orthopsychiatry, 88(4), 488–499. doi:10.1037/ort0000329

Application to Practice

MST specifically states that it is not intended to treat any specific psychiatric conditions; rather its focus is on antisocial and externalizing behavior

For the purposes of discussion, I will apply MST to adolescents with Conduct Disorder as this is the DSM V diagnosis that most closely correlates with the target behaviors

Application to Practice Conduct Disorder

Conduct Disorder: Diagnostic Criteria

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

(see next slide)

American Psychiatric Association, 2022.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: Text revision (5th ed.). American Psychiatric Association Publishing.

Application to Practice: Conduct Disorder (continued)

Aggression to People and Animals

1. Often bullies, threatens, or intimidates others.

2. Often initiates physical fights.

3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).

4. Has been physically cruel to people.

5. Has been physically cruel to animals.

6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

7. Has forced someone into sexual activity.

American Psychiatric Association, 2022.

Application to Practice: Conduct Disorder (continued)

Destruction of Property

8. Has deliberately engaged in fire setting with the intention of causing serious damage.

9. Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

10. Has broken into someone else’s house, building, or car.

11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

American Psychiatric Association, 2022.

Application to Practice: Conduct Disorder (continued)

Serious Violations of Rules

13. Often stays out at night despite parental prohibitions, beginning before age 13 years.

14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.

15. Is often truant from school, beginning before age 13 years.

American Psychiatric Association, 2022.

Application to Practice: Conduct Disorder (continued)

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specifiers include:

Childhood, adolescent, or unspecified onset

With limited prosocial emotions

Mild, moderate, or severe

American Psychiatric Association, 2022.

Application to Practice Conduct Disorder (continued)

Cleveland Clinic. (2022, November 8). Conduct Disorder. https://my.clevelandclinic.org/health/diseases/23924-conduct-disorder

Cohen, M.A. (1998). The monetary value of saving high-risk youth. Journal of Quantitative Criminology, 14, 5–33. http://dx.doi.org/10.1023/A:1023092324459.

Federal Bureau of Investigation (2013). Crime in the United States, 2012. Washington, DC:

U.S. Department of Justice.

Prevalence of Conduct Disorder is between 2 and 10% of children and youth in the USA (Cleveland Clinic, 2022)

Conduct Disorder is almost always a pediatric diagnosis, with onset before 10 years of age not uncommon. Adults who meet diagnostic criteria almost always meet criteria from antisocial personality disorder and therefore CD is not a common diagnosis in adults

“Antisocial behavior is the most common and costly of all child and adolescent mental health problems” (Cohen, M.A., 1998)

“On an epidemiological level, youths under the age of 18 account for approximately 11% of all crime in the United States, including 18% of property crimes and 12% of violent crimes” (Federal Bureau of Investigation, 2013)

Application to Practice Conduct Disorder (continued) + MST

Psychopathy Is. (n.d.). Conduct Disorder Test for Children, Youth and Adolescents | CD Screening. Psychopathy Is. https://psychopathyis.org/screening/cd-screening-vanderbilt/Wiesner, M., Elliott, M., McLaughlin, K., Banspach, S., Tortolero, S. & Schuster, M. Journal of Abnormal Child Psychology, Vol 43(5), Jul 2015. pp. 985-998.

No specific diagnostic tool is available to diagnose Conduct Disorder, but a publicly available screening tool can be found at https://psychopathyis.org/screening/cd-screening-vanderbilt/

One study showed no ethnic or racial correlates for conduct disorder, though [male] gender and [low] household income were statistically significant correlates (Weisner et al., 2015)

Youth with antisocial and externalizing behaviors do not need to carry a diagnosis of Conduct Disorder (or any other psychiatric disorder) to qualify for MST

Youth and families are typically referred for MST through the justice department or through DHS/CPS

Application to Practice Conduct Disorder (continued)

Differential Diagnoses for Conduct Disorder include:

Antisocial Personality Disorder

Oppositional Defiant Disorder

Intermittent Explosive Disorder

Disruptive Mood Dysregulation Disorder

ADHD

Substance Use Disorder

Adjustment Disorder

Mood Disorders

Sagar et al., 2019

Sagar R., Patra BN., Patil V. Clinical Practice Guidelines for the management of conduct disorder. Indian J Psychiatry. 2019 Jan;61(Suppl 2):270-276. doi: 10.4103/psychiatry.IndianJPsychiatry_539_18. PMID: 30745702; PMCID: PMC6345126.

Outcome goals typically include:

Reduction in overall criminal/antisocial behavior and increased length of time between criminal offenses

Reduction in total number of days spent incarcerated

Avoidance of removal from the home

Reduction in psychiatric symptoms (parents and adolescent)

Improved school attendance and functioning

Decreased substance abuse problems

Improved parent-child relationship and communication skills

Improved parenting skills

Treatment with MST: Outcomes

Zajac et al., 2015. Crime Solutions, 2011.

Zajac K, Randall J, Swenson CC. Multisystemic Therapy for Externalizing Youth. Child Adolescent Psychiatry Clin N Am. 2015 Jul;24(3):601-16. doi: 10.1016/j.chc.2015.02.007. Epub 2015 Mar 29. PMID: 26092742; PMCID: PMC4475575.

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

Treatment with MST: Outcomes

Studies summarized by the National Institute of Justice showed statistically significant evidence for MST in the following areas:

Peer aggression

Family cohesion

Re-arrest

Recidivism

Delinquency

Improved mood and emotions

Behavior towards others

Home, school, and work functioning

Crime Solutions, 2011. Tan & Fajardo, 2017

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

Tan, J. X., & Fajardo, M. L. R. (2017). Efficacy of multisystemic therapy in youths aged 10-17 with severe antisocial behaviour and emotional disorders: systematic review. London journal of primary care, 9(6), 95–103. https://doi.org/10.1080/17571472.2017.1362713

Treatment with MST: Outcomes

Studies summarized by the National Institute of Justice showed no statistically significant evidence for MST in the following areas:

Rates of substance use

Peer relations

Social skills

Crime Solutions, 2011

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

Treatment with MST: Alternatives

Cleveland Clinic, 2022

Cleveland Clinic. (2022, November 8). Family Therapy. https://my.clevelandclinic.org/health/treatments/24454-family-therapy

The primary alternative to Multisystemic Therapy is usually individual or family therapy. Functional Family Therapy has been proposed as an effective and less resource-intensive alternative to MST

Although both individual and family therapy aim to improve communication between family members, they are typically not nearly as intensive as MST

Additionally, individual and family therapy do not generally include a root-cause analysis component that aims to address the underlying reasons for the problematic behavior

There are many types of individual and family therapies, including:

CBT, DBT, Internal Family Systems, Interpersonal, psychoanalysis, MI… (individual)

Functional, Marriage/couples, Strategic, Structural, and Systemic Family Therapy

MST vs Functional Family Therapy

Hunkin et al., 2025

Hunkin, H., Malvaso, C., Chittleborough, C., Gialamas, A., Montgomerie, A., Falster, K., Lynch, J. & Pilkington, R Journal of the American Academy of Child & Adolescent Psychiatry April 2025 64(4):427-446

In this presentation we have reviewed the components of MST including theoretical underpinnings, methods, and goals

Functional Family Therapy is typically used for families where there is a child with behavioral problems who is causing distress or problems in the family’s functioning (often with criminal activity and antisocial behavior)

One meta-analysis demonstrated statistically significant effects on:

Number of new offenses/criminal convictions

Time in out-of-home care

Substance use

MST vs Functional Family Therapy

Henggeler et al., 1992,

Bourdin et al., 1995,

Timmons-Mitchell et al., 2006

1-Henggeler, Scott W., Gary B. Melton, and Linda A. Smith. 1992. “Family Preservation Using Multisystemic Therapy: An Effective Alternative to Incarcerating Serious Juvenile Offenders.” Journal of Consulting and Clinical Psychology 60(6):953–61.

2-Borduin, Charles M., Barton J. Mann, Lynn T. Cone, Scott W. Henggeler, Bethany R. Fucci, David M. Blaske, and Robert A. Williams. 1995. “Multisystemic Treatment of Serious Juvenile Offenders: Long-Term Prevention of Criminality and Violence.” Journal of Consulting and Clinical Psychology 63(4):569–78.

3-Timmons–Mitchell, Jane, Monica B. Bender, Maureen A. Kishna, and Clare C. Mitchell. 2006. “An Independent Effectiveness Trial of Multisystemic Therapy With Juvenile Justice Youth.” Journal of Clinical Child and Adolescent Psychology 35:227–36.

Only one study has been published in the past 10 years specifically looking at the effectiveness of MST and FFT compared to “care as usual” for youth with antisocial behavior and criminal offenses

No studies were found on extensive literature search directly comparing MST to FFT head-to-head

One well-designed study from Norway (Olseth, 2024) showed no significant improvement in delinquency, time spent with delinquent peers, school performance, or social skills with FFT vs treatment as usual

Many well designed studies from the 1990s and 2000s showed statistically significant improvement in many of the previously mentioned outcome measures when MST was compared to treatment as usual (Henggeler et al., 1992, Bourdin et al., 1995, Timmons-Mitchell et al., 2006)

Pros and Cons of MST

Pros:

Reduces barriers to accessing care by providing intervention in the home

Addresses multiple root causes of delinquent behavior

Enables access to mental health care for parents who often have untreated needs

Evidence of effectiveness on multiple studies from the 90s and 2000s

Cons:

Labor intensive

Therapists treat 4-6 families at a time

Therapist must be available 24/7 (often on a rotating call schedule)

Costly to provide

Requires special training for Master’s-prepared therapists

Mixed results of effectiveness on more recent studies

Crime Solutions, 2011.

Crime Solutions, 2021.

Public Safety Canada, 2018.

Zajac et al., 2015.

Sawyer et al., 2018.

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST).Retrieved from https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

Crime Solutions. (2021, August 9). Psychosocial interventions for antisocial behavior of juveniles. Office of Justice Programs. Retrieved from https://crimesolutions.ojp.gov/ratedpractices/psychosocial-interventions-antisocial-behavior-juveniles

Public Safety Canada. (2018, January 26). Results of the Multi-Systemic TherapyProgram. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rslts-mltsystmc-thrpy-prgrm/index-en.aspx

Pros and Cons of FFT

Pros:

Therapists can treat many families per week

No extensive training required

Cost-effective

Addresses multiple issues within the family system that are contributing to the problem behavior

Some evidence of improvement in many target outcomes

Cons:

Does not address societal factors that may contribute to delinquent behaviors

No strong, reproducible studies demonstrating evidence of effectiveness in addressing delinquent behavior

MST vs Functional Family Therapy

Clients who would benefit from either MST or FFT:

Families who would have difficulty attending services in an office (both can be provided in-home)

Youth whose parents struggle with SUDs and mental health disorders

Youth who would otherwise be placed in group homes or foster care

Youth at high risk for re-entering the criminal justice system

Clients who would benefit from MST rather than FFT:

Youth who have multiple societal and family factors affecting their ability to succeed in learning pro-social behavior

Risks of Incorrect Therapy for Conduct Disorder

“To be effective, treatment must be multi-modal, involve a family-based and social systems-based approach, address multiple areas, and continue over a longer period.”

Any therapy that is focused exclusively on the individual’s feelings or past (such as psychoanalysis), too short in duration, or failing to address maladaptive, antisocial behavior will be unsuccessful at changing long-term outcomes

Treatment of behavior and conduct problems become less effective over time; a ”wait-and-see” approach is not appropriate (Sagar et al., 2019)

Of note, pharmacotherapy alone is not appropriate for Conduct Disorder. “Pharmacological agents are adjuncts in treatment for acute crisis intervention and short-term management.” (Sagar et al., 2019)

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: Text revision (5th ed.). American Psychiatric Association Publishing.

Borduin, C., Mann, B., Cone, L., Henggeler, S., Fucci, B., Blaske, D. & Williams, R. 1995. Multisystemic Treatment of Serious Juvenile Offenders: Long-Term Prevention of Criminality and Violence. Journal of Consulting and Clinical Psychology. 63(4):569–78.

Cleveland Clinic. (2022, November 8). Conduct Disorder. Retrieved from https://my.clevelandclinic.org/health/diseases/23924-conduct-disorder

Cohen, M.A. (1998). The monetary value of saving high-risk youth. Journal of Quantitative Criminology, 14, 5–33. http://dx.doi.org/10.1023/A:1023092324459.

Crime Solutions. (2011, June 17). Program Profile: Multisystemic Therapy (MST). Retrieved from https://crimesolutions.ojp.gov/ratedprograms/multisystemic-therapy-mst

References

Federal Bureau of Investigation (2013). Crime in the United States, 2012. Washington, DC: U.S. Department of Justice.

Henggeler, S., Melton, G. & Smith, A. 1992. Family Preservation Using Multisystemic Therapy: An Effective Alternative to Incarcerating Serious Juvenile Offenders. Journal of Consulting and Clinical Psychology. 60(6):953–61.

Hunkin, H., Malvaso, C., Chittleborough, C., Gialamas, A., Montgomerie, A., Falster, K., Lynch, J. & Pilkington, R. (2025). Systematic Review and Meta-Analysis: Multisystemic Therapy and Functional Family Therapy Targeting Antisocial Behavior in Adolescence. Journal of the American Academy of Child & Adolescent Psychiatry. 64(4):427-446

Olseth, A. R., Hagen, K. A., Keles, S., & Bjørnebekk, G. (2024). Functional family therapy for adolescent disruptive behavior in Norway: Results from a randomized controlled trial. Journal of Family Psychology, 38(4), 548–558. https://doi.org/10.1037/fam0001213

Psychopathy Is. (n.d.). Conduct Disorder Test for Children, Youth and Adolescents. Psychopathy Is. https://psychopathyis.org/screening/cd-screening-vanderbilt/

References

Public Safety Canada. (2018). Results of the Multi-Systemic Therapy Program. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rslts-mltsystmc-thrpy- prgrm/index-en.aspx

Sagar R., Patra BN., & Patil V. (2019). Clinical Practice Guidelines for the management of conduct disorder. Indian J Psychiatry. 61(Suppl 2):270-276. doi: 10.4103/psychiatry.IndianJPsychiatry_539_18. PMID: 30745702; PMCID: PMC6345126.

Sexton, T., & Turner, C. W. (2010). The effectiveness of functional family therapy for youth with behavioral problems in a community practice setting. Journal of family psychology: Journal of the Division of Family Psychology of the American Psychological Association (Division 43), 24(3), 339–348. https://doi.org/10.1037/a0019406.

Simply Psychology. (2025). Bronfenbrenner's Ecological Systems Theory. Retrieved from https://www.simplypsychology.org/bronfenbrenner.html

References

Timmons–Mitchell, J., Bender, M., Kishna, M., & Mitchell, C. (2006). An Independent Effectiveness Trial of Multisystemic Therapy With Juvenile Justice Youth. Journal of Clinical Child and Adolescent Psychology, 35:227–36.

Wiesner, M., Elliott, M., McLaughlin, K., Banspach, S., Tortolero, S., & Schuster, Mark. (2015). Journal of Abnormal Child Psychology, 43(5).

Zajac K., Randall J., Swenson C.C. (2015). Multisystemic Therapy for Externalizing Youth. Child Adolescent Psychiatry Clinics of North America. 24(3):601-16. doi: 10.1016/j.chc.2015.02.007.

Final self reflection

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