Multisystemic Therapy and Neighborhood Partnerships: Reducing Adolescent Violence and Substance Abuse

Multisystemic therapy (MST) is an intensive family- and community-based treatment that addresses the multiple determinants of serious antisocial behavior in juvenile offenders. Based on systems theory and Bronfenbrenner’s social ecological model of behavior,¹ the multisystemic approach posits that individuals are embedded in a network of systems that encompass individual, family, and extrafamilial (peer, school, and community) factors, and that behavior is a function of their reciprocal interactions within and between these systems. Integrating many empirically guided treatment models and delivering services in the settings where the problems occur, MST strives to promote behavioral change in youths’ natural environment, using the strengths of each system to facilitate change. It is one of the most evidence-supported, successful community interventions available,² and it demonstrates the importance of multidimensional, ecological changes in the modification of behavior. At a time when the study of violence is still largely fragmented among disparate fields, each with its own distinctive theory for prevention, this emphasis on a comprehensive and integrated programming is a welcome approach.

In this clearly written and practical volume, the authors purport to present to an audience of “clinicians, academics, policy-makers, community developers, and citizens in any neighborhood concerned about its youth.” Indeed, in the short span of 272 pages, the authors offer guidelines for everything from clinically implementing MST to community policing, as well as strategies for neighborhood outreach and program subsidizing. They attempt to foster a collaborative process among practitioners of different fields by outlining concisely the major contributions of the various perspectives in simple language. Thus, they address one of the greatest challenges of our time: that while each discipline of study accrues ever specialized and detailed information, it remains isolated and blind to the findings of other fields, so that little communication, integration, or collaboration is possible. Furthermore, there is an expanding gap between theory and practice, and despite the increasingly technical demands of academic research (or rather partly because of them), empirical knowledge and expert analyses have little effect on actual policy decisions.

The authors divide the text into three parts. The first reviews the multiple causes of youth and community violence and the extensive body of intervention research, including the widespread practices that unfortunately exacerbate criminal behavior and substance abuse. The first part also provides an in-depth description of MST. The middle section offers a thorough account of the comprehensiveness of the neighborhood project and how the individual components combine to be mutually supportive. The last part instructs on how to build and sustain neighborhood-based programs and offers some inspiring words from those who have benefited from the Neighborhood Solutions Project, an extended case example the authors use to illustrate the implementation of MST.

The authors rightly point out that the research literature on protective factors against violence and substance abuse is much less extensive than that on risk factors. I might venture further that while much work has been done to investigate the individual factors that exacerbate or mitigate violence and substance abuse, hardly any research has looked into how these factors might relate to each other and how they might affect the overall syndrome for which violence is a symptom. Despite the book’s attempts to address the larger contexts in which violence occurs, it falls short of conceptualizing violence in a way that might be helpful in this approach. For instance, it might have been useful to return to von Bertalanffy’s original vision of real systems being open to, and interacting with, their environments, so that they acquire qualitatively new properties through emergence. Taking into consideration emergent properties, it becomes clear that the whole is more than the sum of its parts, and violent manifestations themselves are events in a process. Hence, their prevention cannot be reduced to piecemeal strategies, merely matching risk factors with risk reduction or pairing at-risk groups with protective schemes, in effect applying Band-Aid strategies to profound systemic problems.

The World Health Organization (WHO), with which I have been consulting since their 2002 launch of the World Report on Violence and Health, has also adopted an ecological approach by emphasizing the multiple and complex linkages among the roots of violence—relating individual, relationship, community, and societal factors—much in the manner that Bronfenbrenner relates the roles of micro-, meso-, and macrosystems in individual development (The Ecology of Human Development: Experiments by Design and Nature, Harvard University Press, 1979). The authors of the book agree with this perspective, although the WHO further relates self-directed, interpersonal, and collective violence in a typology, hinting at the ways in which the myriad forms of violence relate to each other. There is still more room for speculation, which neither yet touches: for instance, more murderers would kill themselves than would ever be killed by the state; there is a significant correlation between so-called accidents, reckless behavior, and homicides; violence levels increase after individuals who were at war return home; and young males are responsible for nearly all of almost every mode of violent behavior. There are many reasons for thinking that all of these forms of violence share at least some etiological factors that relate to each other epidemiologically. If that is the case, then we cannot understand the cause of even one of these forms of violence without understanding all the others. Meanwhile, suicide has been relegated to the domain of psychiatrists; homicide, that of criminologists; warfare, political scientists; so-called accidents and occupational hazards, public health experts; capital punishment, specialists in criminal law; and cannibalism and genital mutilation, anthropologists. Like the proverbial blind men palpating only the surface of each aspect, we have been at a loss to understand this elephant called violence, and it is possible that one person with insight will render far more understanding than seven blind men. It seems that all of these problems might have been discussed in the book, given its intentions of multidisciplinary collaboration.

Still, the authors outline a theoretical ground for MST that is a step in the right direction for addressing violence, and having observed the achievements of a similarly multilevel, comprehensive, jail-based violence-prevention program in San Francisco with a similar philosophy,^3,4 I do not find the immense success of the multisystemic method in North Charleston surprising. Wide-ranging, multidisciplinary programs may seem daunting and costly to implement at first, but two decades of research imply that the only programs that work are comprehensive ones with significant investment and backing by established institutions. The Resolve to Stop the Violence Project (RSVP)^3,4 of San Francisco, which recently won the Ash Institute’s Innovations in Governance Award, required a major initial investment and initiation by the Sheriff’s Department itself, but it eventually saved the community four dollars for every dollar spent. Meanwhile, the reduction in violence accompanied an unprecedented improvement in quality of life, as measured by the disappearance of serious misbehavior (normally occurring weekly or biweekly) in the jail within one month of the implementation of the program. Addressing violence as a matter not only of individual actions but as a public health matter involving community-wide cognitive, behavioral, affective and sociocultural conditioning, the program achieved an overall change of culture, through a program that involves inmate participation 12 hours a day, six days a week. MST works similarly to empower the overall environment so as to transform chronically violent, substance-abusing juvenile offenders, by having case workers carry small caseloads and making themselves available 24 hours a day, seven days a week, providing services at times convenient to the family or community. This treatment involves on average about 60 hours of contact during a four-month period, limiting the length of treatment so as to focus on intensity and comprehensiveness; and the result is that it has been found superior to other programs in cost-benefit analyses.

Comprehensive, major programs such as these have hitherto been difficult to implement, requiring great proficiency and skill on the part of the stakeholders and sometimes entailing a countercurrent battle as well. Most traditional practitioners perceive of them as onerous additions to an already complicated practice. Furthermore, limited support from governments and other institutions has made even effective programs unsustainable, further contributing to the weight of inertia. Conceptually, our propensity toward reductionistic thinking constrains consideration of the larger, underlying causes of violence, which might illuminate simple, systemic changes that can prevent not only violence but also the ecological conditions that cause the quality of life to deteriorate in a manner that gives rise to violence in the first place. Practically, our predilection for quick fixes and simple formulas that solve all problems has resulted in little more than a very impractical morass of “solutions” for each aspect of the problem but not for the whole. The authors do an admirable job in extracting from the existing data elements that work and do not work across programs and in giving advice on how to fund and manage projects within the current climate; the resultant volume presents not only facts and task lists but begins to teach the reader how to think (and apply). The practical guidelines on building trust and overcoming racial barriers through cultural competence are particularly pertinent to American society and appear to arise from extensive hands-on experience, which is a unique strength of the section. However, in the usual manner of such handbooks, the authors limit themselves to the details of the operations and fall short of addressing the true collaboration that is necessary between academicians, practitioners, and policy-makers to tackle a human propensity that takes many forms, depending on the context, and that increasingly threatens the very survival of civilization, if not of the human species itself. The fact remains that grounds-up efforts to dismantle negative ecological effects and years of habitual practices alone are not going to be effective without the implementation of key policy changes that can influence entire communities and societies.

I suggest that the most pressing need is to change the way we think about violence and the way we approach it as a research subject, and to change the very definition of what we recognize as violence, considering that the causes of the various forms are often interrelated if not the same. For example, the word violence has often been used to apply only to injury-producing behavior that is prohibited by the law (i.e., criminal violence), even though far more deaths and injuries are caused by behavior that is either permitted or even required by the law. Far more people in the United States, for instance, die of suicide, accidents, warfare, and structural violence, which is more lethal than all the other acts, both legal and illegal, put together. Structural violence, while the most injurious of all, is created and maintained by the legal system. Thus, one goal might be to expand the definition of violence to include all the means by which human beings inflict injury and death on themselves and others. Investigations at the level of interpersonal violence, usually seen as the domain of criminology, are seldom considered relevant in the preventive efforts of larger-scale, collective violence—warfare, revolution, and terrorism, which are usually referred to the province of political scientists and historians. It is important not to restrict our understanding of violence to forms that are defined as “criminal” by the law or to identify violence with crime because, in fact, most violence is not criminal, and most crime is not violent. To do so would severely limit our understanding of the problem and perhaps entirely cripple our ability to deal with it effectively. Scholarly work that answers these problems would be most welcome at this time, although the current volume seems a good beginning for mental health practitioners interested in interdisciplinary collaboration, as audiences of the American Academy of Psychiatry and the Law (AAPL) would generally be. Defining more clearly and consistently the nature of the causes and manifestations of violence will render the preventive approaches that the book propounds within better reach; and not only will that ounce of prevention be worth a pound of cure, but we will have heeded Einstein’s sage advice, that “[E]verything should be made as simple as possible, but not simpler.”

• American Academy of Psychiatry and the Law