tephen Misher had little hope that his 17-year-old son, Anthony, was going to avoid prison. Anthony already had countless school suspensions. Now, barely a week into yet another therapeutic “intervention,” Anthony was caught at school with heroin.
This time there would be no suspension. This time he was expelled.
Still, the new therapist did not seem dismayed. At meetings in the Mishers’ home, she kept presenting goals, gently insisting that improvements were doable. Anthony said all the right things, but Stephen wasn’t buying any of it. The elder Misher was used to his son’s lies.
“She’ll leave and he’ll go right back to his old behaviors,” Stephen thought.
Such thoughts aren’t just parental pessimism. The majority of juvenile offenders do continue offending, federal statistics indicate. Of the more than 13.6 million juveniles arrested each year in the U.S., close to 55 percent will be arrested again within the next 12 months.
But Anthony was in a subset of the juvenile population with better odds. The therapist working with him and his dad at their Pennsylvania home was providing multisystemic therapy, or MST, an intensive family- and community-based treatment that covers several of the correlating factors for juvenile delinquency. This sets MST apart from the standard approach in which the offender visits a therapist who offers feedback, support and encouragement for behavior change.
MU psychological services professor Charles “Chuck” Borduin helped develop multisystemic therapy back in the 1970s, a time when scholarly reviews of juvenile delinquency interventions were nearly unanimous in their pessimism. Nothing, it seemed, was working.
Borduin, a self-described “incurable optimist,” pressed ahead anyway, staking his career on developing a new model. The gambit paid off. MST is today one of the most widely used evidence-based treatments for juvenile offenders in the world. Study after study has shown MST completers face fewer arrests, and for less violent crimes, than juveniles treated with individual therapy.
And as of 2011, Borduin has shown that the positive effects of MST continue well into participants’ adult lives, with a 22-year follow-up study published in the Journal of Consulting and Clinical Psychology.
“He has answered one of the most important questions in the entire field of behavioral health care services,” says Marshall Swenson, vice president of MST Services, an organization that helps communities implement the multisystemic therapy model. “And that is, ‘If you do something today, will it make any difference tomorrow?’”
Borduin first became interested in working with kids and adolescents after earning his psychology degree and going to work at Pine Rest Christian Mental Health Services in Grand Rapids, Mich. There he noticed that a lot of the families of his child patients had challenges that treating the child did not address.
“And so at that point, I thought this would be something I would be interested in doing in graduate school — looking at how families influence children’s mental health and perhaps treating families, too.”
Borduin began reviewing the literature on juvenile offending as a graduate student at Memphis State University, and rather than being discouraged, he believed a lot of the answers, or at least clues, were there waiting to be picked up. Even before the 1970s, criminologists and sociologists had identified several factors associated with delinquent behavior —problems at home, troubled peer relations, and academic and social challenges at school — but rather than focusing on these known contributors to delinquency, interventions instead targeted a “broken” individual in need of medicine, counseling or some sort of “shock” treatment.
Borduin worked with Scott Henggeler, then an assistant professor of psychology at MSU and now a professor of psychiatry and behavioral sciences at the Medical University of South Carolina. They developed a new model that would address a range of determinants indicating antisocial behavior in juvenile offenders — the “multisystemic” of their therapy model.
Through much research and some trial and error, Henggeler and Borduin came to see families, and parents in particular, as the gatekeepers to change in all spheres of a juvenile’s life, from developing more “positive” friendships to adopting better attitudes about school.
In the earliest stages of MST development, Henggeler and Borduin expected to deliver the interventions in a traditional office setting: Their plan was for parents to come to treatment sessions with their children. But when the doors opened, neither the juveniles nor their parents showed up. “It wasn’t because the therapists weren’t well intentioned — or the families,” Borduin says. “The families might have transportation problems because they were low-income. They might be suspicious of mental health services providers because [the parents] had been told over and over again that they weren’t very competent. So we said, ‘You know what? We know the problem is multi-determined. Why don’t we, to get better engagement, deliver the services where the problems are?’ ”
At first, Anthony was not at all happy about his new therapist coming to his home. “It was different — just having strangers come to the house and having to tell them things and having to talk to them about stuff that was really none of their business,” he says.
Anthony also didn’t appreciate having his dad in the sessions. “I didn’t like it because he was always there to have his input, too, and it usually didn’t help much because we’d get into a fight about it,” he says.
It wasn’t, Stephen explains, that his son didn’t know the difference between right and wrong. He just made bad choices. A lot of them. And consequences, like suspension and getting probation, didn’t deter him.
Within the first couple of weeks, the therapist had made more than a dozen family contacts, including three face-to-face sessions and four phone calls with the Mishers, as well as calls to school officials and Anthony’s probation officer. Slowly, Anthony found himself more willing to share and problem-solve with his dad and his therapist, a change he credits to getting to know the therapist and “knowing she was here to help me and not hurt me,” he says.
And soon, both Anthony and Stephen noticed their relationship improving. “Before MST it definitely wasn’t good,” Anthony says. “I was lying, but now it’s definitely changed, and we’re definitely getting along better. If we would get in a fight, we wouldn’t automatically start yelling. We would talk through it and work it out.”
These are the kinds of improvements that had convinced Borduin to keep going with MST when, after earning his master’s of science and doctorate in child clinical psychology at the University of Memphis, he came to MU in 1982.
“There were people asking me, ‘Why in the world are you working on a treatment model? If you want to get promoted and tenured, and you’re working on a treatment model that fails, then you don’t have much to publish and you don’t have a job anymore.’ What helped me to stick with this early on was in the clinical trials: I could see this was working. We were meeting with the families each week, and I could see the families changing, and I knew we were on to something.”
In 1983, Borduin launched the Missouri Delinquency Project, developed in cooperation with the Missouri Department of Social Services, the Missouri Thirteenth Judicial Circuit Juvenile Court and the University, to deliver MST to juvenile offenders and their families. It was through this project that he ran a three-year, randomized clinical trial — it involved 176 violent and chronic juvenile offenders — between 1983 and 1986.
The study had a control-group design, with a random assignment of the juveniles to either MST or to individual therapy. After each group completed its respective therapies, Borduin followed up four years later to compare the effectiveness of the two treatment models.
The results were striking: After four years post-treatment, the overall recidivism rate for MST completers was just over 22 percent, less than one third of the 71 percent rate of those who completed individual therapy. In addition, those completing MST were arrested less often and for less serious crimes.
Because he knew that families would be key to achieving successful outcomes, Borduin also measured how they fared over the course of the study. These results were instructive, too.
Mothers of MST participants reported a general decrease in household behavioral problems, and said their families developed greater cohesion and adaptability. Conflicts among mothers, fathers and adolescents declined, they said. By contrast, the pre- to post-treatment findings involving the families of individual therapy completers were all either neutral or negative.
“It goes back to the theory of MST, that there are all these different drivers,” Borduin explains. “Individual treatment doesn’t target family; it doesn’t target peers, and sometimes it doesn’t do a very good job of changing individual behavior, either. So some of the kids benefit from being in there, but very often you actually see a worsening of the correlating factors. … It speaks to the problem with individual therapy for these kids; it doesn’t get at the factors that cause or maintain criminal behavior.”
Results of the clinical trial were first published in 1995 in the Journal of Consulting and Clinical Psychology. Meanwhile, several other researchers were conducting studies, not just to test the effectiveness of using MST with juvenile offenders but also with other populations ranging from juvenile sexual offenders to adolescents with chronic health care conditions.
All told, there have been 26 published outcome, transportability and benchmarking studies involving more than 5,200 families. Borduin has served as the principal investigator in studies adapting MST to adolescent sexual offenders, and collaborated with MU’s Thompson Center for Autism and Neurodevelopmental Disorders on an adaptation for aggressive adolescents with an autism spectrum disorder.
In the meantime, various organizations and projects have embarked on their own programs aimed at promoting evidence-based treatments for juvenile offenders. One example is the Blueprints for Violence Prevention program, a project of the Center for the Study and Prevention of Violence at the University of Colorado. It has certified 11 model programs, including MST, that can show substantial evidence for their effectiveness.
Despite confirmation that these interventions work — and the lack of evidence that traditional approaches do — only about 5 percent of even the most high-risk juvenile offenders, those who are incarcerated or at a high risk of being incarcerated, get an evidence-based treatment.
“A lot of them get all sorts of services,” says Henggeler, who published the 5 percent figure in a 2011 study. “But the research literature clearly shows that some of those services make the situation worse, like boot camps and residential treatment, and then a lot of other services just don’t have any positive or negative effect.”
Still, those in the field report that attitudes seem to be moving in the right direction. “There is a general trend throughout social work and education, those two in particular, to base new programs not on somebody’s whiz-bang idea but on some proven thing that’s worked in several different places,” says Peter Greenwood, executive director of the Association for Advancement of Evidence-Based Practice, a Pennsylvania-based organization.
Hard economic times actually might be helping, Swenson adds, as states are becoming more insistent that state-funded programs provide tangible results.
By the Numbers
In 2009, the most recent year for which U.S. Justice Department data is available, some 13.6 million juveniles were arrested in the United States. Of these arrests, 580,000 were for violent crimes, while 1.7 million were for property crimes.
The highest arrest counts were for drug abuse violations (estimated at 1.6 million), driving under the influence (estimated at 1.4 million), and larceny-theft (estimated at 1.3 million).
Close to 75 percent of those arrested were males — 81 percent of persons arrested for violent crimes; 62 percent of those arrested for property crimes.
According to additional data compiled by Advancing Evidence Based Practice, a Pennsylvania-based advocacy organization, in recent years the average rate of re-arrest for delinquency or a criminal offense was 55 percent, the average reconviction or re-adjudication rate was 33 percent, and the reincarceration or reconfinement rate was 24 percent.
“While we are seeing some cuts in behavioral health services, we’re not seeing cuts being aimed at evidence-based practices,” Swenson says. “We’re seeing a lot of cuts being aimed at the non-evidence-based practices, particularly those that involve separating the children from their families and putting them into institutions or residential treatment. Those things are so expensive, they represent the biggest targets for budget reduction.”
Recognizing the resonance of savings-based arguments, Borduin published a cost study of MST in 2010. It was based on a 14-year follow-up of the original randomized clinical trial.
Using factors such as re-arrest costs and expenses related to law enforcement and correctional facilities, Borduin found that the net cumulative benefit of providing MST to a single juvenile offender resulted in a savings of between $75,000 and $199,000. Put another way, $1 spent on MST provided $9.50 to $23.50 in savings to taxpayers and crime victims.
“If something is clinically effective, it should be cost-effective, too, because you are preventing recurrences of problems,” Borduin says. “Something might be cheap on the front end, but if you’ve got to keep treating it over and over and over again, you haven’t really saved any money.” The highest cost of ineffective treatment, he adds, comes down the road when non-rehabilitated juveniles end up in the adult correctional system.
With long-term follow-up, Borduin has been able to show MST’s lasting impact. Among his most encouraging findings are that, since completing treatment, only 4.3 percent of juveniles treated using MST were arrested for a violent felony (compared to 15.5 percent of individual therapy participants). Overall, fewer than 35 percent of MST participants committed a felony, compared to more than 54 percent of those who received individual therapy.
Borduin has also determined that MST participants committed five times fewer misdemeanors than individual therapy participants, and that individual therapy participants were involved in family-related civil lawsuits twice as often as MST participants.
“In our field, Chuck is virtually the only person who is able to provide data like this,” says David Bernstein, director of the Center for Effective Interventions at Metropolitan State College of Denver. In this role, Bernstein works with stakeholders in the juvenile justice system to encourage them to adopt evidence-based practices, including MST.
“It’s important to those of us who can’t do that to be able to access Chuck’s data to gain credibility for what we’re doing. … Every time I do a presentation, I incorporate several of Chuck’s slides.”
The findings are also important validation for those doing MST, says Gary Soltys, an MST director at Adelphoi Village, a private, not-for-profit agency serving boys and girls in Pennsylvania, West Virginia and Delaware.
“That’s why I was so pleased,” Soltys says. “I was never in this just to help the kid get through treatment. It was about doing things with them today that would help them stay in the community and be free of incarceration. … We only have them three or four months, but we’re thinking about their lives 15, 20, 25 years ahead.”
As for Anthony Misher, he is finishing up treatment after three months of MST. His therapist was able to help him get started at an alternative school, and all reports from the new school have been positive. So are reports from his dad.
“He’s honest with me now,” Stephen Misher says. “He’s changed his whole attitude about school. And he’s behaving himself.”
Anthony’s goals are to graduate next year and then to study auto mechanics at a technical school. After that, he hopes to get a good job, start a family and still have a relationship with his dad, too.
“I never thought I’d be very successful,” Anthony says. “But everything is getting a lot better.”
Kayla Cody: From Peril to Promise
uring a ten-month period when she was 14, Kayla Cody [above] ran away from home more than 20 times. “We were in shock,” says her father, Dennis Cody. “We just kept asking ourselves what we did wrong to make her go down that path.” Cody, now 17, disappeared for weeks at a time, sometimes staying with friends and, at one point, spending an entire week sleeping in a car. “Running was scary, but it was the only thing I had,” says Cody. “If it would have continued, I would have ended up in a juvenile home.”
After seeing a family counselor with little success, Cody’s family turned to Rheagan Fernandez, a multi-systemic therapist working at Places for People, a mental health services provider in St. Louis. It didn’t take long for Fernandez to figure out the problem — a lack of communication. Today, thanks to six months of therapy and work with the Missouri Option Program — a Department of Elementary and Secondary Education initiative that allows students to make up missed credits — Kayla is on schedule to graduate with her class. “Kayla is still Kayla. She has a little attitude but knows what she has to do now to succeed,” says her father.