Multisystemic Therapy (MST): A Case Study
Case Presentation
The following is based on a real person whose name and identifying demographics have been altered to protect the client’s identity.
Stacey is a 16-year-old single white female currently in her tenth-grade year of high school. Stacey lives with her mother, stepfather, and four siblings (one older brother, two younger sisters, and one younger brother who has autism). Client’s biological father left when client was an infant and has been absent with minimal contact. Stacey reports that contact with her biological father consists of social media messaging every couple of months, sometimes with year-long gaps. Stacey’s maternal grandfather, who had lived nearby Stacey’s family home and visited frequently, died suddenly in a car accident approximately eleven months ago. The client was in treatment at a residential facility for five months and reunited with family four months prior to this Multisystemic therapy intervention. Client has been diagnosed with adjustment disorder.
There are three main presenting concerns with Stacey. Firstly, the client has experienced truancy and challenges completing coursework as evidenced by her attendance record, which shows she missed approximately 45% of school days in the fall semester, and her report card, which shows she failed four of her fall classes due to missing/incomplete school assignments. She is at risk of needing to repeat tenth grade. Secondly, the client smokes marijuana on weekends with friends and sometimes by herself, as evidenced by self-report. Thirdly, the client has been in physical altercations with classmates in school that resulted in one suspension, as evidenced in her school record, and with her stepfather at home, as evidenced by family reports and a police record. The most recent physical altercation involved police response.
This cluster of antisocial behaviors puts Stacey on the trajectory for being referred to another out-of-home placement. MST helps family and youth by keeping participating youths in their community, decreasing antisocial behaviors while increasing prosocial behaviors, and has evidence of long-lasting benefits, including decreased felony arrests, incarceration rates, and divorce lawsuits (MST Services, 2021). In order to empower the family and help the client in her natural social environment, MST is recommended.
Strengths and Weaknesses
In the Individual Domain, Stacey’s strengths are her optimism, sense of humor, compassion, and protectiveness of her siblings and mother, as well as her openness to learning and participate in therapy. The client’s individual weaknesses or areas of need include challenges low motivation in school, difficulty with managing anger, and her desire to smoke marijuana.
In the Family Domain, strengths include client’s strong bond with youngest brother, client’s friendship with older brother, support from extended family, caring family unit, and the family’s openness to in-home intervention. The family’s weaknesses or areas of need include communication challenges, ineffective discipline, and the absence of client’s biological father from involvement in her life (aside from sporadic social media messages). Additionally, the youngest brother is on the autism spectrum and requires more support and attention from mother and stepfather, which may result in competing for attention among the five children. Lastly, Stacey and her stepfather have a strained relationship.
In the Peer Domain, the main strength is Stacey’s closest friend, who engages in pro-social behaviors and sometimes helps Stacey catch up with missed schoolwork. The main peer weakness is that Stacey spends time with and “parties” with older peers who engage in deviant behavior (underage drinking, smoking marijuana) on most weekends.
In the School Domain, Stacey’s strengths include that she likes writing and her English teacher, tutors are available for a variety of subjects, and the school system offers a structured learning environment. School weaknesses or areas for improvement include a large school population with one teacher to thirty student classroom ratio, which limits availability for individual support and attention, and incidents of school fights and being bullied, as reported by the client. Lastly, Stacey is not involved in any school extracurriculars.
In the Community Domain, the family has outside supports from neighbors and extended family who live in the area. Stacey reports that she is sometimes able to go to her neighbor’s house to “cool down” after an argument with her mother or stepfather. Their community, however, does have gang activity, a drug trade presence, and the violent crime rate is twice as high in the client’s county compared to neighboring counties (Lewis, 2019; MCPD, 2018). Stacey and her family have not reported concerns with gang violence in their neighborhood, but it is worth noting the potential for witnessing gang-related violence and availability of illicit substances.
The youth and her family have a variety of strengths in multiple domains that will be useful to utilize and build upon throughout the MST intervention process. Additionally, we were able to identify areas of need in each domain that will help identify some of the major drivers for Stacey’s antisocial behavior when we work on “finding the fit.”
Fit Circles
Drivers
In multisystemic therapy, there are nine principles to follow: (1) finding the fit, (2) positive and strength focused, (3) increasing responsibility, (4) present-focused, action-oriented, and well-defined, (5) targeting sequences, (6) developmentally appropriate, (7) continuous effort, (8) evaluation and accountability, and (9) generalization (Weisz & Kazdin, 2017). After we find the fit utilizing fit circles, the family, youth, and I will then work towards a positive, strength-based approach and increasing responsibility of youth to replace antisocial behaviors and responsibility of mother and stepfather to support the positive social and emotional development of Stacey and her siblings.
School Truancy
Stacey has a 45% absenteeism rate for her fall semester of tenth grade and is at risk of repeating her tenth-grade year. The two drivers from this fit circle (see Appendix A) I would prioritize for intervention are (1) the individual domain driver, wherein Stacey has low motivation for attending school, and (2) the family domain driver in which her mother and stepfather use an inadequate consequences/rewards system for academic achievement and challenges; this would also include lack of support from parents with her schoolwork.
While individual or insight-oriented treatment is not a focus of MST, Stacey’s low motivation for attending and achievement in school is a key driver and can be enhanced by building support from her social ecology, both in school, from peers, and from her family. In essence, increasing Stacey’s motivation is an overall goal and the steps to get there are part of the action plan that tap into her social environment.
When working towards increasing Stacey’s motivation for school, it will be important to build on her current strengths, such as her love of writing. In order to increase her school attendance, it would be helpful to encourage Stacey to join the journalism club or a similar activity. Furthermore, Stacey has been struggling with academic achievement, so one step could be to connect Stacey with the available school tutoring, as well as working towards increasing assistance and support with homework from her mother and stepfather. This also links to the second driver of Stacey’s school absenteeism.
Discipline and nurturance are key responsibilities for parents, so improving how Stacey’s mother and stepfather apply consequences or rewards, known as contingencies in MST, for school achievement and attendance would be a key task. For this driver, the writer recommends implementation of parental skill building with ongoing monitoring and adjustments as needed.
Marijuana Use
Stacey reported that she uses marijuana most weekends with her friends and has recently been increasing her personal use of marijuana on weekdays, usually at night (see Appendix B). The two drivers from this fit circle I would focus on for intervention are (1) her individual use of marijuana as a coping mechanism in lieu of other healthier coping skills and (2) the poor parenting skills/ inadequate discipline used by Stacey’s mother and stepfather.
One of the major drivers for Stacey’s marijuana use is that it has become a coping strategy for dealing with stressors, including disputes with her mother and stepfather, and grieving the loss of her late grandfather. Additionally, Stacey uses marijuana recreationally and has a history of leaving the house to spend time with friends and “smoke pot” even when she was told she was grounded. Her parents report they do not stop her when she leaves and sometimes, she sneaks out without their knowledge.
Replacing marijuana use with more prosocial behaviors by increasing Stacey’s healthy coping strategies, improving mother’s and stepfather’s parenting skills, and adjusting her peer interactions could help. For instance, the family could work together to improve communication, such as dedicating time to talk about and grieve the loss of Stacey’s grandfather, which would allow for familial bonding and support. Secondly, Stacey reports she prefers to hang out with her friends to cool off after arguments with her parents. This could be a skill that is altered and improved upon. Stacey has the insight to know when she needs time and space to work through her emotions, but then chooses to leave the house without permission and uses marijuana with friends. Altering Stacey’s destination could be helpful. Choosing to walk around the block before returning home, going to her maternal grandmother’s home, or even staying at her best friend’s house for a bit would be prosocial alternatives.
Additionally, altering the negative interactions that lead to arguments between mother, stepfather, and Stacey would be helpful and could alleviate some of Stacey’s stressors. This could be accomplished by working on building parenting skills and improving communication skills among the family members. Building in lessons for the parents and family as whole to achieve this goal would be ideal.
Aggressive Behavior
Stacey has engaged in aggressive behavior on multiple occasions, including one fight at school that resulted in her suspension for three days and altercations with her stepfather, one of which involved a police response (refer to Appendix C). The two drivers from this circle that I would prioritize for intervention are (1) Stacey’s individual maintenance and regulation of anger and (2) her family’s limited communication skills. For the latter, it would be pertinent to begin working with the family to minimize volatile arguments, diminish use of blame, and increase abilities to diffuse hostile situations within the family unit.
One of Stacey’s strengths is her deep compassion for her family. She is willing to stand up for and protect those she cares about no matter the consequences. While this is definitely an individual strength, her choice to engage with people who bully or demean her loved ones has resulted in aggressive interactions, one of which led to a school fight and Stacey’s suspension. In school, she chose to fight her younger brother’s bullies. Based on Stacey’s report of what had transpired, it would be ideal if the school took action to address the bullying. A family meeting among Stacey with her parents and the other youth with their parents may be helpful, as well as a school-wide anti-bullying campaign, presentation, or initiative. At the same time, it would be important for Stacey to recognize her choice and take responsibility for escalating rather than deescalating the situation, which is where personal skill building would be beneficial.
At home, hostile communication and demeaning language triggers Stacey’s irritability and aggression. The family unit would benefit from working toward improved communication, including doing exercises that praise each member rather than blame or antagonize one another. From there, working on resolutions and compromises when arguments occur could help the family. We would work together to recognize that while Stacey did choose to engage with aggression, her stepfather also played a role in their physical altercation. It takes two people to turn an argument into a physical fight, in essence. Therefore, taking responsibility and working toward peaceable solutions to disagreements within the family would be key.
Overall, it would also be helpful for Stacey’s social environment to support her in regulating her anger. Utilizing her more prosocial friend(s) and extended family to vent or take time to cool down, as well as receiving support from her mother and stepfather is vital. Rather than putting blame solely on Stacey, it will be key for the family to choose to build up Stacey and her ecological supports. Stacey is surrounded by supportive resources and she has a caring family, which is a huge positive for her. The key with our MST intervention now is to help Stacey and her family connect with and take advantage of these ecological resources in beneficial ways.
In conclusion, Stacey and her family are a good fit for multisystemic therapy. Based on the analysis of the fit circles and main drivers, several of the interventions that would most benefit the family include building the family’s communication skills, parents’ use of contingencies for consequences and rewards for the children’s behavior, and actively engaging with resources and supports available from friends, family, and the school system.
References
Lewis, K. (2019). Why is Montgomery County’s violent crime rate twice as high as neighboring Fairfax County? Retrieved from https://wjla.com/news/local/why-is-montgomery-countys-violent-crime-rate-twice-as-high-as-fairfax-countys
Montgomery County Department of Police. (2018). 2018 ANNUAL REPORT ON CRIME & SAFETY. Retrieved from https://www.montgomerycountymd.gov/POL/Resources/Files/PDF/PDResources/MCPD_Annual%20Report%20Crime%20Safety_2018.pdf
Multisystemic Therapy Services. (2021). Multisystemic Therapy Research at a Glance 2021. Retrieved from https://www.mstservices.com/mst-reports-research
Weisz, J. R., & Kazdin, A. E. (Eds.). (2017). Chapter 12: Treating Serious Antisocial Behavior Using Multisystemic Therapy. In Evidence-based psychotherapies for children and adolescents (3rd ed., pp. 197–214). New York, NY: Guilford Press.
