Multisystemic Therapy for Emerging Adults: Integrated Care for Emerging Adults in the Justice System with Behavioral Health Conditions

Background and Purpose: The risk of recidivism among emerging adults with serious mental illness (SMI) is very high. Specifically, of arrested 18- to 21-year-olds, half of males and over a quarter of females with a SMI will be re-arrested within the year. This elevated arrest risk among emerging adults with SMIs suggests that reducing recidivism in this population is vital to supporting their transition into adulthood. Yet, there currently are no proven interventions to reduce recidivism in young adults, with or without SMIs. Because standard Multisystemic Therapy (MST) has proven effectiveness for reducing recidivism in delinquent youth up to age 17, it provides a useful foundation for treating slightly older justice-involved youth. To target young adult offenders with SMIs, MST was adapted, MST for Emerging Adults (MST-EA), and pilot tested. 

Major adaptations included shifting from the primary client being parents to being the emerging adult, adapting therapists’ delivery of treatment for antisocial behavior, delivery of mental health and substance use (when appropriate) evidence-based interventions, and a focus on helping clients increase positive functioning in the critical areas of emerging adulthood (school completion, employment, independent living, and positive social relationships).  Structural adaptations include reduced caseloads, coordinating with a psychiatrist and other key providers, and adding Coaches (lay positions to support the client). 

Methods: In an open feasibility trial of MST-EA using a community-based provider, all participants (N=48, 73% male, Ages 17-20) had a SMI, recent (<18 months) arrest or release from incarceration, and were community-living. In a sub-study to refine the Coach approach (n=32), MST-EA Coaches were randomly assigned to be either a Standard Coach or a Standard+Vocational Coach, and MST-EA participants were randomly assigned to Coach condition. Data were collected at baseline, and post treatment, and fidelity assessments were made during treatment. School and work engagement were measured bi-monthly for those in the Coach sub study.

Results: Research recruitment (97%), retention (91%), and treatment retention (78%) were high. Therapist fidelity was strong (possible scores=27-108; Median=95; Range=44-108). Coach fidelity was also strong (possible scores=7-28; Median=24; Range=10-28, no difference between Vocational and Standard Coaches, p>.10). Vocational Coaches taught more vocational skills than Standard Coaches (p<.001). 

Significant reductions occurred in the number of charges (Wilcoxon =-2.6, p<.01) and number of mental health symptoms (Wilcoxon=-3.9, p<.001). While there was no difference between the coach conditions at baseline in being engaged in school or work, more in the Vocational Coach (94%) than Standard Coach (73%;p=.05) condition were in school/work during treatment, with a post-treatment trend (87% vs. 62%, p<.10).

Conclusions and Implications: The MST-EA adaptation can be implemented with high fidelity and client retention with emerging adults with SMI.  These findings suggest that MST-EA will be effective in reducing recidivism and MH symptoms in this very high risk population.  This hypothesis will be tested with a newly funded NIMH randomized controlled trial, the design of which will be described.