Journal of Consulting and Clinical PsychologyIW.Vol. 65, No. 5, 821-833

Copyright 1997 by the American Psychological Association, Inc.0022-006X797/S3.00

Multisystemic Therapy With Violent and Chronic Juvenile Offendersand Their Families: The Role of Treatment Fidelity

in Successful Dissemination

Scott W. HenggelerMedical University of South Carolina

Gary B. MeltonUniversity of South Carolina

Michael J. BrondinoMedical University of South Carolina

David G. SchererUniversity of New Mexico

Jerome H. HanleySouth Carolina Department of Mental Health

The effects of multisystemic therapy (MST) in treating violent and chronic juvenile offenders andtheir families in the absence of ongoing treatment fidelity checks were examined. Across 2 publicsector mental health sites, 155 youths and their families were randomly assigned to MST versususual juvenile justice services. Although MST improved adolescent symptomology at posttreatmentand decreased incarceration by 47% at a 1.7-year follow-up, findings for decreased criminal activitywere not as favorable as observed on other recent trials of MST. Analyses of parent, adolescent, andtherapist reports of MST treatment adherence, however indicated that outcomes were substantiallybetter in cases where treatment adherence ratings were high. These results highlight the importanceof maintaining treatment fidelity when disseminating complex family-based services to communitysettings.

The management of violent and chronic juvenile offendershas become an important issue on the nation's social policyagenda, largely because of the considerable social and economiccosts exacted by these youths. For example, chronic juvenileoffenders are at high risk for mental health problems, substanceabuse, poor physical health, low educational and vocational pro-ductivity, and interpersonal difficulties (Farrington, 1991;Laub & Sampson, 1994). Likewise, the financial cost of violentcrime is staggering, with costs pertaining to victimization (i.e.,

Scott W. Henggeler and Michael J. Brondino, Department of Psychia-try and Behavioral Sciences, Medical University of South Carolina; GaryB. Melton, Institute for Families in Society, University of South Carolina;David G. Scherer, College of Education, University of New Mexico;Jerome H. Hanley, Division of Children, Adolescents, and Their Families,South Carolina Department of Mental Health.

Preparation of this article was supported by Grant R18MH48136originally from the National Institute of Mental Health and later trans-ferred to the Center for Mental Health Services, Substance Abuse andMental Health Services Administration. Special thanks go to JosephBevilacqua, Ida Wannamaker, Bessie Abraham, and Gary Moneypennyof the South Carolina Department of Mental Health; Mary Jane Sanders,Dottie Reynolds, James Lucas, and Margaret Barber of the South Caro-lina Department of Juvenile Justice; and the therapists and researchassistants without whose help the project would not have been possible.

Correspondence concerning this article should be addressed to ScottW. Henggeler, Family Services Research Center, Department of Psychia-try and Behavioral Sciences, 171 Ashley Avenue, Medical University ofSouth Carolina, Charleston, South Carolina 29425.

health related, lost productivity, reduced quality of life), lawenforcement, and the maintenance and expansion of the correc-tional system (Cohen, Miller, & Rossman, 1994).

Compounding the problems posed by violent and chronicjuvenile offenders is the general lack of success that mentalhealth and juvenile justice services have had in ameliorating theserious antisocial behavior of youth (Melton & Pagliocca, 1992;Tate, Reppucci, & Mulvey, 1995). Recently, however, an innova-tive family- and home-based treatment (multisystemic therapy;Henggeler & Borduin, 1990; Henggeler, Schoenwald, Borduin,Rowland, & Cunningham, in press) has documented long-termreductions in the criminal activity of serious juvenile offendersin two randomized trials. With a sample of violent and chronicjuvenile offenders at imminent risk of incarceration, Henggelerand his colleagues (Henggeler, Melton, & Smith, 1992; Heng-geler, Melton, Smith, Schoenwald, & Hanley, 1993) showed thatmultisystemic therapy (MST) improved family functioning atposttreatment, reduced incarceration at a 59-week follow-up,and reduced rearrest at a 2.4-year follow-up. Importantly, suchoutcomes for MST were achieved at considerable cost savings.Similarly, with a sample of chronic juvenile offenders, Borduinet al. (1995) showed that MST unproved individual and familyfunctioning at posttreatment and greatly reduced violent andother criminal activity at a 4-year follow-up.

The success of MST has been attributed to several characteris-tics that differentiate this treatment model from other empiri-cally based treatment approaches (Henggeler, Schoenwald, &Pickrel, 1995). First, MST addresses the multiple known deter-

821

822 HENGGELER, MELTON, BRONDINO, SCHERER, AND HANLEY

minants of serious antisocial behavior (i.e., individual, family,

peer, school, and community factors; Elliott, 1994; Thornberry,

Huizinga, & Loeber, 1995; Tolan & Guerra, 1994) in a compre-

hensive, yet individualized, fashion. Second, identified problems

are treated in the natural ecology of the youth and his or her

family. The provision of services in home, school, and other

community locations overcomes barriers to service access and

largely negates problems of treatment generalization. Third, the

MST therapist training protocol brings a level of clinical rigor

to community settings that is similar in intensity to that used in

clinical trials conducted in university settings (Weisz, Donen-

berg, Weiss, & Han, 1995). This training protocol includes four

components: 5 days of orientation to MST principles, quarterly

booster training, weekly on-site supervision consistent with the

MST model, and weekly treatment integrity checks through

consultation with an expert in MST.

With the documented success of MST when implemented

by therapists working in community (Henggeler et al., 1992;

Henggeler et al., 1993) and university (Borduin et al., 1995)

settings, important directions in the further validation of this

treatment model pertain to the parameters of its successful dis-

semination. The purpose of this study, therefore, was to deter-

mine whether the effectiveness of MST could be maintained in

community mental health settings when experts in MST did not

provide significant clinical oversight. In previous clinical trials

of MST (Borduin et al., 1995; Brunk, Henggeler, & Whelan,

1987; Henggeler et al., 1991; Henggeler et al., 1992; Henggeler,

Pickrel, & Brondino, 1997; Henggeler et al., 1986), an MST

expert hired or consulted with regard to the hiring of therapists

and provided weekly expert consultation to therapists to enhance

treatment fidelity. Such extensive involvement of an MST expert

might constitute financial and administrative barriers to the

broader dissemination of MST; that is, weekly consultation with

an MST expert adds an additional cost to a project for both the

therapists' and consultant's time, relatively few MST experts are

available to provide such consultation, and many experienced

therapists and administrators are reluctant to embrace a form

of oversight that emphasizes program features that may conflict

with current practices (e.g., MST emphasizes program account-

ability for clinical outcomes).

[n consideration of these financial and administrative barriers,

the present public-academic collaboration (Bray & Bevilacqua,

1993) examined the effectiveness of MST under conditions that

reflect one real-world (and convenient) option for the dissemi-

nation of MST. Program administrators at two public community

mental health center sites had primary authority for hiring thera-

pists to deliver MST home-based services. In addition, an MST

expert did not provide weekly integrity checks and consultation

to project therapists and supervisors. Thus, the MST training

protocol took the form of the types of clinical training that are

typically provided in community mental health settings: in-

tensive workshops with little follow-up to monitor treatment

adherence.

In summary, the present study examined whether MST effects

with violent and chronic juvenile offenders could be maintained

when MST training and fidelity checks were similar to prevailing

clinical practices (i.e., workshop training, minimal attention to

treatment adherence). If the treatment effects could be main-tained, the effective dissemination of this complex treatment

model could be greatly expedited. On the other hand, if treatment

effects similar to previous studies were not observed, such fail-

ure to replicate could be due to difficulties in therapist adherence

to the MST treatment protocol. In anticipation of this possibility,

parent, adolescent, and therapist ratings of MST treatment adher-

ence were assessed, and associations between adherence and

clinical outcomes are reported.

Method

Design

The study followed a 2 X 2 X 2 Condition (MST vs. usual services

[US]) X Time (pretest vs. posttest) x Site (Site 1 [SI] vs. Site 2 [S2])

mixed factorial design, with families randomly assigned to treatment

conditions (WMST = 82, raus = 73). In addition to the pretest and posttest

data reported here, we conducted a 1.7-year follow-up to examine arrest

and incarceration rates. To further control for historical and related

threats to validity, we temporally yoked the families assigned to receive

MST services with families assigned to receive the usual services af-

forded to offending youths by the South Carolina Department of Juvenile

Justice (DJJ). Because families were referred by the DJJ staff in a

family's county of residence and rates of referral were very low at certain

times of the year in the more rural and sparsely populated counties, four

of the families in the MST condition could not be yoked to a comparison

family. An additional five MST families were not yoked, either because

of a family's acceptance at the end of the project, when there remained

insufficient time to recruit a comparison family, or because of participant

attrition as is described later.

As a precondition for locating the project at each of the sites, the

judges and solicitors agreed that project participants (chronic or violent

juvenile offenders) would be initially placed on probation rather than

removed from the community as part of the research design. As part of

this arrangement, a judge's consent to remain in the community was

obtained by project staff for each youth recruited in the study. %uths

were randomly assigned to a treatment condition only after the court's

consent was obtained. Moreover, the judges, solicitors, public defenders,

and other court-related personnel were kept unaware of the treatment

condition of the youth through a process agreed on by all parties before

the project's inception.

Sites

The two sites were chosen to achieve representation of racial group

and urban and rural settings. Each site covered a three county area. The

first, SI, encompassed urban and rural areas and had a majority Cauca-

sian population (77.8%; U.S. Bureau of the Census, 1993). S2 was

predominantly rural and majority African American (58.4%; U.S. Bu-

reau of the Census, 1993). Each site was staffed by a therapy team

consisting of two full-time therapists and a therapist supervisor who

were housed in a regional community mental health center of the South

Carolina Department of Mental Health or in one of the center's satellite

offices.

Participants

Participants were 155 violent or chronic juvenile offenders and their

primary caregivers. To be included, the adolescents had to (a) be between

11 and 17 years of age, (b) have committed a serious criminal offense

or have at least three prior criminal offenses other than status offenses,

and (c) be at imminent risk of being placed outside the home because

of serious criminal involvement. At the time of referral, the 155 youths

ranged in age from 10.4 to 17.6 years (M = 15.22), 81.9% were male,

80.6% were African American, and 19.4% were Caucasian. Approxi-

THE ROLE OF TREATMENT FIDELITY 823

mately 40% of the age-eligible adolescents reported being employed

full-time or part-time, and 79% of the sample were in school. The

majority of the youths were from single-parent homes (38.1%) or lived

with their biological mother and another adult who was not their biologi-

cal father (31.6%). The youths averaged 3.07 prior arrests (SD = 2.07),

40% had at least one prior arrest for a violent crime, and 59% had at

least one previous incarceration. The youths' pre-entry offenses averaged

8.8 (SD = 2.21) on a 17-point Seriousness scale (Hanson, Henggeler,

Haefele, & Rodick, 1984) on which low scores were characterized by

status offenses; midrange values by crimes such as assault and battery,

breaking and entering, and carrying a dangerous weapon; and high scores

by armed robbery and criminal sexual conduct.

Primary caregivers ranged in age from 25,5 to 75.5 years (M =

41.30) and were predominantly female (92.2%) and African American

(80.6%). Mothers were overwhelmingly represented as primary caregiv-

ers (n = 136), although the sample also included 10 grandmothers, 3

fathers, 4 other family members (e.g., aunts, sisters, etc.), and 2 foster

parents as primary caregivers. Approximately 50% of the youths lived

in two-parent households, although only 15% lived with two biological

parents. The average family had 5.0 family members (SD = 2.18). Only

14.2% of the adolescents' mothers and 3.2% of fathers had attended

college or were college graduates, and most of the mothers (55.6%) and

many of the fathers (38.1%) had not completed high school. Consistent

with relatively low levels of parental education, the median family in-

come was between $5,000 and $10,000 per year. Moreover, the sample

was quite mobile, with 25.2% having moved at least once in the year

before the pretest and 16.1% having made two or more moves during

the same period. The aforementioned demographic characteristics did

not differ between site or treatment conditions.

Treatment Conditions

MST. The conceptual foundation of MST is Bronfenbrenner's

(1979) theory of social ecology in which the process of human develop-

ment is viewed as a reciprocal interchange between the individual and

interconnected systems including, but not limited to, the family, extended

family, peer, school, work, community, and cultural contexts. From this

perspective, and consistent with findings from the delinquency causal-

modeling literature (Henggeler, 1991), problem behaviors are under-

stood to be multidetermined and linked with the multiple systems in

which youths and families are embedded. Thus, the scope of MST

interventions is not limited to the individual adolescent or the family

system, but includes difficulties between other systems such as the fam-

ily-peer and family-school mesosystems.

Because of the varying demands of each case, MST therapists must

be capable of applying a range of empirically based therapeutic ap-

proaches (e.g., structural family therapy, cognitive behavior therapy) and

tailoring interventions to the unique needs and strengths of each family.

Consistent with family preservation models of treatment delivery, MST

services are most often provided in the home at times that are convenient

for the families—although it is not unusual for meetings to be held in

schools, neighborhood settings, social service agencies, and elsewhere

in the community. MST treatment goals are family driven, rather than

therapist driven, and family members are viewed as full partners and

collaborators in the treatment process. Given the complexity of interven-

tions involving MST, the behavior of the therapists is governed by a set

of nine treatment principles (see Appendix A), rather than explicitly

delineated as a set of sequential and invariant steps or techniques. These

principles are delineated in a treatment manual (Henggeler et al., 1994)

and volume (Henggeler et al., in press), and extensive clinical descrip-

tions are provided by Henggeler and Borduin (1990). Therapist adher-

ence to these treatment principles serves to operationalize MST treatment

fidelity.

Ten MST therapists participated (five per site over the course of the

project), and all were masters-level mental health professionals with

backgrounds in social work or pastoral counseling. Prior clinical experi-

ence varied considerably, ranging from 1 to 15 years of direct service

provision. Supervisory therapists were required to have had at least 2

years of clinical experience. Despite considerable effort to recruit thera-

pists at each site to achieve mixed gender and racial representation,

balance was achieved only for gender; with three male therapists and

two female therapists in each site. The applicant pools in each site

corresponded to the majority racial group in that region, with the result

that all the therapists and therapist supervisors were African American

in S2 and all were Caucasian in SI.

The therapists were trained in MST using one of two training proto-

cols. The first group of therapists (n = 6) was provided with 6 days of

intensive didactic and experiential training that included role playing,

critical analysis of cases, and problem solving exercises. These training

sessions were videotaped in full, and the videotapes were used as the

principal instructional modality for a second group (n = 4) of therapists.

This second group comprised one late hire in SI and replacement thera-

pists from both sites because of staff turnover. Both groups were pro-

vided with a copy of a treatment manual describing MST.

Treatment integrity was supported by means of direct therapist super-

vision provided by the therapist supervisors in individual sessions held

once each week and in weekly staffings that included the therapist super-

visor; the coordinator of child, adolescent, and family services from

each regional mental health center; and the program coordinator. The

families averaged 122.6 days (SD = 32.6 days, range = 68-226 days)

and 116.6 days (SD = 39.8 days, range = 60-286 days) in treatment

in SI and S2, respectively. In addition, quarterly booster trainings were

held to discuss current cases and increase the therapists' overall under-

standing of MST. However, as noted previously and in contrast with

other evaluations of MST, the therapists did not have weekly access to

consultation with an expert in MST.

US. Youths in the US condition were, without exception, placed on

probation for a minimum of 6 months and, depending on the nature of

the adolescent's offenses, were often further instructed by the courts to

make restitution. During probation, the youth was typically seen by his

or her probation officer at least once per month, although in some cases

a youth may have been seen as frequently as once per week. The youth's

school attendance was monitored during this time, and he or she was

referred to other social service agencies (e.g., the Department of Mental

Health, alcohol and drug abuse programming, vocational counseling

or training) for help in particular problem areas. Youth experiencing

difficulties in school were occasionally placed in alterative schooling or

referred to special programs for school dropouts. If progress was not

noted in the case during the probation period, DJJ had the option of

initiating an out-of-home placement.

Research Procedures

Participants were referred to the project by DJJ intake officers in the

family's county of residence following the juvenile's arrest for a criminal

offense. When an opening occurred in the project, a list of names of all

adolescents meeting the eligibility criteria at that time was compiled by

the intake personnel at the local DJJ offices. A research assistant at each

site then randomly selected a number of families equal to the number

of openings (plus two alternates in case of refusals) from the list. These

families were approached by a project staff member either at the local

DJJ office or in the family home, the project was explained in full, and

the families were asked to participate in the study. Over the course of

the project, only 6.6% of the families approached refused to participate.

After we received written informed consent, the family was randomly

assigned to a treatment condition, and the initial assessment made within

3 days of consent but before the beginning of therapy for the MST

condition. The identical assessment battery was administered to an MST

824 HENGGELER, MELTON, BRONDDSKX SCHERER, AND HANLEY

family and its yoked comparison within 72 hr of the termination of the

MST family from therapy. Families were paid $50 for each completed

assessment battery. In addition to the outcome measures, families in the

MST condition were asked to complete treatment adherence measures

following two randomly selected therapy sessions during the fourth and

eighth weeks of therapy.

Measures

The assessment battery was developed to tap key constructs represent-

ing instrumental and ultimate outcomes. An emphasis was placed on

measuring the constructs from multiple perspectives. Ultimate outcomes

tapped the adolescents' criminal activity and incarceration rates and the

primary caregivers' and adolescents* emotional-behavioral functioning.

Instrumental outcomes included changes in family functioning and the

adolescents' peer relations. In addition, parents, youths, and therapists

in the MST condition completed a treatment adherence questionnaire at

two intervals during treatment.

Individual emotional adjustment and adolescent behavior problems.

Primary caregiver and adolescent psychological distress were assessed

by the Global Severity Index (GSI) of the Brief Symptom Inventory

(BSI; Derogatis, 1993), which is a short form of the Symptom Check-

list—90—Revised. The 53 self-report items of the BSI are rated on a

scale ranging from 0 (not bothered in the previous week by the symptom)

to 4 (extremely bothered by that symptom). The GSI is considered the

best single index of respondent emotional distress and is formed by

summing scores across the items and dividing by the total number of

items. Coefficient alphas for the BSI subscales range from .71 to .85,

test-retest reliability is .90 for the GSI, and the subscale scores correlate

.90 or above with those of the SCL-90-R subscales. As described in

the manual (Derogatis, 1993), numerous studies have supported the

convergent, discriminant, and predictive validity of the BSI. A sample

item is, "How much are you bothered by feelings that others are to

blame for most of your troubles?"

Adolescent behavior problems were assessed through caregiver re-

ports (total score) on the 89-item Revised Problem Behavior Checklist

(RBPC; Quay & Peterson, 1987). The RBPC has strong psychometric

properties (McMahon & Forehand, 1988) and has predicted serious

offense history in delinquents (Hanson et al., 1984). Item scores range

from 0 (no problem) to 2 (severe problem), and caregivers are asked

to indicate how much, for example, "staying out late" and "stealing in

company of others" has been a problem for their child.

Criminal activity. Adolescent responses on the Self-Report Delin-

quency Scale (3RD; Elliott, Ageton, Huizinga, Knowles, & Canter,

1983) were used to assess youth reports of criminal activity during the

previous 3 months. The 40-item SRD, used in the National \buth Survey,

is probably the best validated of the self-report delinquency scales1

(Henggeler, 1989) and includes a General Delinquency scale that pro-

vides a summary measure of criminal offenses and an Index Offense

scale that includes only relatively serious offenses. Elliott et al. (1983)

reported test-retest reliabilities for SRD subscales to range from .80-

.99, and the discriminant validity and predictive validity have been

supported with chronic offenders (Dunford & Elliott, 1984) and serious

offenders (Elliott, Huizinga, & Ageton, 1985). Moreover, the SRD has

been sensitive to MST treatment effects in a previous clinical trial (Heng-

geler et al., 1992). A sample item is, "How many times in the past 3

months have you stolen (or tried to steal) a motor vehicle, such as a

car or motorcycle?"

Arrest and incarceration histories of the adolescents were obtained

from a database maintained by the DJJ that includes offense, arrest,

adjudication, and incarceration histories. These data were collected ap-

proximately 1.7 years from the project's ending date for all participants.

Offenses were coded as to their severity using the Seriousness Index

developed by Hanson et al. (1984). In the analyses that follow, a time

point 100 days past the adolescent's 17th birthday or the date of the

final data collection was used as a cutpoint because DJJ records do not

extend past the 17th birthdate of a client. The additional 100 days

allowed us to take into account the lag in reporting that usually takes

place in service systems.

Family relations. The Family Adaptability and Cohesion Evaluation

Scales (FACES-III; Olson, Portner, & Lavee, 1985) and Family Assess-

ment Measure (FAM-JJI; Skinner, Steinhauer, & Santa-Barbara, 1983)

were used to assess family functioning with separate reports being made

by the primary caregiver and the adolescent. The 20 items on the FACES-

III (Olson et al., 1985) assess family adaptability and cohesion. The

validity of this self-report instrument has been supported in previous

research on delinquency (Rodick, Henggelei; & Hanson, 1986) and with

violent juvenile offenders (Blaske, Borduin, Henggeler, & Mann, 1989).

Internal consistency has been estimated to be .67 for the Adaptability

subscale and .77 for the Cohesion subscale. The Lifcert-type items are

rated on a scale from 1 (almost never) to 5 (almost always). Consistent

with the recommendations of Henggeler, Burr-Harris, Borduin, and

McCallum (1991), the Cohesion subscale and Adaptability subscale

scores were treated as linear in the analyses. A sample item is, "Family

members feel closer to other family members than to people outside of

the family." The FAM-III is a 50-item self-report measure that covers

the areas of task accomplishment, role performance, communication,

affective involvement, and control. Responses to items are made on a

scale ranging from 1 (strongly agree) to 4 (strongly disagree). The

General Index provides an overall measure of family functioning and is

derived by summing across the 50 items. Low scores on the FAM-III

indicate low rates of problems and high scores indicate increased prob-

lems. Internal consistency for the General Scale has been estimated to

be .93 for adults and .94 for children. A sample item is, "We are as

well adjusted as any family could possibly be."

Parental monitoring. The parent version of the Monitoring Index

(Patterson &. Dishion, 1985) contains 17 items representing aspects of

monitoring behavior (e.g., the parents' direct supervision of, control of,

and trust in the child; the number of hours per day that the child is

un supervised; and a dichotomous item indicating whether the child wan-

ders from home in the evening unsupervised). Factor scores were formed

using the scoring procedures originally developed for the measure. An

overall monitoring index was created by summing the factor scores

associated with parental control and direct supervision and adjusting

these scores through subtraction for leaving the child unsupervised and

allowing the child to wander. The adolescent version of the Monitoring

Index was formed by summing across the factors on the 14-item adoles-

cent version of the scale. Information on the reliability and validity of

the indices reported here are not currently available, but over a decade

of research has examined the associations between composites of these

items and measures of antisocial behavior in children (Patterson, Reid, &

Dishion, 1992). The following sample item was taken from the parent

version: "If s/he tells you that s/he is going to a friend's house, how

often do you think that s/he will be there?"

Peer relations. Adolescent peer relations were assessed using pri-

mary caregiver and adolescent reports on the 13-item Missouri Peer

Relations Inventory (MPRJ; Borduin, Blaske, Cone, Mann, & Hazelrigg,

1989) and adolescent responses to the 14-item Parent Peer Conformity

Inventory (PPC1; Berndt, 1979). Results of factor analyses indicate that

the items on the MPRI represent three dimensions of adolescent peer

relationships: emotional bonding, aggression, and social maturity. This

three-dimensional factor structure has been replicated, and the subscales

have been demonstrated to have acceptable internal consistency (.65-

.82) and test-retest reliability (.71-.94) over a two week interval

(Blaske, Borduin, Henggeler, & Mann, 1989). A sample item is, "Please

circle the number on the 5-point scale that best describes your child's:

temper: lack of impulse control with friends." The PPCI was used to

measure prosocial and antisocial peer conformity. This instrument pro-

THE ROLE OF TREATMENT FIDELITY 825

vides the respondent with a brief description of a scenario such as being

in a position to cheat off a copy of an exam accidentally dropped by a

teacher. The adolescent is then asked to tell what he or she would dounder those circumstances. A difference score created by subtracting thescore on the Antisocial Behavior subscale from that of the Prosocial

subscale provides an index of reported antisocial peer conformity. Relia-bility is satisfactory for antisocial conformity (.81) but poor for proso-

cial conformity (Berndt, 1979). The validity of the PPCI has beensupported in a study of adolescent drug use and criminal behavior(Brown, Clasen, & Eicher, 1986).

MST treatment adherence. The MST Adherence Measure (Heng-geler & Borduin, 1992) is a 26-item Likert-format questionnaire de-signed to measure family and therapist behaviors specific to the practiceof MST. MST is specified through therapist adherence to nine treatment

principles (Appendix A), and, as such, items were developed by expertconsensus to reflect these principles (Appendix B). The adherence mea-sures were completed by the parents (n = 62), adolescents (n = 67),

and therapists (n = 77) after randomly selected therapy sessions duringthe fourth and eighth weeks of therapy for each family in the MST

condition.

To delineate the central constructs tapped by the adherence measureand to reduce the number of variables for use in the data analyses,

separate exploratory factor analyses using a maximum likelihood (ml)extraction method and nonorthogonal rotations were completed for eachgroup of respondents. Input data matrices were constructed by averaging

the four and eight week ratings on the adherence measures. As an initial

step in the factor analyses for each group, a principal components analy-sis was run and a scree plot was output from the analysis. On the basis

of the scree plot and using the criterion of the number of eigenvaluesgreater than 1.0, a starting point for the optimal number of factors wasidentified for the analysis of the data for each group of respondents.

Factor analyses were then conducted for the parent, adolescent, andtherapist groups with solutions obtained for ±2 factors around the ini-tially identified optimum number of factors. The final choice of solutions

was based on the criterion of the interpretability of the results.

From these analyses, we selected a six-factor solution for the parentdata, a five-factor solution for the therapist data, and a four-factor solu-

tion for the adolescent data as most interpretable. Table 1, Table 2, and

Table 3 list the items and factor loadings for each group of respondents,and the interfactor correlations are provided in Table 4. The six-factor

solution for the parent ratings included factors representing: therapistadherence to the MST treatment principles, the degree to which thesessions were nonproductive, the effort by the family and therapist tosolve the family's problems, therapist attempts to change the family's

interactions within the family and with persons outside of the family, alack of therapeutic direction in the session, and the degree of family-therapist consensus. The five dimensions characterizing the therapist

ratings included factors representing: engagement of the family, adher-ence to the MST principles, the degree to which the sessions werenonproductive, the need of the therapist to focus on the family's noncom-

pliance, and the degree of family-therapist conflict. For the adolescentdata, the following factors were represented: therapist adherence to theMST principles, therapist focus on the family's noncompliance, lack ofdirection in the sessions, and level of productivity of the sessions,

Table 1

Factor Loadings for the Six-Factor Solution for the Primary

Caregiver MST Adherence Ratings

Results

Attrition

Between pretest and posttest, 9.7% (n = 15) of the families

were lost from the study because of their having moved out of

South Carolina, death, or voluntary withdrawal from the re-

search protocol. Differences between the project dropouts («MST

= 7, nus = 8) and project completers (n = 140) were examined

Factor

Item no.

232565

112113122

221424

1171526163498

1819207

10

PI

.94

.91

.88

.88

.82

.82

.79

.78

.74

.71

.61

.58

.45-.06

.10

.01-.09

.18

.25

.00

.06

.06-.01-.09

.55

.22

P2

-.09.07

-.07.02

-.14.00.03

-.10.20

-.11.12.10.27.77.72.46.39.08.02

-.09.14

-.08.22

-.02-.02-.04

P3

-.01.01

-.06-.02

.05

.06-.05-.19

.22

.21-.03

.01

.03

.04-.09

.07

.17

.75

.71

.08-.08

.08-.08

.16

.31

.39

P4

.08-.05-.03-.14

.00

.03-.05-.01-.11

.06.11.19.13

-.09.10.27

-.14.04.04.79.75.20.06.26

-.06-.02

P5

.03

.05

.23

.21

.21-.09-.16-.03-.13-.02-.17-.11-.24

.40

.00

.03-.07-.02

.12

.18

.11

.67

.60

.25

.07

-.14

P6

-13-.00

.14-.07

.10-.02

.41

.48-.21

.09.30.19.01.21

-.05-.02-.12

.09

.09

.04-.09-.08-.09

.02

.49

.46

Note. MST = multisystemic therapy; P = primary caregiver.

using univariate analyses of variance (ANOVAs) on pretest

scores on demographic and dependent measures. Dropouts were

denned as any participant who, for any reason, refused or was

unable to continue in the project. Primary caregiver reports

indicated that the mothers in the dropout group were slightly

better educated than were the completers, F(l, 153) = 6.81, p

< .02 (Md™,™,, = 12.29, Mcorop,̂ = 10.55). No other between-

groups differences were observed. The small number and some-

what equal distribution of dropouts across treatment conditions

in conjunction with the finding of no differences outside of the

mother's educational status suggests that participant attrition

should have little impact on the interpretation of the results

reported subsequently.

Treatment Effects

We conducted a series of 2 X 2 X 2 Time (pretreatment [Tl]

vs. posttreatment [T2]) X Treatment Condition (MST vs. US)

X Site (SI vs. S2) ANOVAs on the psychosocial measures

collected during the pretreatment and posttreatment assessments.

In addition, 2 x 2 (Treatment Condition X Site) ANCAfts were

used to evaluate longer term outcomes for rearrest and incarcera-

tion through the 1.7-year follow-up (T3). The following presen-

tation of outcomes focuses on treatment-related effects, as the

examination of such effects is the major thrust of the study.

Main effects for time- and site-related effects are presented

826 HENGGELER, MELTON, BRONDINO, SCHERER, AND HANLEY

Table 2

Factor Loadings for the Five-Factor Solution for the

Therapist MST Adherence Ratings

Item no.

21233

227

101

1765S94

1125182

162015192614132412

Tl

.91

.84

.83

.79

.71

.59

.57-.76-.01

.14-.21-.19

.35

.25

.29-.04

.32

.06

.10

.10-.22

.01-.14

.21

.18

.25

T2

.01

.09

.12

.13-.15-.15

.02

.18

.85

.79

.73

.73

.68

.67

.64

.62

.37-.00

.16-.23

.04-.18

.17

.09

.17-.16

Factor

T3

.06

.24-.17

.16-.01-.15-.44

.03

.06-.00

.07-.02-.20

.03-.17

.00-.01

.84

.62

.57

.57

.53-.21-.18

.18-.29

T4

-.05.22

-.02.13.18.22.02.14.12.07.25.02

-.25.02.06.04

-.15.01

-.35-.10

.14

-.05.80.76.67.42

T5

.00-.37-.11

.05

.07

.32-.11

.42

.12-.06

.11-.01-.01

.15-.12-.27

.18-.00-.01

.15-.21-.14

.05-.11

.06

.23

Note. MST = multisystemic therapy; T = therapist.

secondarily. Table 5 presents a summary of the means, standard

deviations, and treatment and time effects for each measure.

Emotional and behavioral functioning. Emotional function-

ing of parents and youths was assessed through self-reports on

the BSI, and youth behavioral functioning was also assessed by

caregiver reports on the RBPC. On the basis of the OS I of the

BSI, a significant Treatment Condition x Time effect emerged

for adolescent reports of emotional distress, F( 1, 136) = 7.67,

p < .006. \ouths in the MST condition reported substantially

reduced psychiatric symptomatology, whereas US counterparts

reported slightly increased symptomatology. A main effect for

time was observed for parental reports of youth behavior prob-

lems on the RBPC, F(\, 138) = 25.06, p < .0002, with the

frequency of reported problems decreasing from Tl to T2 for

both groups.

Criminal activity. Criminal activity was assessed through

self-reports on the SRD and through a search of archival records

for rearrest. Significant treatment effects did not emerge for

youth reports on the SRD. Although the annualized rate of

rearrest was 26% lower for youths in the MST condition from

Tl through T3, this difference did not approach statistical sig-

nificance. The average seriousness of rearrests did not differ

between groups. Significant main effects for time were observed

for the General Delinquency and Index Offense scales of the

SRD, Fs(l, 135) > 28.00, ps < .0002. Substantial decreases

in self-reported offending were reported across treatment

conditions.

Incarceration. On the basis of the search of archival re-

cords, the annualized rate of days incarcerated was 47% lower

for youths in the MST condition (33.2 days per year per youth)

than for their US counterparts (70.4 days per year per youth)

from Tl to T3, F(l, 151) = 7.26, p < .008. This difference

amounted to 37.2 days per year per youth and is especially

meaningful because all youths who were randomized to the

MST condition were included in the archival follow-up (i.e.,

treatment dropouts are included). In addition, the treatment con-

ditions differed marginally from Tl to T2 in the percentage of

youths incarcerated (7.6% for MST vs. 18.1% for US), x2O,

N = 151) = 3.75, p < .06; but such differences (38% for MST

vs. 50% for US) were not significant from T2 to T3, x2(l , N

= 151) = 2.22, p < .14. Such findings suggest, however, that

the aforementioned between-groups differences in days incar-

cerated are not due primarily to outliers in the US condition.

Family relations. The assessment of family relations was

based on adolescent and parental reports on the FAM-III,

FACES-HI, and Monitoring Index. No treatment effects were

observed on these measures. Main effects for time emerged for

adolescent reports of family adaptability on the FACES-III, F( \,

134) = 11.99, p < .0007; adolescent reports on the Monitoring

Index, F( 1, 139) = 22.40, p < .0002; parent reports of family

cohesion on the FACES-III, F(l, 137) = 6.16,p < .014; and

parent reports for the General Index of the FAM-III, F( 1, 138)

= 5.31, p < .022. Across conditions, adolescents reported that

their family relations became less structured (more flexible)

Table 3

Factor Loadings for the Four-Factor Solution for the

Adolescent MST Adherence Ratings

Factor

Item no.

2524112310121342

14376

2122

15

1726151920

89

1816

Al

.97

.83

.82

.80

.80

.74

.74

.74

.71

.71

.69

.68

.61

.58

.58

.46

.41

.00-.19

.04-.21

.11

.28

.02

.17

.00

A2

-.11-.13

.00-.15

.20

.09-.10

.02

.16-.20

.06-.06-.07

.17

.23

.13

.06

.69

.67

.25-.54-.66-.22-.02

.32-.05

A3

-.04-.09-.01

.05-.33

.00

.03-.04

.09

.03

.01

.11

.22

.33

.27

.28

.28-.22-.01

.12

.07-.17

.52

.52-.27-.03

A4

-.20-.11

.08-.06-.07

.17

.06

.07

.11

.05

.15-.14-.23

.06

.05

.23

.18-.10

.05-.06-.28

.65-.08

.05-.41-.44

Note. MST = multisysffimic therapy; A = adolescent.

THE ROLE OF TREATMENT FIDELITY 827

Table 4

Inter/actor Correlations for Adherence Factors by Respondent Group

Factor

Group and factor 3 4 5

Primary caregiver

PI. AdherenceP2. Nonproductive session

P3. Therapist-family problem solving effortP4. Therapist attempts to change interactionsP5. Lack of direction

P6. Family-therapist consensus

—.16.49.29.06.16

—.03.25.06

-.01

—.15.01

-.06

—.10 —.01 .05 —

Therapist

Tl. Engagement

T2. Therapist adherenceT3. Nonproductive session

T4. Need to focus on noncomplianceT5. Family-therapist conflict

—.49

-.35

.32

.43

—-.30

.38

.30

—-.29 —-.32 .18 —

Al. Adherence

A2. Family-therapist task-oriented sessionA3. Lack of directionA4. Nonproductive session

Adolescent

.10

.40

.23-.06

.10 .14 —

Note. P = primary caregiver; T = therapist; A = adolescent.

from Tl to T2 and that their parents monitored and supervised

them less. Parents reported that family cohesion decreased and

overall family functioning improved from Tl to T2.

Peer relations. The assessment of peer relations was based

on parent and youth reports on the MPRI and youth reports on

the PPCI. Treatment effects were not observed for either of these

instruments. On the MPRI, main effects for time emerged for

parental reports of youth aggression with peers, F(l, 137) =

4.22, p < .041, and social maturity with peers, F(l, 137) =

4.06, p < .045. Main effects for time also emerged for adoles-

cent reports of emotional bonding with peers, F(l, 136) =

16.22, p < .0001, and aggression with peers, F(l, 136) =

17.22, p < .0001. Adolescents reported increased aggression

and decreased emotional bonding with peers, whereas parents

reported decreased aggression and social maturity with peers.

MST Adherence and Ultimate Outcomes

As indicated above, MST had significant effects on two im-

portant ultimate outcomes (incarceration, adolescent symptom-

atology), but no significant effects on several other measures

of ultimate outcome. To investigate the possibility that outcomes

in the MST condition were associated with treatment adherence,

hierarchical multiple regression analyses were conducted in

which the T2 measures of ultimate outcome (BSI, RBPC, and

SRD) served as the dependent variables and the Tl measure of

the respective dependent variable and the treatment adherence

factors, per respondent, served as the independent variables. To

assess for adherence effects on rearrest and incarceration, the

T1-T3 archival indices were used as the dependent variables.

The results of these analyses are presented in Table 6.

BSI, adolescent. Several MST fidelity measures were sig-

nificantly associated with changes in the adolescents' symptom-

atology from Tl to T2. On the basis of parental reports of

treatment adherence, poor outcomes for adolescent symptom-

atology were associated with low emphasis of the therapist on

changing intrafamilial and extrafamilial interactions, F(l, 48)

= 5.90, p < .02; a lack of direction in therapy, F(l, 48) =

5.29, p < .03; and low family-therapist consensus, F(l, 48)

= 5.52, p < .03. Similarly, on the basis of therapists' reports

of treatment fidelity, poor outcomes for adolescent symptomatol-

ogy were associated with nonproductive sessions, F(l, 65) =

8.35, p < .006; and high family-therapist conflict during ses-

sions, F(1, 65) = 6.66, p < .02.

BSI, parent. On the basis of parental reports of MST treat-

ment fidelity, high ratings of parental emotional distress were

significantly associated with high emphasis of the therapist on

changing intrafamilial and extrafamilial interactions, F(l, 49)

= 4.54, p < .03.

SRD. From the therapists' perspective, high adolescent re-

ports of index offenses were significantly associated with low

therapist adherence to MST principles, F(l, 65) = 5.40, p

< .03.

Arrests. On the basis of parental reports of MST fidelity,

high rates of rearrest after Tl were significantly associated with

low therapist adherence to MST principles, F( 1, 51) = 9.55, p

< .004, and low emphasis of the therapist on changing intra-

familial and extrafamilial relations, F(l, 51) = 4.41, p < .05.

Incarceration. On the basis of parental reports of MST fi-

delity, subsequent incarceration of youths was associated sig-

nificantly with nonproductive treatment sessions, x 2 ( l , A f = 5 8 )

828 HENGGELER, MELTON, BRONDINO, SCHERER, AND HANLEY

Table 5

Means, Standard Deviations, and Analyses of Outcome Measures

MST US Analyses

Pre Post Pre PostGroup X

Time Time

Measures M SD SD M SD

Ultimate outcomes

Emotional behavioral functioningBSI-GSI

YouthParent

RBPCCriminal activity

SRD"Gen. Del.Index Off.

Arrests"-'Incarceration°'d

0.500.69

43.2

0.950.36

0.490.67

33.3

0.57

0.38

0.27

0.4931.0

0.580.110.89

33.2

0.340.53

30.2

0.570.251.39

62.8

0.500.47

44.8

1.060.36

0.430.53

33.8

0.580.40

0.53

0.4335.2

0.750.231.20

70.4

0.66

0.4830.3

0.620.34

3.11103.5

7.673.210.35

0.383.03

0.637.26

.006

.075ns

ns.083ns

.008

4.92

7.1625.06

39.8028.00

.028

.008

.0002

.0001

.0001

Instrumental outcomes

Family relations

FAM-mParentYouth

FACES-HI: ParentCohesionAdaptability

FACES-III: YouthCohesionAdaptability

MonitoringParentYouth

Peer relationsMPRI: Parent

Emot. bondAggression

Social mat.MPRI: Youth

Emot. bondAggression

Social mat.PPCI

6.086.30

33.429.6

31.927.7

2.787.19

11.96-0.49

3.82

11.37-1.30

4.811.99

1.97

1.43

3.94.5

4.94.0

0.861.07

3.303.732.24

3.023.66

2.773.94

5.556.31

32.828.6

32.329.4

2.926.86

12.12-1.62

3.20

9.740.664.522.64

1.791.95

5.04.6

6.45.4

0.881.15

3.413.93

2.43

3.363.56

2.484.24

5.726.62

34.429.4

30.928.4

2.837.04

12.28-0.88

4.15

10.93-0.49

4.401.52

1.611.53

3.64.8

4.74.9

0.761.16

2.963.72

2.38

2.853.87

2.264.45

5.626.56

33.2

29.6

31.629.9

2.806.33

12.40-1.10

3.78

9.430.694.161.87

1.291.50

3.94.4

4.44.0

0.721.22

3.273.78

2.29

3.493.62

2.723.95

2.550.09

0.521.92

0.090.03

2.262.84

0.012.050.19

0.031.11

0.000.12

nsns

nsns

nsns

nsns

nsnsns

nsnsnsns

5.310.03

6.160.73

1.1311.99

0.9122.40

0.254.22

4.06

16.2217.22

0.901.36

.022ns

.014ns

ns.001

ns.0001

ns.041

.045

.0001

.0001

nsns

Note. MST = multisystemic therapy; US = usual services; pre = pretreatment; post = posttrearment; BSI-GSI = Brief Symptom Inventory, GlobalSeverity Index; RBPC = Revised Problem Behavior Checklist; SRD = Self-Report Delinquency Scale; Gen. Del. = General Delinquency scale;Index Off. = Index Offense scale; FAM-in = Family Assessment Measure; FACES-III = Family Adaptability and Cohesion Evaluation Scales;MPRI = Missouri Peer Relations Inventory; Emot. bond = emotional bonding; Social mat. — social maturity; PPCI = Parent Peer Conformity

Inventory.a Log-transformed scores. b Annualized rate of arrest when hi the community at an approximately 1.7-year follow-up. c Test of main effect forgroup. d Annualized rate of days incarcerated at an approximately 1.7-year follow-up.

= 4.01, p < .05, and low ratings on therapist attempts to change taken into account, observed therapeutic effects on outcomes

intrafamilial and extrafarailial interactions, X2(l . N = 58) =

7.46, p < .007. Moreover, youth incarceration was significantly

associated with low family engagement based on therapist re-

ports, x2( 1. N = 58) = 4.99, p < .03.

Discussion

The findings demonstrate the importance of treatment fidel-

ity in the effective dissemination of MST. When fidelity is not

are minimal, with the exception of the incarceration and ado-

lescent symptomatology data. On the other hand, when treat-

ment fidelity is considered, the effects of MST are consistent

with those of previous MST trials with violent and chronic

offenders; trials that included weekly procedures to enhance

treatment fidelity. Such findings have important implications

for the dissemination of effective mental health services to

community settings.

THE ROLE OF TREATMENT FIDELITY 829

Table 6

Standardized Regression Coefficients and Significance Levels from the Multiple Regression

Analyses Relating MST Treatment Adherence to Ultimate Outcomes

Adherencefactors

ParentPIP2P3P4P5P6

TherapistTlT2T3T4T5

AdolescentAlA2A3A4

BSI

Adolescent

.04

.10-.22-.31*

.29*-.30*

-.21.07.39**.11.36*

-.01-.18-.22

.02

SRD

Parent

.00

.21

.03

.25*-.01-.18

.01

.07

.17-.04

.10

.03-.07-.01

.03

RBPC

-.01.10

-.06-.06-.04-.19

-.15.05.10

-.10.12

-.12-.13

.08

.13

Gen. Del.

.11

.21-.12-.18

.06-.02

.05-.22

.18

.20

.11

-.02-.12-.06-.10

Index

-.01.03

-.03-.27

.07

.20

.12-.33*

.22

.22

.09

-.02.03

-.03.14

Arrests

-.48**.10.22

-.28*.06.12

-.04.04

-.18-.15-.02

-.21*.01.05.04

Incarceration

.34

.36*-.28-.59**

.19-.11

-.45*-.06-.28

.28-.06

-.29.09.15

-.24

Note. MST = multisystemic therapy; BSI — Brief Symptom Inventory; RBPC = Revised Problem BehaviorChecklist; SRD = Self-Report Delinquency scale; Gen. Del. = General Delinquency scale; Index = IndexOffense scale; P = parent; T = therapist; A = adolescent.*p < .05. **p<.01.

MST Outcomes Irrespective of Treatment Fidelity

In previous randomized trials with violent or chronic juvenile

offenders, in which considerable supervisory resources were

devoted to maintaining treatment fidelity, MST demonstrated

43% (Henggeler et al., 1992) and 64% (Borduin et al., 1995)

reductions in rearrest, a 64% reduction in incarceration (Heng-

geler et al., 1992), a reduction in self-reported offending (Heng-

geler et al., 1992), and a variety of effects for improved family

relations, peer relations, youth behavior problems, and parental

symptomatology. In the present study, MST produced a 26%

reduction in rearrest (not statistically significant), a 47% reduc-

tion in days incarcerated, and a significant improvement in ado-

lescent psychiatric symptomatology. Overall, the improvements

in adolescent symptomatology and the decrease in days incarcer-

ated are consistent with the goals of MST On the other hand,

the lack of significant effects on instrumental outcomes and

criminal activity is disappointing, as such effects are central

goals of MST.

In light of the modest outcomes achieved by MST in this

study and the fact that several factors interacted during the

course of this project to influence therapists' adherence to the

MST treatment protocol, it seems possible that poorer outcomes

in the MST condition were associated with low treatment adher-

ence. As discussed next, treatment adherence played an im-

portant role in achieving desired outcomes.

MST Fidelity and Ultimate Outcomes

Therapist adherence to the MST treatment principles was an

important predictor for key outcomes pertaining to the adoles-

cents' criminal activity and incarceration during the 1.7-year

follow-up. Parent and adolescent ratings of treatment adherence

predicted low rates of rearrest; and therapist ratings of treatment

adherence and treatment engagement predicted decreased self-

reported index offenses and low probability of incarceration,

respectively. These findings support the underlying clinical as-

sumptions of MST that have been operationalized by the nine

MST treatment principles (Henggeler et al., 1994). Importantly,

these assumptions are largely consistent with recommendations

that leading investigators (Gendreau, 1996; Mulvey, Arthur, &

Reppucci, 1993; Tolan & Guerra, 1994) have made regarding

the types of services that are most likely to achieve favorable

results with juvenile offenders (i.e., goal oriented, family based,

structured). Thus, as demonstrated in this and previous studies

of MST, treatment of serious antisocial behavior in juveniles

can be successful when the known determinants of antisocial

behavior are intensively addressed in the natural environment

with youths and families.

A second set of interesting findings pertains to the frequent

link between favorable clinical outcomes and parent reports of

therapeutic attempts to change intrafamilial and extrafamilial

interactions. On the basis of parental reports, therapists' empha-

sis on such change was associated with low rates of rearrest,

incarceration, and adolescent emotional distress. Such findings

are highly consistent with the extensive causal modeling litera-

ture (Henggeler, 1991, 1997) showing that serious antisocial

behavior in youths is linked with key aspects of family relations

(e.g., discipline) and with the child's and family's relations

with important extrafamilial systems (e.g., peers, school,

church, social support system). In contrast with findings that

830 HENGGELER, MELTON, BRONDINO, SCHERER, AND HANLEY

improved adolescent functioning was associated with therapist

attempts to change intrafamilial and extrafamilial interactions,

such therapeutic emphases were associated with increased pa-

rental emotional distress. This finding most likely reflects the

increased stress that parents may experience as they implement

important interventions within the family (e.g., setting curfews,

enforcing limits, addressing personal barriers to effective parent-

ing such as drug abuse) and outside the family (e.g., negotiating

with teachers, disengaging their child from deviant peers). Al-

though therapists attempted to address this stress by building

indigenous support networks, increased parental stress, at least

temporarily, may be an inevitable effect of the types of changes

emphasized by MST.

Finally, several findings suggest that favorable outcomes are

linked with the emphasis of MST as a task-oriented, goal-ori-

ented, and efficient set of interventions, within a collaborative

family-therapist context. On the basis of parental reports, fam-

ily-therapist consensus was associated with decreased adoles-

cent psychiatric symptomatology; a clear direction in treatment

was associated with improved adolescent symptomatology; and

productive sessions were linked with a low probability of adoles-

cent incarceration. From the therapists' perspective, productive

sessions and low family-therapist conflict were linked with

improved adolescent symptomatology. Overall, these findings

support the association between high adherence to MST treat-

ment principles and improved functioning in adolescents who

are serious criminal offenders.

Clinical and Policy Implications

The findings support the view that a lack of treatment fidelity

may be a key reason why mental health treatment approaches

have had more success in research settings than in community

settings (Weisz et al., 1995). In the present study, an important

component of the standard MST protocol for maintaining treat-

ment fidelity was withdrawn: weekly feedback from an expert

regarding treatment adherence. We contend that the elimination

of this component greatly increased variability in following the

MST treatment protocol, which resulted in an overall reduction

in the fidelity of MST. Such a contention is supported by the

modest outcome results of this study in comparison with previ-

ous MST studies that provided such weekly feedback, and by

the compelling findings regarding the linkages between MST

fidelity and favorable outcomes. Assuming that our views are

accurate, a critical goal of future research is to develop and

validate cost-effective strategies for transferring the rigor of

university-based treatment protocols to community settings.

Typically, such rigor includes the training of therapists to speci-

fied adherence criteria, followed by consistent monitoring oftherapist behavior and feedback aimed at maximizing treatment

fidelity. Although such training and intensive supervision

increase program cost, the incremental costs are minimal whencompared with the costs of providing services that are

ineffective.

Yet, even when effective training and supervisory protocols

are developed, many potential barriers must be overcome for thesuccessful dissemination of an innovative treatment technology

(Gendreau, 1995). Regarding MST, for example, therapist, ad-

ministrative, and fiscal barriers may attenuate the effectiveness

of dissemination. Therapist characteristics that hinder treatment

fidelity include clinical belief systems that are nonecological,

pejorative attitudes toward parents of youths who have signifi-

cant problems, reluctance to assume accountability for out-

comes, and difficulty in viewing families as full collaborators

in all aspects of treatment. Likewise, a lack of administrative

support of therapists regarding issues such as scheduling, travel,

salary, and clinical support can undermine program integrity, as

can fiscal incentives for moving children to out-of-home place-

ments rather than providing the intensive community-based ser-

vices that may be needed to maintain a child with his or her

family. Thus, to disseminate effectively to community settings,

a broad, complex, and multifaceted set of issues must be ad-

dressed (Schoenwald & Henggeler, in press).

At the policy level, perhaps the most persuasive argument for

the dissemination of family- and community-based alternatives

to out-of-home placements is the potential cost savings and cost-

effectiveness. The present study supports the fiscal viability of

MST as a treatment of serious juvenile offenders and their fami-

lies. Through the first 1.7 years of follow-up, MST reduced

incarceration by an average of 37.2 days per year. Assuming

that this rate of reduced incarceration was maintained for 2.0

years and that 1 day of incarceration costs $100, a savings of

57,440 would be realized for each youth receiving MST. This

savings compares favorably to the per-adolescent program costs

of approximately $4,000 for this study. Tb conclude with greater

confidence that the MST programs in the present study were less

costly than usual services, however, we need a comprehensive

examination of service utilization across service sectors (e.g.,

social welfare, mental health, juvenile justice, primary care) to

more fully explicate the types of services received by the youth

and to explore the possibilities of cost shifting. Nevertheless, a

recent cost analysis of MST with substance-abusing and depen-

dent delinquents has shown no evidence of cost shifting

(Schoenwald, Ward,Henggeler, Pickrel, & Patel, 1996). Indeed,

the incremental costs of MST in that study were nearly offset

by the savings incurred as a result of reductions in days of out-

of-home placement during the first year after referral.

In conclusion, the results of this study highlight the impor-

tance of maintaining treatment fidelity in the dissemination of

complex interventions to community settings. Moreover, the out-

comes further support the view that intensive family- and com-

munity-based services can serve as viable alternatives to out-

of-home placement of youths presenting serious antisocial be-

havior. Such services, however, must be delivered with fidelity

and have the capacity to attend to the multiple known determi-

nants of serious clinical problems and to provide services with

high ecological validity (Henggeler et al., 1995).

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Appendix A

MST Treatment Principles

1. The primary purpose of assessment is to understand the fit between

the identified problems and their broader systemic context.

2. Therapeutic contacts should emphasize the positive and should use

systemic strengths as levers for change.

3. Interventions should be designed to promote responsible behavior

and decrease irresponsible behavior among family members.

4. Interventions should be present-focused and action-oriented, targeting

specific and well-defined problems.

5. Interventions should target sequences of behavior within or between

multiple systems that maintain identified problems.

6. Interventions should be developmentally appropriate and fit the devel-

opmental needs of the youth.

7. Interventions should be designed to require daily or weekly effort by

family members.

8. Intervention effectiveness is evaluated continuously from multiple

perspectives, with providers assuming accountability for overcoming

barriers to successful outcomes.

9. Interventions should be designed to promote treatment generalization and

long-term maintenance of therapeutic change by empowering care givers

to address famiry members' needs across multiple systemic contexts.

THE ROLE OF TREATMENT FIDELITY 833

Appendix B

Items on the MST Adherence Measure

1. The session was lively and energetic.

2. The therapist tried to understand how the family's problems all fit

together.

3. The family and therapist worked together effectively.

4. The family knew exactly which problems were being worked on.

5. The therapist recommended that family members do specific things

to solve their problems.

6. The therapist's recommendations required family members to work

on their problems almost every day.

7. The family and therapist had similar ideas about ways to solve

problems.

8. The therapist tried to change some ways that family members inter-

act with each other.

9. The therapist tried to change some ways that family members inter-

act with people outside the family.

10. The family and therapist seemed honest and straightforward with

each other.

11. The therapist's recommendations should help the children to mature.

12. Family members and the therapist agreed upon the goals of the

session.

13. The family and therapist talked about how well the family followed

her/his recommendations from the previous session.

14. The family and therapist talked about the success (or lack of suc-

cess) of her/his recommendations from the previous session.

15. The therapy session included a lot of irrelevant small talk (chit-

chat).

16. Not much was accomplished during the therapy session.

17. Family members were engaged in power struggles with the therapist.

18. The therapist's recommendations required the family to do almost

all the work.

19. The therapy session was boring.

20. The family was not sure about the direction of treatment.

21. The therapist understood what is good about the family.

22. The therapist's recommendations made good use of the family's

strengths.

23. The family accepted that part of the therapist's job is to help change

certain things about the family.

24. During the session, the family and therapist talked about some expe-

riences that occurred in previous sessions.

25. The therapist's recommendations should help family members to

become more responsible.

26. There were awkward silences and pauses during the session.

Received August 27, 1996

Revision received March 28, 1997

Accepted April 12, 1997 •