Serious Emotional Disturbance in Children and Adolescents: Multisystemic Therapy

Had this book started with a more modest and accurate title and a frank statement that it describes one energetic and probably useful proprietary model of multisystemic therapy, largely for teenagers, I think that I, and the average reader, would have had a less conflicted path toward liking and respecting its many good points. In fact, however, the main title of the book is a bit misleading and inflated. The book is not about serious emotional disturbance in children and adolescents. It is about a particular proprietary form of multisystemic therapy, used especially for antisocial teenagers; the book suggests that that this form of multisystemic therapy may also be used for younger children and for additional major mental illness diagnostic categories.

The style is repetitive. There are many largely sensible generalizations about biopsychosocial causality and repair, familiar to most child and adolescent psychiatrists but perhaps aimed, in this case, at legislators and sources of grant funding. Whatever the category of readership, however, I expect there may be some confusion arising from the authors’ frequent use of acronyms: not just NIMH, DHHS, DSM, PTSD, CBT, and not just the book’s focus—MST—but also a peppering of, for example, TFC, CRA, SAM, FRS, FSRC, CQI, TAM, and ACT, often without nearby referents.

The multisystemic therapy described in the book (for purposes of this review, I will follow the authors and call it MST) tries to diagnose and treat youngsters by paying attention to several simultaneous systems and biopsychosocial parts. Although the training of the participant therapists seems to me somewhat thin and formulaic, the therapists do seem to have relatively low and manageable caseloads, and MST does usefully and repeatedly try to inventory strengths and problems, prioritize treatment goals, and monitor goals and results. Some of the goals, as is typical with such protocols, seem a bit neater and cleaner than the complex realities usually seen with troubled teenagers; “accountability for engaging families,” for instance, is one of many worthy but rarely tidily measurable goals.

MST usefully looks beyond the individual patient to the parents, principal caregivers, families, social and community systems, and risk factors and protective factors. It tries to overcome barriers to round-the-clock service access. Much of this makes excellent sense. The models of treatment used rely heavily on cognitive behavior therapy, behavior therapy, and pharmacotherapy but also clearly use cogent indirect therapeutic interventions with family and environmental systems. There is a refreshing acceptance that in real life, as opposed to the world of many research protocols, complexities and comorbidities are common. The authors suggest that MST is appropriate for youngsters with “complex multifaceted and challenging mental health and behavioral problems, especially problems that are costly to service systems,” and their examples suggest that these are youths who would otherwise have to be, or deserve to be, psychiatrically hospitalized.

That the book is about one particular and proprietary type of multisystems therapy limits and, I think, confuses the book’s scope somewhat. It will take the average reader a while to realize that the book is not about the very useful, underused, and potentially flexible concept and practice of multisystemic therapy per se, but only about one particular form of it. The book now and then implies, but does not tell us until page 231, that the authors are apparently working within a licensed system of “technology and intellectual property.” Since the authors again and again tell us that MST therapists must keep control, one might reasonably suspect that self-interest may well be crowding in with clinical validity and scientific objectivity. When limitations of MST are discussed, these are pretty well narrowed to dangers if MST is not applied long enough or with enough control; there seems little openness to the possibility that there may be real limitations to the cost-effectiveness, usefulness, rightness, and details of MST for some youngsters.

In general, the attempt to include, and even systematize, a relatively wide biopsychosocial context in diagnosing and treating youngsters seems fine to me, and far too rare in the current American climate of underdiagnosing and undertreating and extruding troublesome youngsters. MST, to its great credit, does not just medicate symptoms. Also, to its great credit, it tries to create a system without the usual abandoning of many difficult children to the streets, the courts, the prisons, or the cracks in our systems. On the other hand, MST still falls short of encompassing as much of the biopsychosocial reality as it implies it does, and this will probably be a problem for the authors’ wish to extend MST to younger children and to other mental illness diagnoses, where its usefulness is still less clear than it is with antisocial teenagers. MST selectively omits some areas in the biological and social realms, but the most striking omissions, as in many more purely behaviorist programs, seem to be in the psychological realm. Psychoanalytic as well as psychiatric, child guidance, pediatric, educational, and commonsense experience suggests that there will be great cost to mostly or totally ignoring such areas as feelings, conflicts, resistance, the unconscious, the irrational, the importance of relationships, eclectic and dynamic psychotherapy, and even wisdom. Can one build more of that into the already complex protocols of MST? Much more research, and not just by insiders, will be needed to study the long-term costs and benefits of such omissions in the protocols of MST, as in more traditional cognitive behavior therapy and behaviorism in general.

The style of the book is often somewhat inspirational, self-congratulatory, and cheery (“MST borrows from the best of the evidence-based treatments”),with an odd whiff of both Brave New World and Babbittry. MST feels somewhat mechanical and feels (and I suppose is) unapologetically run by a manual. The authors seem fond of simple measures and short-term measures, and they claim they rely on “evidence-based” treatments. They are not modest about their use of the currently fashionable term “evidence-based.” That gives a sensible reader some reason to beware, since the phrase, sounding so unarguably good, implies vastly more than it can currently legitimately deliver in many areas, certainly including much of child and adolescent psychiatry.

On a somewhat different note, the book provides little detail about financial cost, except to point out that where MST is a successful alternative to psychiatric hospitalization it very likely saves money.

Overall, this is a book whose focus on analyzing and treating and getting cooperation from many people and systems in the diagnosing and treating of antisocial teenagers—and perhaps also of children and youngsters with other severe mental illness diagnoses—seems to me fine and important. The simultaneous major focus on one particular proprietary way of doing this, however, seems to me to lessen the importance of the book.