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Transport Findings Update and Summary_____________________________________

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Sonja Schoenwald, Ph.D.January 14, 2009

FSRC Update & Publications

MST Transport & Implementation Research

Thanks to:Office of Juvenile Justice and Delinquency Prevention

National Institute of Mental HealthNational Institute of Drug AbuseFamily Services Research Center

Charles GlissonDon Hedeker

David MackinnonService systems, organizations, clinicians, and families

Transporting New Treatments: MST as Test

Case

Funded by National Institute of Mental Health

MH59138 1999 – 2004

National Institute of Drug AbuseDA018107

2005 – 2007Schoenwald, PI

MST Transportability Study Aims

To Examine Relations Between: MST therapist adherence and outcomes Organizational climate and structure,

adherence, & outcomes Supervision, adherence, & outcomes Impact of clinician training & experience on

adherence A mediation model of transport

Social Ecological Model of Treatment

TransportabilityExtra-Organizational Context(Referral, Reimbursement, Disposition)

Organization Clinician Child (Structure,Climate,) Adherence Outcomes

MST Supervision (Behavior, functioning,

criminal activity)

Clinician Variables Professional Training & Experience

Design

Prospective, uncontrolled study Children nested within therapists nested within

organizations within service systems Repeated measures

Youth: Pre, post, 6 & 12 months post-treatment; lifetime pre through 1-year post criminal charges

Clinicians: TAM monthly; SAM bimonthlyOrganizations: biannuallyService system: biannually, & per case

Participants

45 MST programs in 12 states and Canada 452 therapists: 73% female, 73% Caucasian,

15% African American, 6% Asian/PI, 2% Hispanic 64% masters (social work, counseling,

psychology) 1979 youths and their caregivers Youths were: 15.5 years old, 65% male,

58% Caucasian, 19% African American, 6% Asian, 4% Hispanic, 13% Biracial

MST Transportability Study Published Findings Redux

Predictors of Post-Treatment Change

Therapist Adherence (Schoenwald, Sheidow, Letourneau, & Liao, 2003; FSRC Pub. # 235)

Select Organizational Climate & Structure Scales (Schoenwald et al., 2003; same as above)

Consultant Adherence (Schoenwald, Sheidow, & Letourneau, 2004; FSRC Pub. # 242)

Organizational Factors Assessed

Climate Psychological impact of work environment Validated measure, OCQ, has 10 scales

Structure Formal features of organization

Hierarchy of Authority Procedural & Rule Specification Participation in Decision-making

“Fit” of work with structure is more important than structure per se

Organizational Predictors

Select climate and structure factors predicted short-term outcomes, some in unexpected directions.

Climate & structure did not predict adherence.

Adherence moderated relations between climate and structure and outcomes.

Findings at Long-Term Follow-Up

Youth Change Over Time

Significant reductions in behavior and

functioning problems through 1-year post-

treatment

Significant reductions in criminal charges

through 4-year post-treatment

Did Adherence Predict Longer-Term Post-Treatment Change?

Reductions in behavior problems one-year post-treatment differed significantly as function of therapist adherence ratings

Schoenwald, S. K., Carter, R. E., Chapman, J. E., & Sheidow, A. J. (2008). Therapist adherence and organizational effects on change in youth behavior problems one year after Multisystemic Therapy. Administration and Policy in Mental Health and Mental Health Services Research, 35, 379-394; FSRC Pub #326)

Adherence – Criminal Outcomes

At the highest level of adherence, the annualized rate of post-treatment charges for youth was 47% lower than at the lowest level of adherence.

When therapist adherence scores were one SD above the mean, annualized rate of post-treatment charges was 29% lower than when therapist adherence scores were one SD below the mean.

Schoenwald, S.K., Chapman, J.E., Sheidow, A.J., & Carter, R.E. (in press). Long-term youth criminal outcomes in MST transport: The impact of therapist adherence and organizational climate and structure. Journal of Clinical Child and Adolescent Psychology.

Structure & Climate Findings

Higher Therapist Adherence Was Predicted By

Greater organizational average levels of Growth & Advancement

Therapist perception of greater Growth & Advancement and Job Satisfaction

Lower Therapist Adherence Predicted By Therapist perception of greater Emotional

Exhaustion

Greater reductions in youth Externalizing behavior were predicted by:

Higher organizational average levels of Growth & Advancement

Lower organizational average levels of Hierarchy of Authority

Therapist perceptions of greater Participatory Decision making

Structure & Climate Findings (2)

However, When therapist adherence was added to the

statistical models, the effects of these organizational climate and structure factors

on youth outcomes weakened.

Structure & Climate Findings (3)

Structure & Climate Findings (4)

Youth Criminal Charges (on average 4 years post-treatment) Were Predicted By

Therapist perceptions of greater Job Satisfaction, Growth & Advancement

Higher organizational average Participatory Decision making

But,These effects washed out when therapist

adherence was included in the model

What Does This Mean For Your Work?

When adherence is good, but youth long-term outcomes are not, it may be that select aspects of organizational climate or structure are affecting the outcomes.

BUT: Depending on the outcome in question, those organizational effects are either weak or wash out compared to the effects of adherence

SO: Keep focusing on adherence

Supervisor Adherence

Supervisor Adherence Measure (SAM) Subscales

Supervision structure & process (SP)

Promotion of MST principles (AP)

Promotion of MST analytic process (ANP)

Supervisor development of clinician’s skills and competencies (CD)

*

Supervisor Adherence Findings

Greater supervisor average focus on Adherence to Principles predicted therapist adherence.

Greater supervisor adherence to the Structure and Process (SP) of supervision during a youth’s treatment episode predicted greater reductions in youth behavior and functioning problems.

Greater average focus on Clinician Development predicted a lesser decrease in youth functioning problems.

Schoenwald, S.K., Sheidow, A.J., & Chapman, J.E. (in press). Clinical supervision in

treatment transport: Effects on adherence and outcomes. Journal of Consulting and Clinical Psychology.

Empirically – Supported Fidelity Links

Consultant Supervisor Therapist Outcomes

CAM

TherapistReport

SAM

TherapistReport

TAM

ParentReport

Behaviors FunctionCriminal Activity*

Organization*