Therapy gives family a second chance

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This story is being co-published with The Imprint, a national nonprofit news outlet covering child welfare and youth justice.

On a Tuesday evening in February, the parents of three children are seated with a therapist at their kitchen table in Cheektowaga. They’re sorting out ways to help their oldest, a 15-year-old girl.

She loves TikTok and weightlifting and wants to be a counselor for young children when she grows up. But for years, the teen has exhibited harmful behaviors. She has attempted suicide, cut herself, lashed out violently and shrieked at members of her family when they tried to help. 

Struggling to care for her, the parents have called police and there have been two referrals to Child Protective Services. The family has tried dialectical behavior therapy and sought emergency psychiatric care at three mental health facilities and a local children’s hospital. Last November, they applied to the Persons in Need of Supervision family court program for children with behavioral issues, but the application was denied.

“Her behaviors were really extreme,” her mother said. “You’d say anything to her, and it could set her off. The whole house was in chaos.” 

Mother and daughter (left) at the family pool. Photo by Malik Rainey.

After speaking with various medical professionals, “nobody came up with the same thing,” said her father, ticking off four or five possible diagnoses. “Everybody had their own idea of what was going on.”

One more attempt eventually paid off: a referral to receive multisystemic therapy, or MST — a treatment aimed at addressing the teen’s behavior within her home, school and community. A key aim of MST is to keep young people out of juvenile halls, group homes or psychiatric hospitals. 

During their visit earlier this year, the family’s therapist, Alexandra Samsonik, listened intently as the younger kids played in another room — taking notes as she absorbed the family dynamic unfolding around her. 

To protect the teen’s privacy, The Imprint is not naming her, and identifying her parents — dad David and mom Mara — by their first names only. Mara said she’s sharing her family’s journey in the hopes that it can benefit others.

“If our story can help any other parent or even let them know they’re not alone,” she said, “I don’t mind.”

Addressing a gap

The treatment method is used internationally and is one of the most heavily relied-upon interventions in hundreds of juvenile justice and child welfare systems in the U.S. The company that trademarked the method, MST Services, vows to “do whatever it takes to reach families in need.” 

Through a local government contract with Catholic Charities of Buffalo, like other MST clients, Mara and David’s family has access to on-call services during nights and weekends, as well as therapy sessions that can involve schools and community groups.

MST is increasingly being eyed nationwide as states receive new federal funding under the 2018 Family First Prevention Services Act that aims to keep kids out of foster care whenever possible. More than a dozen states, including New York and California, have planned to include MST in their Family First plans.

New York’s Family First plan describes MST as a way to target “parenting and adolescent mental health and behavioral needs,” that are “complex and inter-related.” The Administration for Children’s Services in New York City relies on MST to assist families reunifying after a foster care separation and for children in residential programs.

Both skeptics and supporters of MST interviewed by The Imprint agreed: There are huge gaps in care for young people who are not being abused and neglected at home, and whose behavior problems fall short of criminal. Though some critics point to shortcomings in the evidence base for multisystemic therapy, many say the method offers hope to struggling children and families.

Samsonik, who works for Catholic Charities of Buffalo, worked with the Cheektowaga family from December 2022 through April of this year. She was tasked with assessing the teen’s behavior and determining why she was acting out; identifying dynamics in her relationships at school that might impact her behavior; and developing coping strategies.

After a February session, her 15-year-old client offered an initial assessment of the MST method she had just begun.

“I don’t notice a huge difference,” she said in an interview, “but I do notice I’m catching myself.”

Learning different responses

MST is as much about people in a child’s life learning to better respond to challenging behaviors as it is about the teen changing. 

In the kitchen during their February session, Mara and David offered Samsonik some explanations for their daughter’s most recent outbursts. She had been suspended from social activities at school, including a dance. She lacked solid friendships, and her boyfriend recently broke up with her. Disagreements at home involved cell phone use and the teen’s frustration that her parents were more strict with her than with her siblings.

At one point before engaging in MST, child protection workers visited the home after a fight between Mara and her daughter got physical, and the teenager told a doctor that her mother struck her. That led to a CPS report, although the case was later deemed unfounded.

Mara, a stay-at-home mom, and David, a forklift operator, also described a recent “meltdown” with their son during a home visit from CPS. That same night, their teenage daughter was enraged by what they were having for dinner.

Mara told Samsonik she feels like her daughter fails to take accountability for her behavior.

“I could have held myself back better, but how do you expect me not to hit you or defend myself if you’re sitting there kicking, punching and scratching me?” Mara said. “In her mind, she had no part in it.”

Urging restraint, Samsonik explained that there was nothing wrong with physically getting her daughter out of the way. She also reminded her that a lack of accountability is typical in teenagers. 

But there was more going on the parents were concerned about. With her friendships and romantic life not turning out well, the teen had begun seeking negative attention from strangers online. Again, Samsonik offered guidance: reward her with positive attention, continue to set reasonable limits, she told the parents.

The family meets with their MST counselor. Photo by Malik Rainey.

This coaching steered David to re-define “reasonable limits” with a testy teenager and what consequences, as her father, he should be imposing.

Before engaging in family therapy, David said, “She wouldn’t have a cell phone.” But after learning about the required mutual give-and-take, he added: “MST — that’s the only reason why she has a cell phone.”

When the two parents said they feared more permissiveness as a way to de-escalate tense situations was “letting her get away with murder,” Samsonik coached them on the goal of taking gradual steps. She wanted to get the teen “to the point where she isn’t destroying property and getting physical.” 

But for now, the family should work on “lower levels of that verbal aggression” she said. “Maybe there’s something smaller that we can use when she’s being snarky or nasty, making rude comments, because that’s still not OK.”

Mara noted that her teen feels she had been raised in a stricter environment than her siblings. Attempting to acknowledge her sense of injustice, Mara assured her daughter: “We’re trying to do better.” 

Assessing the program’s effectiveness

Multisystemic therapy was first conceived in the 1970s by psychologist Scott Henggeler. In 1996, he and a group of other academic, clinical, and business professionals launched the for-profit MST Services, which now has licensed providers in 38 states and 17 countries. 

The New York State Youth Justice Institute at the University at Albany gave the service program a ranking of 4.4 out of 5 as a treatment for “parent and youth behavior management, skills-building, and family functioning.”

Jennelle Hammill, MST program manager at Catholic Charities of Buffalo, oversees between 10 and 20 therapists serving roughly 100 families living in Western New York through a contract with Erie County. David and Mara’s family met with Samsonik twice a week, but families can meet with therapists daily if needed. 

Treatment in the program is free and usually lasts three to five months. In addition to therapy sessions, participating families can receive help with basic needs, such as groceries and gas. 

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Referrals in Erie County must come from probation or the social services department, but in nearby Niagara County anyone can refer a child, including school officials, counselors or parents. To be eligible, children must have exhibited criminal acts, run away, used drugs, behaved aggressively or skipped.

Hammill described MST as evaluating the intersecting systems in a child’s life to determine for parents what’s working and what needs to be modified. 

“We’re not here to tell you how to parent; we’re here to help you figure out what’s not working out with what you’re doing,” Hammill said. “It’s not changing their parenting styles so much as helping them fill in gaps where something’s not working.”

Roughly one-third of families complete follow-up surveys at six months and then a year after completing the MST program in Western New York. Hammill said for the past three years, those surveys showed that in 85 to 95 percent of families, the child is still living at home, going to school or working, and has had no new arrest. 

Erie County Probation Commissioner Michelle Olszowy, whose team of juvenile probation officers makes referrals to the program, said MST helps the child and the parent “understand why rules and consequences are essential.” 

But it’s not for everyone.

If a child is acting out but the parent has the skills to address the behavior appropriately, she added, then “a referral to MST would probably not be made.” 

Experts debate outcomes

MST has been used with children involved in CPS cases and the juvenile justice system for decades. But the outcomes of the therapy have mixed reviews.

According to MST Services, $75 million in research funds has produced 96 studies and more than 175 peer-reviewed articles involving 70,000 families. The benefits, the company states, are fewer arrests and out-of-home placements, and significant cost savings to local governments.

But there are critics of the model as well, who claim its evidence base and outcomes are often overstated. 

Professor Julia Littell of the Bryn Mawr College Graduate School of Social Work and Social Research has studied MST since 2004 and said she values its impact, although her research has raised some concerns. She said there is a potential conflict of interest because some of the research on MST was performed by program developers affiliated with its founders, and those findings tend to report benefits while omitting information on potential negative effects. 

“The first thing to say about our findings is that the results are inconsistent across studies,” Littell said of a meta-analysis of MST studies she published in 2021. “Sometimes you’ll hear people say MST works consistently across populations and programs. Our review of the research evidence shows that’s not true. It does not have consistent effects on any outcome.”

Multisystemic therapy arose with the growing interest in evidence-based practices for social services, she said, and led the field “because they had conducted controlled studies long before many other programs did.”

Littell praised the program’s structure, which involves home visits and sessions with entire families and intensive training and supervision of workers. 

But she noted: “Any good social worker or caseworker worth their salt would go in and disrupt harmful and inadequate patterns of behavior and communication — MST did not invent that.

“Cognitive behavior therapy can do that, structural family therapy does that, and functional family therapy does that.”

But most families overseen by child welfare agencies are tied up in the justice system, and those receiving mental health services won’t get that level of intervention, she added.

“We do know that giving people time and attention and help can be beneficial — whatever you do.”

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Brenda Szumski, executive director of MST Services, said there are similarities and differences between the various treatment modalities. In response to the critique about research independence, funding did not come from her firm, but rather “a variety of private and public sources.”

“While the MST model has been researched by the developers of MST, there have also been 69 independent evaluations of MST demonstrating its robustness and credibility,” she wrote in an email.

Szumski hailed the model. 

“MST is an absolute game-changer when it comes to keeping youth at home, in school, and out of trouble,” she said. “Research demonstrates that MST consistently and reliably delivers quality clinical outcomes at cost savings to communities.”

Former MST therapist Kaitlin Sheerin, currently a researcher at Brown University, conducted a study at the University of Missouri on MST participants who had a history of illegal sexual behaviors as juveniles in Illinois. She said when MST has not produced positive results in studies, it could be due to “low adherence to the treatment model.” 

Sheerin said she endorses the model because — unlike other treatment modalities — it addresses the stress of poverty in families’ lives that might impact a child’s behavior.

Family notes progress

In mid-April, the Cheektowaga family wrapped up its final sessions. The 15-year-old’s behavior had significantly improved over four months, her parents said. There were also positive reports from  school, and the teen had started running track.

“We greatly appreciate her newfound sense of keeping herself happy in a more positive headspace,” David said. “She’s been doing a great job.”

David and Mara agreed they’ve seen new progress with their daughter and an evolution in their approach to parenting. These days, she tells them when she feels the need to harm herself with sharp objects — instead of her prior pattern of slipping out of view. And they’ve reconsidered old patterns in the home, even the most basic tussles like banning cell phone or internet use.

“I’m used to being really, really strict, so I kept taking everything away,” David said. “But if you take everything away and they get in trouble again and there’s nothing to take away, what are you going to do?” 

Mara chimed in, noting the therapist had taught them that children often “feel hopeless at that point because ‘Oh, well, I’m taking it for weeks, and then I’m never going to get it back. So, why be good?’”

From her perspective, the teenager reports mixed feelings.

Her social relationships have “plummeted,” but she doesn’t blame MST. She said she’s gained better coping skills from the therapy than from other methods she’s tried. She currently sees a therapist from a different organization once a month.

“Other counselors just make it seem like everything’s gonna be great, everything is wonderful,” she said referring to her misbehavior, “but Alexandra makes me think that yeah, that’s me most of the time, but there’s also going to be times that are better.”

Jim Heaney