MST Treatment Process: A Case Example continued. . .

The “Fit”
The youth’s curfew violations appeared to be a good area to target first. This involves identifying the factors in his life that contributed to the behaviour or, in “MST speak”, finding the fit. In this case, there were several pertinent factors that led to the youth breaking curfew. The youth was impulsive and couldn’t say no when presented with an opportunity to stay out late. Being summer and having just been released from custody, he just wanted “to chill.” Many of his friends did not have curfews. In his community, there was a generally pro-criminal attitude. His drug and alcohol use, condoned by his father, was also identified as contributing to this behaviour. He tested his Mum’s limits constantly and she often relented and gave in to his demands. She was not consistent or effective in giving consequences for curfew violations.

From among all these factors, one is selected to target first. Traditional therapy might concentrate on the youth, perhaps on his impulsivity or his inability to deal with peer pressure. In contrast, MST dictates that the caseworker should look at systemic factors in the youth’s ecology. Generally, interventions are prioritised according to which efforts will contribute to the greatest amount of positive change in the shortest period of time. In this case, the caseworker first targeted the factors that prevented the Mum from being consistent and effective in enforcing curfew violations, as this change would facilitate improvements across all the youth’s problem behaviours and could be achieved in a fairly timely manner.

When the caseworker considered the strengths within the family to use as levers for positive change, she focused on the fact that Mum did have house rules and wanted to develop more consistent discipline. Although Mum could clearly identify what she considered to be the house rules after some thought, this youth used her initial vagueness to his advantage. The establishment and written documentation of clear and consistent house rules was a good starting point.  Sessions that involved both the Mum and youth served to clarify the Mum’s expectations and to establish predictable rewards and consequences associated with the rules. The son was responsible for typing the list of rules, rewards and consequences on the computer and making copies for himself, his Mum, the caseworker and probation officer. The rules were clearly posted on the refrigerator, and the youth was asked to recite the rules in his own words, in order to ensure that both Mum and son shared a common understanding.

When the youth continued to break his curfew, the caseworker and Mum continued to explore the other systemic factors that were contributing to the problem, now knowing that ignorance of the rules was no longer the barrier to curfew compliance. Upon further assessment, it was discovered that the Mum had sporadic health problems that prevented her from enforcing the rule consistently. Accordingly, a referral was made to a reputable physician so that her health concerns would be adequately monitored and treated. The caseworker accompanied the Mum to her first appointment and ensured that she was able to attend all subsequent appointments and obtain her prescribed medication. Accordingly, Mum’s health improved and over time, she was able to follow through on rules more consistently.

It was also agreed that Mum did not have the support of other adults in her parenting role and did not possess all of the requisite skills to discipline effectively. In order to remedy this situation, the caseworker engaged the Mum in a detailed evaluation of her existing social support network and ultimately determined that she had a couple of friends who managed their children’s behaviours effectively and who functioned well within the community.  She helped the Mum to strengthen her relationships with these friends and to enlist their help in providing practical and emotional support to her in developing new parenting skills. The caseworker and Mum would first problem-solve and develop strategies together, and then inform Mum’s friends of these strategies so that they could remind and support her in implementing them on an ongoing basis.  These friends were initially included in the treatment sessions and as Mum became more confident in her friendships with them, she was able to communicate relevant information to them directly (without the caseworker’s assistance).

Finally, it was discovered that another barrier to the youth’s curfew compliance was that his father undermined the Mum’s authority and her attempts to give consequences. Some initial meetings with both parents revealed that they actually had similar hopes and expectations for their son, but that the conflictual relationship between the Mum and father was contributing to the father’s undermining behaviours. Accordingly, the caseworker worked with both parents to help them realize the negative effect of their conflict on their son’s behaviour. Due to the previously abusive relationship between Mum and father, Mum was initially resistant to communicating with the father, and the caseworker worked to re-establish this communication in several ways.

Specifically, the caseworker helped Mum to begin thinking about the relationship with her ex-partner as a business arrangement by developing agendas for meetings and helping her to remain calm and unemotional. Role-playing with the MST caseworker was an effective strategy in coaching this Mum on how to deal with her ex-husband. Once she had both parents’ engagement to work together around parenting their son, specific plans were developed by which the parents would communicate with one another regularly about rules and expectations. Moreover, the caseworker helped the parents to support one another by maintaining consistency between their homes, so that the youth was less able to avoid negative consequences and rules imposed by either parent. All of these areas of intervention, once addressed, eventually had a significant impact on this youth’s curfew behaviour.

The process documented above is reflective of how the multiple systemic risk factors to the youth’s curfew violations were systematically identified and dealt with. In a multi-step process similar to the one described above, the factors related to the youth’s other problem behaviours were subsequently identified and interventions were developed to address them. In many cases, interventions in one area (e.g., increased parental monitoring) had a dramatic impact across numerous problem behaviours, thereby enhancing the efficiency and progress of the overall treatment process.

Summary of Systemic Changes
By termination of the case, the youth was following house rules (chores, curfew) and accepting consequences (grounding, removal of privileges) as required. Mum had developed the needed skills to not only consistently consequence rule violations, but also to reward and encourage positive behaviours. The communication between the youth and his Mum was supportive and demonstrated a sound negotiation and problem-solving ability. Mum’s increased active listening and consistent use of time out to deal with sibling conflict and non-compliant behaviour resulted in a significant decrease in incidents of violence and aggression in the home. During the summer months, Mum and the MST caseworker worked together to explore an appropriate school placement to meet the boy’s academic and behaviour needs. At the time this family exited the program, he had demonstrated perfect attendance and completed all homework assignments for over a month. Communication between his Mum and the school teachers (she called them weekly) and her daily monitoring of homework was evidence of a strong family-school partnership. Privileges at home, including the use of the telephone (a highly valued activity) were contingent on completion of chores and homework.

In the community, this young man resisted joining the youth groups or recreational activities suggested by the MST caseworker and his Mum. However, he did show interest in a part-time job, and at the time of termination from the program had completed applications to several stores in the area and had received some responses and invitations for interviews.

At case closure, this young man primarily associated with peers who attended school regularly and maintained part-time jobs. His Mum had given clear and consistent messages of non-acceptance of his drug and alcohol use and continued to monitor and consequence as necessary. Reports from both the youth and his Mum indicated a significant decrease in substance use after major consequences and loss of privileges had been attached. He negotiated appropriately with his Mum about inviting peers to his home. His Mum kept a telephone list of all his peers and contacted parents when necessary. The MST caseworker closed the case after observing strong evidence of this Mum’s ability to manage future parenting issues. Despite a continued strained relationship with her ex-partner, she clearly benefited from excellent informal and reciprocal social supports that helped her to maintain her positive parenting skills. Specifically outlining all the individuals in this Mum’s life who provided her with emotional, instrumental, appraisal and/or informational support had helped to provide the evidence that she was well connected to significant informal supports in her community. Although she was not interested in a parent support group at the time of termination from MST, the caseworker ensured that she was aware of the resources available to her in the area.

What made this intervention successful? First, the focus on empowering the youth’s Mum was an effective strategy. It is the Mum and other family members who will continue to care for and manage this young man, so it is only through her and them that the work is successful. Second, the caseworker directly engaged other formal and informal supports in the youth’s natural environment. For example, the MST worker and the probation officer and school staff worked collaboratively throughout the intervention. This was essential in modelling for the Mum the steps taken in developing a partnership with agencies outside the home. In addition, the caseworker worked to identify and strengthen the Mum’s informal friendships so that she would become more comfortable and competent in maintaining supports that would facilitate positive parenting. Third, a consistent emphasis on sustainability ensured that all changes taking place during the treatment process would be maintained over the long-term.

return to page 1