Dr. Philip Reynolds Consultant Clinical Psychologist and MST Supervisor Louise Crookenden-Johnson

1. A new approach, supporting children to return home from care successfully, findingsJan 2015 – September 2016 Dr. Philip Reynolds Consultant Clinical Psychologist and MST Supervisor Louise Crookenden-Johnson Safeguarding Children’s Services, Improvement Manager With thanks to Joshua Leblang MST-FIT Consultant, Washington State University

2. Workshop aims • MST-FIT- the model • What Northamptonshire have delivered and discovered through this process • Outcomes for young people • Overall benefits • A chance for you to try out the skills

3. 69, 540 Children in care March 2015 Context of care in the U.K 60 children in every 10,000 are in care. 6,570 in secure units and children's homes Cost of failed attempts £300 million a year 1/3 of all children leaving care return home £61,614 the cost of a child re entering care plus year on year costs (Holmes, 2014) 30% return to care within 5 years

4. 993 Children in care in October 2016 Context of care in Northants 62.4 children in every 10,000 are in care. 232 in children's homes and secure units The cost of all care placements is £900,000 per week 913 days is the average length of time in care for our current cohort £193m is the projected cost for our current LAC until the age of 18* 581 looked after children are aged 11-17 years *Based on the current weekly placement cost and upon the premise that placement cost nor placement type changes for our existing LAC cohort

5. Multi Systemic Therapy - Family Integrated Transitions (MST-FIT), Northamptonshire Pilot - What happens…? Start Week 2 Week 4 Week 6 Week 8 Week 10 Throughout their time in Raven House, the young person receives the Integrated Treatment methodology (ITM), the residential element of the MST-FIT intervention. Whilst the young person is in Raven House their parents receive support from an MST-FIT Coach in the home 2-3 times per week. Week 12 – Returned Home 24 – 34 weeks later MST FIT Coach uses MST-FIT approach with family & young person. Reinforcing skills learnt in Raven House Closed to MST-FIT, young person remains at home with sustainability plan Returned Home to Family

6. MST-FIT Model • Multisystemic Therapy (MST) is the foundation (30+ years research) • Adds skills from Dialectical Behavioral Therapy (DBT) • Uses elements of Motivational Interviewing & Relapse Prevention • Integrated treatment model in the Residential home • MST-FIT team work with family during transition and once home

7. Integrated Treatment Methodology • 12 week programme in the residential home. • Skills focused, structured approach to working with young person in the Res. home • Individualised, group and milieu treatment • Changes residential focus to skills, family involvement, and goal of re-integration • Utilises CBT principles & DBT skills to focus on skills deficits identified in adolescents

8. FIT addresses the multiple determinants of behavior change Engagement factors Commitment to change Participation in therapy Family factors Parenting skills Family relationships Systemic factors School Community Faith-based organizations Juvenile Justice Individual factors Emotion regulation Interpersonal Effectiveness Substance use/abuse Mental Health problems Prosocial behavior Motivational Enhancement Multisystemic Therapy Multisystemic Therapy Dialectical Behavior Therapy Relapse Prevention

9. Learning points • So many……but the principal ones • Invest in time to build trust and confidence • There are certain types of cases or situations at referral that we would not consider again

10. Benefits- Residential context • Young peoples skills and behaviour management • Twice weekly skills groups and recap session, including role play • Token economy based on proportionate rewards • Staff investment in new skills • Individual knowledge, confidence in coaching young people • Integrated Treatment Methodology part of their supervision agenda, and weekly conference calls with Behaviour Chain analyses undertaken • peer support and skills groups • Joint work with MST therapist

11. Benefits- Residential context • Ofsted improved rating • from inadequate to good with outstanding features • Health and Safety incidents and accidents and restraint of young people hugely positive reduction • Staff Sickness dramatically reduced • Missing Episodes nil • CSE risk to young people reduced

12. Benefits- MST team • Many of the approaches used across non MST-FIT cases (MI, DBT skills, Mindfulness) • Team report addition of new skills is helpful • Benefits from weekly Mindfulness practise before supervision • Closer working with care home, detailed learning about this process

13. Benefits- strategic • Young people-improved Educational attendance and performance • Improved Care planning for home to long term Foster • Financial for NCC • Potential placement savings of around £200k per young person using an average length of stay in care for this age group • Potential rolling savings of £1.4m by year three

14. Mindfulness Skills Learning these skills will help you to be aware of your surroundings and your feelings, and to act wisely.

15. Distress Tolerance Skills These skills help you deal with upsetting emotions or situations without making things worse.

16. Interpersonal Effectiveness Skills These skills will help you get what you want from other people.

17. Emotion Regulation Skills These skills help you reduce your vulnerability to out of control emotions and improve your ability to get control over your emotions.

18. You are able to see the sequences and avoid pushing buttons which stops x from communicating well with you Consequences and rewards are having a significant effect on the behaviour – this is allowing you to feel like the behaviour is being dealt with so you can get back to a positive focus Focusing on the positives and avoiding focus on negative behavior has reduced conflict with x which has increased the amount of time spent together for positive communication to happen There is less systemic stress from formal agencies as you are focused on what you can do to resolve issues rather then looking for other agencies to do something ? You are less emotional around behaviours – you have changed your reaction to the behaviours so they have less impact on you which allows you to respond more effectively and at the right time Why has positive communication increased? You have an agreed process and structure in place to deal with communication – it is made clear to x that if she communicates she will be rewarded and opportunities will be offered to her to communicate at the right time You are modeling more and more pro social skills and how to manage conflict better which x is replicating You are confident in challenging the behaviour and not feeling there is nothing you can do

19. Feedback from a social worker I would like to state most emphatically, that I now believe that we could definitely not have done this rehabilitation to home without the MST Therapist. Mum agrees. He has been of immense help. I can see her getting more confident day-by-day. She is learning about setting boundaries, rewarding her children. He is supporting her through dealing with fallouts. He is dealing with issues that are coming up. He is advising us about possible course of action we can consider for the future, how to time them to work with his MST. His knowledge about cases of this type is proving a boon. Mum has told me how he knowing he’s there is helping her deal with it. And she is gaining in courage as she does more and more of what he is advising her to do, because it is working. In short, he is invaluable. I would give anything to have his type of help extended to more of our families. I sincerely believe, if this could be put in place more, much less of our children would come into care in the first place. Social Worker

20. Family Quotes • Offered hope that things could get better • Helped us see how the behaviour of our children and ourselves can be functional • We could see that x had learnt new skills around communication while at Raven House • Therapist understood it from our perspective, seemed that others did not have a full picture of what was happening

21. ‘Sheer passion’ of staffat Raven House • Key partners see improved expertise of Residential staff in empowering positive change in young people • Positive feedback from Ofsted Inspectors “Staff at this home have been trained and continue to develop skills in multisystemic therapy and family integrated transitions (MST-FIT). Managers have effectively implemented the MST-FIT approach to working with children and families. Staff are committed to the approach, and have received training and regular case consultations to enhance their skills and knowledge base.”

22. Ongoing learning/challenges • Referral process for FIT, continuous feed and peaks and troughs to maximise the capacity • Communication with wider social work staff impacted by large contingent of agency workforce to impact referral • Managing expectations and ‘belief’ during intervention • Committing time for supervisory requirements in the residential home • Quality assurance processes for Residential home • Post intervention crisis management

23. MST FIT is Designed to... • Eliminate or reduce the frequency and severity of the young person’s referral behaviour(s) • Empower parents with skills and resources for raising the young person • Empower the young person to cope with their emotions and to work better with family, peers, their school and their neighbourhood Multi Systemic Therapy - Family Integrated Transitions (MST-FIT), Northamptonshire Pilot - What happens…? Start Week 2 Week 4 • How does the intervention look…? • The young person must be placed at Raven House the skills coaching happens there for up to 12 weeks, separate to the family • MST-FIT coach works with family at home for 8 weeks before the young person returns home • MST-FIT coach continues to support the family for 12 – 22 weeks once home Throughout their time in Raven House, the young person receives the Integrated Treatment methodology (ITM), the residential element of the MST-FIT intervention. Whilst the young person is in Raven House their parents receive support from an MST-FIT Coach in the home 2-3 times per week. Week 10 Week 8 Week 6 • What to expect…? • To facilitate in increased contact • Improve relationships • Expect ups and downs, including at the point at which the young person is returned home • Encourage parents to put in place consequences when problems occur to deal with them e.g. young person going out without permission /coming back late • Prior to the young person leaving Raven House, both the young person and the family will have; • New skills in place, • Clear rewards and proportionate consequences, • An understanding of what triggers a slip, a lapse, or relapse • An effective group of non professional people to support the family (friends, family, faith group) • Plans for areas to work on with their MST-FIT coach • What helps…? • Clear commitment from all involved • Everyone trusts that change can be made and sustained in the family • Remaining positive with the family and commit to being collaborative in style • Share information or concerns with the MST coach and Raven House as early as possible • Work with key partners to give young person positive influences and experiences in their community; actions schools can take that will underpin MST practice as well as linking to positive activities and peers Week 12 – Returned Home 24 – 34 weeks later MST FIT Coach uses MST-FIT approach with family & young person. Reinforcing skills learnt in Raven House Returned Home to Family Closed to MST-FIT, young person remains at home with sustainability plan

25. Contacts • Dr Philip Reynolds, Consultant Clinical Psychologist preynolds@northamptonshire.gov.uk • Brigitte Squire, MST Programme Manager • Brigitte.squire@cambridgeshire.gov.uk • Phil Willcock, Residential Home Manager pwillcock@northamptonshire.gov.uk • Louise Crookenden-Johnson, Service Manager • lcrookendenjohnson@northamptonshire.gov.uk

26. MST Referral process Northants

27. Current Programmes FIT is currently a licensed adaptation of Multisystemic Therapy (MST-FIT) • Four teams running in Washington State • One teams in Chicago • Four teams in NYC • Two teams in Connecticut • Two teams in the UK (Northamptonshire & Leeds) • Norway developments