MST-CM and an MST-CM Therapist’s Typical Day Jeff Randall, Ph.D. Family Services Research Center

1. MST-CM and an MST-CM Therapist’s Typical Day Jeff Randall, Ph.D. Family Services Research Center Medical University of South Carolina

2. Family Services Research CenterMedical University of South Carolina

3. Overview • Client Characteristics • What is MST-CM • Components of MST-CM • Common Implementation Challenges • Differences Between Standard MST and MST-CM • Needed Skills and Support for MST-CM • MST-CM Outcomes and Dissemination

4. Who are We Treating? • Meets DSM IV – TR Criteria for Substance Abuse • Meets DSM IV – TR Criteria for Substance Dependency • 25% • Substance Abuse Related Referral or Arrests • Substance Abuse Determine During Treatment • 30% to 40%

5. Determinants of Adolescent Drug Abuse • Individual (favorable attitudes) • Family difficulties (poor monitoring) • Caregiver (substance abuse, depression) • Association with deviant peers • Poor school performance • Neighborhood conducive to substance use

6. What is MST? • Addresses multidetermined nature of substance abuse and co-occurring problems (e.g., individual, family, peer, school factors) • Integrates evidence-based intervention models • Caregiver viewed as key to long term outcomes • Program accountability for family engagement and outcomes • Home based services • Therapists available 24/7, low caseloads

7. What is Contingency Management? Definition Contingency management is a type of treatment used in the substance abuse field in which youth are rewarded or punished for drug use. Additionally, plans are developed and implemented to address specific reasons for drug use.

8. What are Contingency Management Theoretical Underpinnings? Budney and Higgins Community Reinforcement Approach (CRA) Excellent outcomes with adult cocaine abusers Intensive tracking of drug use with contingencies Functional analysis of substance use triggers CBT interventions aimed at substance use Conceptually and clinically compatible with MST Azrin and Donohue Excellent outcomes with adolescents Reward Menu

9. Why Integrate Contingency Management (CM) into Multisystemtic Therapy? • 1. CM includes three components that have not been typically been used in MST that have been empirically demonstrated to reduce substance use. • 2. MST has tended to focus on building protective factors and reducing the impact of risk factors, and not on detecting substance use and providing contingencies for substance use or abstinence. • 3. Several features of the CM point system have been easily imported into the MST protocol. • 4. Several Drug Avoidance Strategies further support the goal of substance abstinence.

10. Developing and Implementing the Contingency Management Point System 1. Complete with the youth and caregivers a contract that lays out a system, including three levels, for earning, losing, and spending points. 2. Complete with the youth and caregivers a Reward Menu to specify prosocial items and activities that the youth wants to earn for having clean screens. 3. Set up and monitor a checkbook tracking system for points earned, spent, or lost. 4. Implement contingency management point system. 5. Develop plans to sustain the incentive system after treatment completion.

11. Materials Required • Point System Contract • List of Potential Rewards • Reward Menu • Personal Checkbook • Personal Checks

12. Functional Analysis • Assess events in the environment that occur before, during and after youth drug use. • Teach caregivers skills to help the • youth identify environmental events • associated with drug use.

13. Materials Required 1. Discovering Triggers of Your Substance Use Worksheet 2. Functional Analysis Form Components of a Functional Analysis: 1. Triggers 2. Thoughts and Feelings 3. Drug Use 4. Consequences

14. Self-Management Planning • Self-management planning is the term used • to describe the process of using specific • strategies to actively manage drug use • triggers. • Three Basic Ways of Managing Triggers: • Avoid triggers • Rearrange the environment • Make a new plan

15. Self-Management Planning Cont 1. Help the youth develop strategies and skills to manage drug use triggers. 2. Help caregivers assist and reinforce their adolescent for managing drug use triggers. 3. Generate as many alternative strategies as possible for managing drug usetriggers. 4. Help the youth become more responsible in becoming abstinent.

16. Self-Management Planning • Cravings • Strategies Used to Help Youth Manage Cravings: • Relaxation training • Thought stopping techniques • Habit reversal training (i.e., practicing a competing response).

17. Drug Refusal Training • Develop drug refusal skills for the youth to use during unavoidable social situations. • Help the youth develop a unique drug refusal style. • Provide opportunities for the youth to practice drug refusal skills (e.g., role-plays) in managing drug offers inunavoidable social situations.

18. Drug Testing Protocol Provide a reliable and valid measure of substance use so that contingencies can be applied appropriately and quickly.

19. Drug Testing Protocol Cont Determine the Frequency of Testing Guidelines for Collecting Urine Specimens and Breath Scans Where to Collect Specimens Position of the Observer Adulterants

20. Common Implementation • Challenges • Substance Screens Remain Dirty or the Youth Remains Noncompliant. • The Youth Escalates to Violence or Threats of Self-Harm. • Caregivers Do Not Believe that Children Should Be Rewarded for Not Using Drugs. • Caregivers Believe that Substance Use is a Medical Condition that Should Be Treated Medically. • A High Level of Negative Caregiver-Adolescent Affect is Undermining the Steps of CM Implementation.

21. Common Implementation Challenges Continued 6. The Family Has Few Resources to Use as Rewards and Privileges.

22. Difference Between Standard MST and MST-CM Functional Analyses (FA) - In standard MST, FA may be conducted as part of fit for some cases - In MST-CM FA is required for each instance of substance use or non use FA is conducted in a prescribed, step by step manner

23. Difference Between Standard MST and MST-CM Cont Self Management Plans - Standard MST therapists develop interventions - MST-CM therapists develop, write, and revised a specific kind of plan for the youth to follow to avoid substance call a self management plan

24. Difference Between Standard MST and MST-CM Cont Drug Refusal Skills (DRS) -In Standard MST, therapists may teach DRS when necessary -In MST-CM • DRS training is required for all youth in program • DRS is conducted using a specific structure • DRS includes extensive role plays

25. Difference Between Standard MST and MST-CM Cont Voucher Points and Levels System - In standard MST, incentives are sometimes given - In MST-CM Incentives are a required part of MST-CM Incentives are specified in a contract Incentives are funded by the MST-CM program

26. Difference Between Standard MST and MST-CM Cont Drug Testing - In standard MST, drug testing is conducted -In MST-CM • Random drug testing is required at frequency based on the youth’s drug of choice • MST-CM program pays for the cost of screening

27. Difference Between Standard MST and MST-CM Cont Individual Sessions with Youth - In standard MST, individual sessions are less likely to occur - In MST-CM • As part of initial assessment process, MST-CM therapists conduct functional analysis and obtain a list of desired rewards without the caregiver being present

28. Skills Needed by Therapists • MST-CM Training • Effort and Accountability • Conceptualization and Thinking • Strength-Focus and Engagement • Skill, Knowledge, and Experience • a. Clinical Modalities (family, ecological, CBT) • b. Organization and Time Management • c. Cross Agency Collaboration • d. Experience with Common Clinical Problems (e.g., • aggression, family conflict, parental depression, • drug use, truancy)

29. Conditions for Successful Start-up and Running • Stakeholder Commitment/Support • Strong stakeholder commitment is necessary for success. • Greater stakeholder commitment will be earned: • -- Robustness and Credibility of MST-CM • -- Accountability • -- Transparency • -- Understanding and Addressing Stakeholder’s • needs

30. Conditions for Successful Start-up and Running • Community Support • Substance abuse and dependence can be treated in the community. • Group treatments, AA, and NA have a deviant peer component. • Teaching the importance of caregivers actively participating in treatment with youth.

31. Program Outcomes • Randomized NIDA and NIAAA Study • MST-CM Significantly Reduced Drug Use • CM with MST Enhanced MST’s Effectiveness

32. Current Implementation • Approximately 20 MST-CM Teams • 9 Stand Alone Teams • 3 Synergy Pure MST-CM Teams • 6 Juvenile Justice Initiative, New York Blended MST-CM Teams • 11 Teams via the 2 Network Partners

33. Queens New York MST-CM Teams 2009 Outcomes • Substance Use Success Rate at Discharge: SCO Queens 80% Child Center 85% • Youth with no New Arrests at Discharge: SCO Queens 81% Child Center 88% • Youth with no Placements at Discharge: SCO Queens 84% Child Center 85%

34. Network Partner and Synergy Teams 2009 Substance Use Outcomes • Representative Network Partner Outcomes at Discharge: 77% Success Rate • Synergy 3 Pure MST Teams at Discharge: 70% Success Rate

35. Projected Implementation • Projecting 10 Plus MST-CM Teams in 2010 • New York (8 Teams) • Denmark (? Teams) • England (2 Teams)

36. More Information Jeff Randall, Ph.D. Phone: (843) 876-1816 Fax: (843) 876-1808 Email: randallj@musc.edu