Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy.
Foster S.L., Cunningham P.B., Warner S.E. et al. Journal of Family Psychology: 2009, 23(5), p. 626–635.

How to get parents more engaged in becoming a positive influence over their seriously delinquent drug abusing teenagers through family therapy integrated in to a US juvenile drug court. Some of the therapist tactics expected to work did deepen engagement, others did not.

Summary
Multisystemic Therapy (MST) is an intensive family-and community-based treatment programme which focuses on the entire world of chronic and violent young offenders – homes, families, schools, teachers, neighbourhoods and friends – in the attempt to reduce antisocial and undesirable behaviour including problem substance use. It targets severe and intractable offenders aged 12–17 with very long arrest histories. MST clinicians are always on call, and work intensively in the home and elsewhere with parents or other caregivers to improve parenting and help focus the child on school and gaining job skills. Therapist and caregivers also introduce the child to sports and recreational activities as an alternative to 'hanging out'. Each therapist has a small caseload of one to five families. On average, treatment lasts four months and the therapist spends several hours a week with the child and/or their family.

The featured study addressed two gaps in research on this approach. First, whether therapist comments and responses expected to deepen the engagement of caregivers and make them feel more positive about the treatment process actually do have this effect. Secondly, whether such skills were more or less important for black families and whether matching these families with a black therapist would deepen engagement and make caregivers feel more positive.

Data for this analysis were drawn from audiotapes of mid-therapy Months two and three, chosen to capture the period when engagement is likely to be the most difficult because therapists are most likely to be making demands of caregivers in the attempt to improve parenting. sessions involving 89 The ones with decipherable audiotapes. of the 94 families/children allocated to Multisystemic Therapy as part of a study of the effectiveness of integrating this approach into a court specialising in young drug-related offenders. The youngsters aged 12–17 were randomly allocated to be sentenced and supervised by this court with or without also being offered Multisystemic Therapy, which was for some randomly selected children also combined with rewards and sanctions contingent on urine test results ('contingency management'). The original study concluded that in respect of substance use reductions, adding Multisystemic Therapy improved the effectiveness of the court. In this study, two thirds of primary caregivers identified themselves as black or African-American. Of these, 85% were living at or below the poverty level compared to 25% of white caregivers.

In consultation with MST therapists, scales were developed to identify therapist behaviours thought to contribute to treatment success with families in general and black families in particular. For families in general, these were:
• teach: the therapist directs the session, instructs, or educates the client, but not in an authoritarian manner;
• problem solve/collaborate: the therapist suggests an idea or plan of action;
• validate/empathy: the therapist legitimises the client's point of view or feelings; and
• reinforce: the therapist comments positively on a specific client behaviour or statement.

Four other behaviours were deemed especially relevant for black families:
• instrumental support: the therapist offers specific help with practical needs;
• strength focus: the therapist highlights something positive about the client, family, or situation;
• takes responsibility: eg, the therapist admits lack of understanding or acknowledges their possible contribution to a problem in therapy; and
• storytelling: the therapist uses a story or an example to illustrate a point.

The other side of the therapeutic interaction is the caregiver's responses. These were classified along two dimensions:
• positive responses: the proportion of caregiver comments which expressed agreement with the therapist about strategies, plans, or outcomes, or positive opinions, feelings, judgments, or hope.;
• engagement: a general impression of the degree to which the caregiver was involved in sessions, embracing commitment to therapy and agreement on treatment.

These therapist and caregiver behaviours were rated for each of an average eight segments Therapy sessions were transcribed verbatim and segmented into thought units (sentences or phrases that expressed complete thoughts). Transcripts were then divided into segment groups of approximately 100 thought units per group to ensure that each session was divided into equal parts. Transcript lengths varied from two to 20 segment groups. of each audiotaped therapy session.

The key issue was whether generally, and for black caregivers in particular, these therapist and client behaviours were related in such a way as to provide guidance on how therapists can deepen caregiver engagement and promote positive responses to therapy. Relationships were assessed within the same segment of the session and across succeeding segments.