No Gurus Need Apply

This article first appeared in the January/February 2007 issue.

Back in the 1970s, a handful of psychotherapists and theorists radically altered the way clinicians viewed and helped emotionally troubled kids. Innovators like Salvador Minuchin, Jay Haley, and Urie Bronfenbrenner audaciously suggested that the existing modes of therapy, still predominantly Freudian in perspective, simply weren’t working, and they proposed what would be a complete rethinking of child and family mental health.

So influential were these thinkers that their basic ideas seem unassailable—indeed obvious—today. Children and adolescents, they preached, couldn’t be viewed or treated in isolation from the many intertwining worlds they inhabited. They were individuals, of course, but they were also sons and daughters and siblings, nephews and nieces, church members and boy scouts, and more. Any effective intervention would need to acknowledge and build on these overlapping systems. In the jargon of the emerging family systems therapy, counseling had to have “ecological validity.”

One doesn’t hear much about social ecology and systems theory these days. The practice of family systems therapy, while hugely popular, was intense and time consuming, requiring the careful pulling away of layer upon layer of experience and emotional entanglement. It was an expensive form of treatment, mostly carried out in private practice, which would become a luxury in the new era of cost effectiveness and evidence-based care. Because of these cultural shifts and economic pressures, no second-generation gurus have emerged with the stature of a Minuchin, Haley, or Bronfenbrenner.

Unless you count Scott Henggeler.

Scott Who? Few people in the broad mental health community, much less the culture at large, probably know the name. But Henggeler has arguably carried the torch for family systems therapy more effectively than any other practitioner, though its 21st-century embodiment might surprise the early practitioners.

The comparison also bemuses Henggeler himself. A clinical psychologist by training, he’s the pioneer of what’s called Multi-Systemic Therapy, or MST. As its name suggests, MST is focused on the many overlapping worlds of childhood and adolescence. It emphasizes treating problem kids in their own natural environment, and practitioners routinely use genograms to visually depict the stresses and sources of support in a teenager’s life.

Yet Henggeler is cautious about tracing MST’s roots entirely back to the family therapy of the ’70s. While acknowledging the influence of those innovators, he’s quick to point out important departures from the scriptures. Most notably, he rejects guru status not only for himself but for the field generally. “Thirty years ago,” Henggeler recalls, “the training model was to go to the guru, the grandmaster, and sit at his feet, then go out and be a guru yourself. From a public policy perspective, this is not a very effective model.” It isn’t effective, he adds, because it produces a very limited number of trained therapists—not nearly enough to take on the massive public health challenge of keeping a growing population of troubled kids out of jail.

In place of the flamboyant-guru model, Henggeler emphasizes the mundane task of “service transport”—getting what works to those who need it in the most efficient way possible. To that end, he’s devised a training program (licensed to the Medical School of South Carolina, where Henggeler is a professor) with a rigid protocol, which MST therapists (almost exclusively M.S.Ws.) are expected to use as unvaryingly as possible. Since MST began gaining popularity in the mid-1990s, this practical approach has produced a large cadre of public sector clinicians, practicing in 30 states and 10 countries. An estimated 12,000 teenagers have received MST treatment, many of them because they’ve been arrested for illegal drug use or violent crimes like sexual assault.

But don’t look for the flashes of creativity, the brilliant “Aha!” moments of therapy past. In their place is another dull, but deeply useful, concept: quality assurance. MST therapists are constantly supervised, and deviations from the basic principles are corrected quickly. “Training gets you off on the right foot,” Henggeler says, “but newly trained therapists tend to drift, without continuous coaching and feedback.” Most of the MST “experts” who do the supervision are Ph.D. psychologists.

Much of MST is focused on clearly defined, short-term, measurable goals—changes in behavior like eliminating school truancy and curfew violations. If therapists stick to the basics of their training, Henggeler claims, about two-thirds of MST interventions are successful—meaning the kids are not rearrested and avoid residential placement or jail time. Although Henggeler is a clinician, his expertise is evaluation of service effectiveness, and MST is one of the most thoroughly and rigorously evaluated interventions available for juvenile delinquents.

The real challenge with such interventions, he says, is making the results stick after the therapist is gone, typically after about four or five months. To that end, MST emphasizes empowering the primary caretaker to do the therapy. This often involves correcting some ingrained patterns of dysfunctional communication, both within the family and between the family and others in the community, especially teachers and principals.

Henggeler didn’t envision MST when he was starting out, nor could he possibly have imagined its current reach and influence. As a newly-minted Ph.D. at Memphis State in the mid-’70s, he was interested in antisocial kids, but distressed by the interventions typically in use. “Either they got individual therapy—Gestalt therapy, client-centered therapy, psychodynamic therapy—or they were put into group homes,” he recalls. “From what I knew of obnoxious adolescent behavior, it seemed that putting them together in homes wouldn’t work. They feed on each other.” MST grew out of this early skepticism, and today is entirely home based.

Perhaps the most significant departure from classical family therapy is MST’s inclusiveness: it’ll basically incorporate any therapeutic idea, as long as it’s been proven to work in rigorous evaluations. For example, MST therapists will often incorporate Cognitive-Behavioral Therapy (CBT), because so many troubled teenagers suffer some degree of depression along with their antisocial behavior. The therapists instruct the primary caretakers in the principles and practice of CBT, which they can then use as long as needed. Similarly, MST therapists don’t hesitate to recommend drugs, especially for the many antisocial kids with attention problems that impair their schooling.

The demand for proven interventions has intensified in recent years, as cash-strapped public health agencies are feeling pressure to show taxpayers hard results. This has been a boon for MST. Although a typical intervention takes months and requires a 24-7 commitment of the therapist’s time, even this investment is cost effective when compared to the price of running a kid through the juvenile justice system, providing residential treatment, or imprisonment. The approach has been so effective with juvenile delinquents that some localities are experimenting with it as an intervention for kids with psychiatric disorders alone, which is sometimes paid for by Medicaid.

Interestingly, despite its significant debt to the geniuses of family therapy, few MST practitioners are trained in family therapy. That’s the way Henggeler likes it. “Too much familiarity with family therapy can actually get in the way of effective work with kids,” he says. “It’s harder for family therapists to switch to our multidimensional approach.” Just as in any family system, it appears, the offspring—even the offspring of family therapy itself—must eventually break with the parent to fulfill their potential.