A Comprehensive In-home Intervention to Reduce Justice System Involvement (an interview)
Abstract: The interviewees describe an evidence-based practice to reduce justice system involvement among emerging adults via a youth-specific modification to the extant Multi-Systemic Therapy (MST) intervention.
"A Comprehensive In-home Intervention to Reduce Justice System Involvement (an interview)" (2017)
An interview with Maryann Davis & Ashli Sheidow
Focal Point (F.P.): Could you give us a little background about why you are conducting this research?
Maryann Davis (M.D.): Research done in the mid-2000s revealed a high rate of justice system involvement up to age 25 among youth who were adolescent clients of the Massachusetts state mental health system. In fact, between the ages of 15 and 25, when these youth were arrested they had a 35–50% risk of being re-arrested on a new charge within the next year. Clearly, there was a need to reduce reoffending among young people who were involved in the mental health system. At the time we started developing our intervention (around 2007), there were numerous evidence-based practices to reduce justice system involvement in juveniles, but no evidence-based practices (EBPs) that would work with young adults – with or without serious mental health conditions. We considered a modification to Multi-systemic Therapy (MST), as it was an established EBP with a strong track record of reducing recidivism among adolescents. We focused the initial adaptation of MST-EA (Multisystemic Therapy for Emerging Adults) on 17-21 year olds because those ages are the first following the age covered by standard MST.
F.P.: Please briefly introduce us to MST-EA – what is involved in treatment? How is it different from MST?
M.D.: Both emphasize recidivism reduction, through a comprehensive, ecological method. In standard MST, therapists promote behavior change by empowering parents/guardians and working with the ecosystem surrounding the young adult. Our modification focused on empowering young adults to be decision-makers when it came to changes in their lives. MST-EA still leverages family support to help the young person make changes whenever appropriate, but also leverages the broader social network of young adults. Like standard MST, MST-EA is an intensive, home-based treatment provided by a team of 3 or 4 therapists. Coaches are added to the MST-EA therapy team, and MST-EA works extensively with other providers in the community. The coach works on developing independent living, wellness, school, and work skills. The focus on independent living and work, key life domains for this age group, are another key distinction of MST-EA. Like MST, MST-EA employs empirically based clinical techniques from cognitive behavioral therapy (CBT) and other behavioral therapies. Motivational interviewing is also a fundamental technique. Finally, MST-EA treatment is longer than standard MST – averaging 7 months. (You can also see our articles published on MST-EA for more details.1,2)
F.P.: What are the goals of MST-EA?
M.D.: There are a number of goals, but first and foremost is to reduce reoffending. MST-EA also targets the symptoms of mental illness. Although reducing mental health symptoms doesn't equate directly with reducing reoffending, it does promote involvement in pro-social relationships and activities (which reduces the risk of reoffending). The explicit focus on mental health distinguishes it from standard MST. When present, which is common, reducing substance use is always a goal. Another goal is for young people to be positively engaged in school, work, or both – and have secure housing and positive social relationships.
F.P.: Thanks. I'd like to turn our attention to your research on MST-EA. I understand that MST-EA has gone through some feasibility testing. Could you tell me a little about it?
M.D.: Sure – I should tell you that our feasibility study was an open trial with no control group and a small treatment group. However, our initial results were very encouraging! First, we found a significant decrease in re-arrests, as well as decreases in mental health symptoms and anti-social peer involvement that can result in reoffending behavior. While we did see positive changes in substance use and school and work engagement, these were not statistically significant. All in all, our findings were promising enough for us to be awarded two grants for studies with randomized control that will measure the effectiveness of MST-EA.
F.P.: That's great! Before we focus on future research, could you tell me about any challenges you faced implementing MST-EA?
Ashli Sheidow: It's important to recognize that this population finds themselves in a perfect storm. Where they have the highest needs, supports seem to be slipping away as they age out of one system and into another. These young people are also most likely to drop out of therapy because they've already had experiences with therapy that didn't work. Because of all this, MST-EA therapists need to develop strong motivational interviewing skills and creativity when engaging young people.
Another complexity actually arises from a strength of MST and, thus, MST-EA. On a positive note, both are highly individualized interventions, so community and cultural contexts are leveraged as strengths to support a young person's recovery. (MST-EA is based on MST, which shows promise of being efficacious across cultures.3) However, being individualized means understanding that no two young adults have the same set of circumstances. An MST-EA therapist needs to be very flexible because each case can present complex challenges unique to an individual's situation.
Lastly, the elephant in the room: paying for the treatment. In our initial work, we were lucky to find champions in the child welfare system who saw that this program could reduce long-term personal and system costs. Many thanks are owed to Anne McIntyre-Lahner, Sara Lourie, and Tere Foley, with the Connecticut Department of Children and Families. This is an expensive program, but it aims to reduce even more expensive outcomes like incarceration, medical and psychiatric emergencies, homelessness and unemployment, suicides and homicides.
F.P.: Could you please tell us about your future directions with this research?
M.D.: Currently, we are working on two funded studies. Our NIMH grant will allow us to replicate our prior study with a control group. The control group will get a masters-level facilitator who can provide appropriate referrals, talk to young people about available services, and provide travel vouchers to get to services. This 4-year study will involve 240 participants, with 120 of those being treated by MST-EA teams. Our NIDA grant will test MST-EA's effectiveness in individuals who have substance abuse disorders. Both grants will include individuals with co-occurring mental health and substance use disorders, and both aim to find out what factors are making the treatment actually work. We want to know if our positive behavioral health model will help with mental health conditions, substance abuse disorders, or both. Both studies are effectiveness trials that will be delivered in communities by community providers – so they will be a real world test of MST-EA. We hope to have preliminary results available in the next couple of years.
- Davis, M., Sheidow, A.J., & McCart, M.R. (2015). Reducing recidivism and symptoms in emerging adults with serious mental health conditions and justice system involvement. The Journal of Behavioral Health Services & Research, 42(2), 172–190.
- Sheidow, A.J., McCart, M.R., & Davis, M. (2016). Multisystemic therapy for emerging adults with serious mental illness and justice involvement. Cognitive and Behavioral Practice, 23, 356–367.
- Huey, S., & Polo, A. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child & Adolescent Psychology, 37(1), 262–301.
For a blog posting describing an MST-EA case study, please visit http://info.mstservices.com/blog/population-at-risk-young-people-aging-out-of-juvenile-justice-system; for an in-depth discussion of MST-EA, please visit Pathways' 2017 webinar archive at: https://www.pathwaysrtc.pdx.edu/webinars-2017.
Davis, M., & Sheidow, A. (2017). A Comprehensive In-home Intervention to Reduce Justice System Involvement (an interview). Focal Point: Youth, Young Adults, and Mental Health, 31, 27-28. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.