MST Treatment Process: A Case Example
This case involved a 16-year-old male who lived with his Mum but had weekly contact with his father. At the time MST involvement began, he had recently returned home from his second secure custody stay. Referred by his probation officer, he came to MST with this constellation of presenting issues:

Repeated Criminal Activity
His prior record involved thefts, possession of stolen property, breach of probation and robbery.
Non-compliance/Breaking House Rules
He did not meet curfew and was very threatening to his Mum.
Anti-Social Peers
He was involved with gang members in a community where kids “just hang out,” and there is an atmosphere of crime with lots of drug and alcohol use.
School Refusal
He was supposed to be entering Form 5 in the fall but had not yet completed any Form 3 credits. There were no positive interactions with school personnel and his previous school was refusing to have him back due to his poor behaviour and lack of attendance.

Over the four months of involvement, the MST caseworker saw this family three to four times per week to begin with, along with lots of telephone contact. Visits decreased to twice weekly, and for the last month were weekly with less telephone contact.

Assessment of Systemic Struggles and Needs
Before the MST process can begin, the caseworker reviews available information and meets with all parties to determine the strengths and struggles of the youth in relation to the family, school, peers and community. It is typical that the struggles and needs are obvious in youths referred to MST. In this case, the youth was disrespectful of authority figures, non-compliant, and truant. He abused drugs and alcohol and angered readily. His history of behaviour concerns was long-standing. He had been on Ritalin for many years for ADHD but had ceased the medication because of side effects. His attitude at home was sometimes poor. His Mum minimized his academic needs and overestimated his abilities. She sometimes shouted when frustrated and gave in to her son’s threatening behaviour at home. She was on financial assistance and had no transportation. None of her extended family members lived nearby. His father was strict, harsh and controlling with the youth, and nagged him about his clothing, hair etc. His visits were inconsistent and often contingent upon his son’s behaviour. He had physically abused his wife during their 12-year marriage and the relationship with his ex-wife was strained. In school, where this youth was three years behind his other same-age peers, he had been suspended several times and his relationship with the school staff was poor. School staff believed they could neither meet his academic needs nor deal with his behavioural concerns. They saw him as unfocused and not motivated. With his peer group, he liked to show off and hang around at the mall. His close friends drank and did drugs. He was easily influenced by his peers. He associated with known gang members and had been approached about joining a gang.

Assessment of Systemic Strengths
MST uses systemic strengths as levers to address systemic struggles and needs. Accordingly, a crucial part of the initial assessment involves the identification of the strengths within the individual, family, school, peer group and community. In this case, the young man was good at sports, had a strong bond with his sister, was fun to be with, attended church with his Mum, was good with the younger children in the church group, did chores at home, was willing to say “sorry” when he made a mistake, got up willingly in the morning for school, hoped to be successful at school, and wanted a summer job. He was also protective of his Mum and sister. His best friend was a somewhat more positive influence who did well in school and had not been in trouble with the law. Since the separation three years ago, his Mum had upgraded her academic credentials. The MST caseworker experienced her as a kind person, a good listener, with friends in her church and a commitment to keeping her son in the home. She knew some of her son’s friends and welcomed them into the home. She had established rules for her children to follow. She was able to extricate herself from an abusive marriage and acknowledged the effect of the abuse on her children. The father had a fairly stable job and sometimes helped out financially with child maintenance. He wanted the best for his son and was willing to be involved with parenting. Communication between Mum and son was good and there were clear affective ties between the Mum and her children. Family members cared for each other, attended church together, and had a stable, well-kept residence.

Overarching Goals
As part of the initial assessment process, the MST caseworker helps the family to establish overarching goals of treatment. Identification of overarching goals guide all MST interventions, based on presenting problems and the desired outcomes indicated by family members and other key stakeholders. They also provide the basis for case closure (i.e., the “closure criteria”) in that their attainment can easily be observed and measured and is evidence that the family will be able to maintain gains in the long term. These were the overarching goals targeted in this case, pertaining to family, school and peers:

1. To follow the rules at home and in the community as evidenced by self-reports, parent observations and no further police contact.
2. To regularly attend a stable school placement able to meet his academic and behaviour needs as evidenced by school attendance records, passing grades, Mum’s report, and reports from school staff.
3. To increase association with pro-social peers as evidenced by weekly involvement with an organized recreational activity and/or a part-time job.
4. To decrease drug and alcohol use as evidenced by self-report, parent observations, and clean urine screens for at least 6 weeks.

From these overarching goals, weekly intermediary goals were developed which were action oriented, present focused and often took the form of homework for the family.

Engagement and Alignment
In this case, the MST caseworker started by spending much of her time engaging the parents separately and seeking their alignment with her interventions. Although this youth’s father was not living in the home, his power and control was evident and he initially expressed interest in being involved. The MST caseworker met with the father on his own terms (closer to his home, convenient times for him). She engaged the Mum in a different way, by providing useful things. For example, she drove her places, which made her life a little easier but also provided time to seek information and give emotional support. Note that the initial efforts were focused on parents. Their alignment with the intervention is crucial in the effort to change their child’s behaviour.

Once a sufficient degree of engagement has been achieved, the caseworker works with the family to prioritise the targets of treatment based on the overarching goals that have been developed. Problem behaviours are generally prioritised according to the family’s level of concern about different problems and the negative implications of different problem behaviours (e.g., physical aggression might be targeted before compliance with household chores).

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