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Implementation of MST in NorwayIceland June 2008
Bernadette Christensen Clinical Director of the Youth Department Anne Cathrine StrüttMST Consultant
The Norwegian Center for Child Behavioral Development
Why MST In Norway?
• Much media attention to the deficiencies within the child welfare systems and the lack of professional personnel within some of the institutions
• The fact that kids were being institutionalized, for longer period of time, far away from their homes and returning not having been helped (no changes in their original environment and little changes in their own behavior)
Why MST In Norway? (continued)
• Great budgetary deficits because of the amount of out-of-home placements
• The child and youth psychiatric clinics had little or no treatment services for adolescents with serious behavior problems
• By law - family based help and support should be tried before the children are placed out of home
Implementation Process in Norway
• 1997: Lack of services and competence in Child Welfare and Child Psychiatric Services: An international expert conference hosted by the Norwegian Research Council
• 1998: An expert panel report recommending the implementation and controlled evaluation of selected evidence based programs
• 1999: Towards ”evidence based practice”: nationwide implementation of PMTO and MST
• 2000: PMTO/MST clinical outcome studies – new standards for clinical outcome research
• 2003: The Norwegian Center for Child Behavioral Development (Atferdssenteret – University of Oslo Affiliate
Facilitators at the National Level• A genuine interest and commitment at the political and administrative level –
consistent funding from The Ministry of Child..and the Ministry of Social and Health
• Determination and support to establish a national implementation and research center• National implementation teams for children and youth• Research group
• Plans for program implementation in all of Norway - Establishing comprehensive training- and maintenance programs for therapists and supervisors
• Creating professional networks for collaboration and quality control
• Conducting research on clinical outcomes, the implementation process and on the development of serious behavior problems in children and youth
• Positive feedback from families and media
MST
Goals &Guidelines
Site assessments
MonthlyReview
ProgramImplementation
Review
Weekly clinicalSupervision
Weekly clinical consultation
TAM SAM
5 day MST training
IndividualDevelopment
Plans
THE MST MODEL
Treatment Adherence
Quarterly boosters
Implementation of the MST treatment model in Norway has required a persistent multi-level effort:
• Legal adaptation• Organizational factors – nationwide and regionally• Attitudes towards treatment and therapist role• Development, consolidation and maintenance of an MST
organization in Norway• Development of the Norwegian adaptation of the Quality
Assurance System
18.04.23 © Norsk senter for studier av problematferd og innovativ praksis
MST in Norway
• 22 MST-teams are established across all regions of Norway as part of the National Child Welfare Services
• All MST training, consultation and boosters are done by 7 Norwegian Consultants in Collaboration with MST Services
• 3500 families and youth have received MST
• Clinical Outcome Study MST (100 families)
• Clinical Outcome Study with Contingency Management and Treatment Adherence
Transportability Challenges
• The Transportability of the clinical method
• Conflicting Ideologies
• Support of evidence based methods and willingness to work in a structured and systematic way
Continuous Challenges
• Treatment Fidelity• Sustainability• Referrals
– getting the right referrals
- caseload
Characteristics of the Norwegian MST clinical outcome study
• The first controlled evaluation study (RCT) of MST outside North America and in a non-english speaking country
• One of the first trials not involving the developers of MST • The trial was conducted by independent investigators who did
not participate in the training and supervision of MST therapists nor in the actual treatment of families
• One of the first MST studies examining site differences in treatment effects
• Implemented as ’real world’ treatment in a country without a juvenile court system (Child Welfare Services only).
Conclusions of the Norwegian MST EvaluationConclusions of the Norwegian MST Evaluation
• The Norwegian findings support the effectiveness of MST relative to the services usually available for youths with serious behaviour problems at three out of four sites
• MST prevented placement out of home to a greater extent than regular services
• MST was associated with decreased internalising and externalising problem behavior in youths
• A marginally greater caregiver satisfaction with treatment relative to RS was reported by the MST families at post assessment
• Differential MST treatment effects across sites at post treatment and at follow up, may be due to variability in the quality of treatment implementation.
Future Plans for the Department of Youth
• Training MST consultants in collaboration with MST Services
• Continuous Development of MST training documents in Norwegian
• More MST teams where needed• Participation in research studies on Drug abuse
CM (Contingency Management)• More evidence based programs for youth –
FFT and MTFC
MST in Norway
• 1999: The first 4 teams• 2007: 22 teams - nation-wide• 1997-2007: 3500 families in MST
Organization
Supervisor TherapistYouth/family
TAM-R
ManualManual
Consultant
Manual
Program data and treatment
results
Manual
Adherencemeasure
Adherencemeasure
Organization
Supervisor TherapistYouth/family
TAM-R
ManualManual
Consultant
Manual
Program data and treatment
results
Manual
Adherencemeasure
Adherencemeasure
10 30 50 70 90 110 130 150 170 190 210 230 250 270 >2800
100
200
300
400
500
600
Length of treatment (days)
10 30 50 70 90 110 130 150 170 190 210 230 250 270 >2800
100
200
300
400
Length of treatment (days)
Before 2005 2005-2007
Therapist adherence
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
V 01 H 01 V 02 H 02 V 03 H 03 V 04 H 04 V 05 H 05 V 06 H 06 V 07
Lives at home (completers)
93 % 97 % 89 % 85 % 83 %0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Admission Discharge 6 mths 12 mths 18 mths
Attends school/work
26 % 88 % 82 % 80 % 80 %0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Admission Discharge 6 mths 12 mths 18 mths
Abides the law
57 % 96 % 91 % 90 % 92 %0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Admission Discharge 6 mths 12 mths 18 mths
Does not abuse substances
56 % 90 % 85 % 84 % 86 %0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Admission Discharge 6 mths 12 mths 18 mths
Refrains from violence
38 % 94 % 88 % 90 % 91 %0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Admission Discharge 6 mths 12 mths 18 mths
The MST Quality Assurance System
• Research-validated adherence technologies• Development planning for all professionals • Structured training (orientation and booster)• On-the-job training (on-going, weekly expert case review and
consultation)• Weekly clinical supervision
Organization
Supervisor TherapistYouth/family
TAM-R
ManualManual
Consultant
Manual
Program data and treatment
results
Manual
Adherencemeasure
Adherencemeasure
Why such an extensive Quality Assurance System?
• Target population is therapeutically challenging • Treatment model places high demands on therapists
Why such an extensive Quality Assurance System?
• Target population is therapeutically challenging • Treatment model places high demands on therapists
• Evidence based practices: Treatment results rely on adherence to the treatment model
0.60
0.72
0.83
0.95
1.07
Nu
mb
er
of
Ch
arg
es
pe
r Y
ea
r P
os
t-T
x
-0.64 -0.36 -0.09 0.19
Deviation from Mean TAM Score (TAM - .64)0 .28 .55 .83 1
Therapist adherence
High therapist adherencegives better outcomes
MST Evaluation studies in Norway(Ogden & Halliday-Boykins, 2004)
• MST teams that did not follow up on the quality assurance system, had the poorest outcomes
• High treatment adherence led to better outcomes
The MST Quality Assurance
TREATMENT RESULTSHow are the outcomes for the youths and their families?
Monitoring
MST (therapy, supervision, consultation)
Manual
MST clinical outcome study
Ogden,T. & Halliday-Boykins,C.A. (2004). Multisystemic Treatment of Antisocial Adolescents in Norway. Replication of Clinical Outcomes Outside of the U.S. Child and Adolescent Mental Health, 9, 77-83.
Ogden,T. & Hagen,K.A. (2005). Multisystemic Therapy of Serious Behaviour Problems in Youth: Sustainability of Treatment Effectiveness Two Years After Intake. Child and Adolescent Mental Health, in print.