Merging Multisystemic Therapy into CCBHCs for At-Risk Youth

As an evidence-based intervention practice, Multisystemic therapy (MST) is a viable option for the CCBHC. It has been effective because it empowers the youth (ages 12-17) and their families or caregivers by giving them the tools to function with accountability over the long run. Accountability is the keyword here. For the youth to be successful in treatment, they first must hold themselves accountable for their behaviors. The family must also be supportive in their roles in the child’s development and learn to provide constructive support to the youth in need. MST requires very intense involvement and contact with the patients, their families, and their support system. It is a long-term solution that has been found to help at-risk youth.

What is a CCBHC?

A Certified Community Behavioral Health Clinic, or CCBHC, is a treatment model first authorized in 2014 through the “Protecting Access to Medicare Act”. The CCBHC is a person-centered, holistic, value-based model that is designed to be accessible to all people with a behavioral health or substance use disorder regardless of their ability to pay, geographic location, or age. One key element of the CCBHC model is that it is designed to get people into care quickly without long waiting lists.

The CCBHC has nine required service types:

Crisis Services
Treatment Planning
Screening, Assessment, Diagnosis & Risk Assessment
Outpatient Mental Health & Substance Use Services
Targeted Case Management
Outpatient Primary Care Screening and Monitoring
Community-Based Mental Health Care for Veterans
Peer, Family Support & Counselor Services
Psychiatric Rehabilitation Services

There are currently 450 CCBHCs operating across the country. The 2022 CCBHC Impact Report from the National Council for Mental Wellbeing provides data that demonstrates that CCBHCs have been able to improve access to care. CCBHCs are working to reduce unequal healthcare among minority populations by providing medication-assisted treatment to 1.3 million people nationwide and increasing coordination and integration with primary care.

Multisystemic Therapy in CCBHCs: How it Works

At Qualifacts Systems for Certified Community Behavioral Health Clinics (CCBHCs), we are following the progress of the Multisystemic Therapy (MST) treatment model, since it is similar to CCBHCs in general.

Here is a definition of the model:

Multisystemic therapy is an intense form of therapy involving a basis of family and community treatment; it’s intended for underage individuals who have been seriously involved with the justice system and may have substance use issues. This treatment is most common with individuals between 12 and 17 years old, specifically those who may require out-of-home placement due to behavior or legal involvement.

MST has been established and practiced in 15 countries worldwide and within 34 states. There are over 2500 clinicians trained to deliver MST and they have served 200,000 plus youth to date.

Benefits of Integrating MST in CCBHCs

MST can effectively reduce delinquent and antisocial behaviors by addressing the root causes of such behaviors. This ability has enabled MST to also preserve the home placement with 91% of youth remaining living at home at the close of treatment. Data from the MST SERVICES website shows that, at the close of treatment, 87% of those who participated in MST had no juvenile arrests. MST includes a web-based data management tool (MST Institute) which is used to track case-level outcome data. This enables MST to track fidelity and quality adherence to the MST intervention.

One way MST works is that it helps youth develop self-esteem by setting future goals and achieving them. Through MST, the youth also learn how their behaviors negatively impact those they care about and those who care about them. The youth also learn the consequences of their behavior and begin to have empathy for those they hurt.

Two factors that had the most impact on the outcomes were the development of prosocial aspirations and empathy. MST helped the children identify positive future goals, such as completing school, which increased their self-esteem. Together, these two factors significantly increased prosocial behaviors in children.

One of the characteristics of MST that make it such a good fit for CCBHCs is that it is community-based. It aims to keep the child in the home with the family. The MST treatment model engages the youth and the family in therapy to reap the greatest outcome. The practice of MST includes the collaboration between the judicial system and the CCBHC which is consistent with the criteria of the CCBHC. One could predict that the use of MST could prevent or reduce the costs associated with avoidance of incarceration of those youth who might end up incarcerated should they go untreated or receive ineffective treatment.

Data from the MST website, research has been able to demonstrate that the use of MST reduces criminal activity and other undesirable behavior in at-risk youth. At the close of treatment, 87% of youth have no arrests. The clinician(s) who delivers MST works in all the youth’s environments including the home, the school, and the community. There is a provider available 24/7 for crisis events. The key to MST is that the therapists give the caregivers the tools they need to transform the lives of troubled youths.

MST is evidence-based and CCBHCs are required to utilize evidence-based practices (EBP) making MST a good fit for the CCBHC treatment model. MST includes measurable goals. The success of MST is not measured by the length of time the youth is engaged in MST but rather by the outcome or the meeting of the set goals.

Challenges and Strategies for Implementing MST in CCBHCs

To provide MST treatment, the clinician must be trained in MST and possess a master’s degree in counseling or social work. MST is not a one-time training but rather an ongoing intervention program. As an EBP, adhering to the treatment model is critical. In order to maintain MST the CCBHC must make a long-term commitment to the training. This could pose a challenge to some CCBHCs. Ensuring the consistent use of MST requires an organizational commitment and the ongoing oversight to ensure the MST is being implemented as it was trained to be. Fidelity and quality assurance of the model is critical.

MST has to be implemented correctly and requires a team. The team is typically made up of a supervisor, two to four therapists (all on the on-call team), and an outside team manager to call for emergencies. The medical personnel must be trained to provide MST services by the leading company at the time. Developing and maintaining this team requires great commitment from the CCBHC. In this time of shortage of healthcare professionals, maintaining this high-quality team could present a challenge. A recommendation would be to build the team directly into the staff structure of the CCBHC.

Each youth participating in therapy will have specific, measurable goals that were developed with the involvement of the youth and their caregivers. The involvement of the family/caregivers is critical to the success of the child. Success is measured by the attainment of those goals. The goal of the MST is to help at-risk youth.

These goals can be achieved by the following:

Individual therapy
Family therapy
Cognitive-behavioral therapy
Treatment for drug use or other substance use
Tools to promote behavior change
Follow-up when issues arise

MST views the child as part of a larger ecosystem which includes the community, the neighborhood, the school, peers, and family.

MST would be a positive addition to any CCBHC “jail diversion” program serving at-risk youth aged 12-17. Like the CCBHC treatment model, it is community based and client centric. It is evidence based and holistic in its approach and focuses on the root cause of the behavior so it can result in true, lifelong changes. MST can change the course of a youth’s life by keeping them out of incarceration, keeping them with the family, and allowing them to remain in school or at work. These are significant life goals for this market segment. CCBHC are required to utilize evidence-based practices and MST is another tool they can leverage for the continued success of the CCBHC treatment model. It is community-based which is consistent with the CCBHC. I understand that utilizing MST is a commitment because the organization must remain certified, participate in ongoing training, collect, and report data, and must adhere to the efficacy of the intervention model. If you are a CCBHC that is successfully using MST, I’d love to talk to you about its effectiveness. You can reach me at mary.givens@qualifacts.com.

MST Services, licensed by the Medical University of South Carolina, is the organization responsible for disseminating Multisystemic Therapy with clinical fidelity. MST Services supports the implementation and ongoing fidelity of MST worldwide by charging standard fees for program development, intellectual property licensing, ongoing training, support, and quality assurance.

Future Directions for MST in CCBHCs: Research and Policy Implications

Multisystemic Therapy is one of the evidence-based practices recommended in the SAMHSA CCBHC “Criteria 4.F: Outpatient Mental Health and Substance Use Services”. Additional research would need to be done to assess the impact of the use of MST in the CCBHC treatment model. If SAMHSA recognizes MST as one of the suggested EBP, it is possible that CCBHCs will eventually adopt it.

MST had many of the characteristics that align with the CCBHC criteria.

MST is person-centered with family /caregiver involvement and support.
It is community-based and seeks to promote change in the home.
MST is also an evidence-based practice.
It is a valuable tool for use with diversion efforts particularly when it comes to reducing involvement with the criminal justice system.
Through its preventive and crisis management elements it also results in reduced healthcare costs and system costs by avoiding or minimizing ED visits and incarceration.

If you are a CCBHC who would like to learn more about MST, here are resources for more information on MST and how to start your own MST program.