Implementing Multisystemic Therapy (MST) in your Organisation
This document provides a blueprint of how an organisation can implement MST within its existing structure. The first part of this document will review the critical elements of MST programme implementation, followed by an outline of the standard processes that usually occur prior to and in the first year after the inception of an MST programme. Finally, commonly experienced barriers to programme implementation are highlighted, including possible solutions to these barriers.

MST is not a “cure-all” treatment for all types of youth difficulties, but it has the potential to effectively reduce antisocial behaviour in a significant percentage of high-risk youth if implemented properly. There must be a clear understanding of MST at all levels of the organisation in order for the programme to get the strongest case outcomes. From the executive levels on down, there must be a firm commitment to implement MST fully: it is not possible to “partially” implement MST and expect to receive the positive treatment outcomes that have been documented in the empirical literature.

Moreover, in order for an MST programme to be optimally successful, it is crucial to have the support of those agencies that have legal mandate for these youths or who are otherwise involved in their lives. Typically, the key agency stakeholders include Youth Aid, CYFS, mental health services, the schools, and special educational services, among others. Failure to attain the support of any one of these stakeholders can severely limit the viability of an MST project. Thus, prior to the development of an MST programme, substantial energies must be devoted to obtaining community collaboration and developing a suitable interagency framework for successful implementation.

Critical Elements of Programme Implementation
There are a number of factors that are critical to the successful implementation of the MST model in community-based programmes. The four most important elements are:

I. A continuous focus on outcomes
II. Adherence to the MST treatment model
III. The accessibility of treatment
IV. Cultural best practice

These elements operate at different levels of the service system. In particular, we would like to discuss how these elements of programme implementation may be facilitated: (1) within the provider organisation, (2) within the clinical team context, and (3) within the broader service system with other key stakeholders.

I. A continuous focus on outcomes:
Traditionally, service systems for children and youth have focused on providing services, no matter their quality. Serious systems-level attention to individual case outcomes and demands that providers achieve specific outcomes are relatively new in most service systems. Consequently, many of today's “standards of practice” are not oriented toward getting positive case outcomes; rather, they are oriented toward perpetuating a system that is good at providing services. By implementing an MST programme, your organisation will be placing a very high priority on getting the very best and strongest outcomes with each case. MST will demand that all parts of the system maintain a continuous focus on outcomes and, perhaps, that some long-standing “standards of practice”be changed in the pursuit of these outcomes. A continuous focus on outcomes is best maintained when the following exist:

1) Within the provider organisation:

• Clear understanding of MST at all levels
• Willingness to modify policies and dedicate resources to achieve outcomes.
• With the agreement of other organisations and agencies, MST Therapists must be able to “take the lead”for clinical decision making on each case. The organisation sponsoring the MST programme has responsibility for initiating collaborative relationships with other organisations and agencies. Each MST Therapist sustains these relationships through ongoing, case-specific collaboration.
• Inappropriate referrals to the MST programme include youth primarily referred for sex offences (in the absence of other behavioural problems) and youth in need of crisis stabilization due to suicidal, homicidal, psychotic behaviour.
• Funding for MST cases should be in the form of case rates or annual programme support funding in lieu of billing mechanisms that track contact hours, “productivity,” etc.
• MST programmes should use outcome-focused personnel evaluation methods

2) Within the clinical context:

• MST programme discharge criteria must be outcome-based and ameliorate the referral problem/behaviour

3) Within the broader service system with other key stakeholder:

• Interagency agreement that defines the role of MST services and articulates the nature of relationships between agencies

1) Within the provider organisation:

• Clear understanding of MST at all levels
• Commitment to implement MST fully
• A focus on MST compatible populations
• MST Therapists who are experienced Bachelors' level or Masters level professionals
• MST Clinical Supervisors who are clinically experienced Masters level or Ph.D. level professionals

• MST Therapists must track progress and outcomes on each case weekly by completing case paperwork and by participating in team clinical supervision and MST consultation
• Task oriented supervision practices that include weekly team clinical supervision, ongoing weekly MST telephone consultation, individual clinical supervision for crisis cases, and staff development and training
• MST Clinical Supervisors must be assigned to the MST programme a minimum of 50% time per MST Team and have both clinical authority and administrative authority over the MST Therapists they supervise
• MST Therapists must operate in teams of no fewer than 2 and no more than 4 therapists (plus the Clinical Supervisor) and use the Family Preservation model of service delivery
• The excepted duration of treatment is 3 to 5 months. MST caseloads must not exceed 6 families per therapist, with a normal range being 4 to 6 families per therapist

3) Within the broader service system with other key stakeholders:

• Funding structure in place
• Established routes for MST compatible referrals from other agencies
• Ability of MST therapists to take the “lead”in clinical decision making

1) Within the provider organisation:
Willingness to modify policies and dedicate resources to achieve outcomes

2) Within the clinical context:
MST Therapists must be accessible at times that are convenient to their clients and in times of crisis, very quickly. Issues to be addressed in this area include the dedicated nature of the MST Therapist role, the use of flex-time/comp-time, policies regarding the use of personal vehicles, and the use of pagers and cellular phones MST Therapists must be full-time employees assigned to the MST programme 100% time The MST programme must have a 24 hour/day, 7 day/week on-call system to provide coverage when MST Therapists are on vacation or taking personal time. This system must be staffed by professionals who know the details of each MST case and who understand MST thoroughly

3) Within the broader service system with other key stakeholders:
Interagency agreements that define the role of MST services and articulate the nature of relationships between agencies

IV. Cultural best practice:
MST recognises its clear obligations under The Treaty of Waitangi to enhance and improve the design of, access to, delivery, and monitoring of policies and programmes that impact the well-being and influence social outcomes for Maori. In order for MST to be optimally effective and appropriate for all New Zealand families, it is imperative that cultural best practice principles are observed at all levels of programme implementation. Accordingly, the development and maintenance of an MST programme demands that certain processes are followed in order to ensure cultural safety for whanau, hapu, and iwi. Of course, we acknowledge that cultural best practice is an integration of the cultural processes followed by the provider organisation and the processes denoted by MST.

1) Within the provider organisation:
Commitment to the obligations and principles denoted in the Treaty of Waitangi. Commitment to the practical interpretations of the Treaty of Waitangi. Commitment to working with Whanau, Hapu, and Iwi representatives of the family's heritage. Commitment to expose MST Therapists and Clinical Supervisors to all of the cultural aspects of the MST training process (both the initial training and ongoing education through quarterly trainings and case-specific consultation)

2) Within the clinical context:
A commitment to employ therapists with ethnic backgrounds that reflect those of the families that they will be working with. In the absence of ethnically matched therapists and families, the development of a consultation process by which Whanau, Hapu, and Iwi will be consulted on a case-by-case basis. Establish processes by which clinicians can consult with all relevant Whanau, Hapu, and Iwi with regards to all of their client's tribal affiliations

3) Within the broader service system with other key stakeholders:
A commitment to establish and maintain collaborative relationships with Whanau, Hapu, and Iwi in the provider organisation's local community. Establish routes by which Whanau, Hapu, and Iwi can deliver appropriate referrals to the MST programme. Establish processes by which organisations can consult with all relevant Whanau, Hapu, and Iwi with regards to the tribal affiliations of their client base.