Lessons from Sweden on Implementing Multisystemic Therapy

Posted by Emma Ulfsdotter, MST Sweden

May 16, 2017 8:15:00 AM

A little bit about us

Sweden is a small country in northern Europe with a population of 10 million. It is divided into 290 municipalities, all of which have autonomy. Only 25 have a population of more than 80,000. So, most Swedes live in small towns across the country. This means that there is no state involvement in local programs. The National Board of Health and Welfare gives guidelines for best practices, but these are just guidelines. 

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MST was introduced in Sweden

In 2003, Multisystemic Therapy (MST) was introduced to help Sweden deal with its juvenile-delinquency problems. From the start, we faced an uphill battle. Not everyone was convinced that an American program would work in a Swedish context, especially in our welfare system, of which we are all very proud.   

In addition, the autonomy of the municipalities and their individual structures created unique challenges for the implementation of MST. MST was not funded from the state, but grew from the inside out—from the municipalities. Considering their autonomy, growth would be dependent on the size of the municipality, the economy and the political leadership. Some places were, and still are, interested in starting an MST program, but the population was too small to support a team. Cross-municipality collaboration is a challenge because of the governance structure. Often, there is not time, money or a champion with enough influence to create those necessary connections.

Without the involvement from the state, the six original teams were fairly isolated. We realized early on the important role that collaboration between teams to identify and troubleshoot their strengths and struggles would play.

Support from Norway

Norway had implemented MST nationwide just a few years earlier. So, we sought their advice. This guidance paved the way to the effective coordination between our six Swedish teams. That was the starting point for what became the MST Sweden Network Partnership four years later.

Becoming an MST Network Partner—Hiring a Swedish-speaking expert

The tide really turned when we hired our first Swedish expert. Not only could we begin writing our weekly reports in Swedish, we could have boosters and training in Swedish, as well. Meetings with our internal and external stakeholders suddenly became much easier without a language barrier. Having a local community expert who was the voice of the model helped others to see and hear how it was being implemented, and helped them see that it could work in Sweden.

Encountering and embracing challenges 

One significant struggle we encountered was working with the results from a randomized trial that showed MST did well, but not significantly different from Treatment as Usual (TAU). The outcome of this study produced many questions about the effectiveness of the MST model and its implementation not only in Sweden, but in other countries outside the U.S., reinforcing some of the original concerns about implementing an American model in a Swedish context. We realized we needed to work hard to implement MST with strong fidelity to achieve positive outcomes for young people and their families. 

A new study

At the same time, the discussion had been ongoing with MST Sweden and The National Board of Health and Welfare (which did the randomized MST study). We could see how increased fidelity to the MST model was improving quality.  A new study focused on implementation. It found a clear connection between adherence and outcomes, which was not there in the randomized trial. We learned that the second of MST therapists implemented the model with stronger adherence than the first.  In short, adherence got better over time, and this had a direct positive impact on outcomes.

Sustaining and growing MST

With some of the major hurdles behind us, we were able to focus on sustaining and growing teams. This process, though slow and ongoing, has been largely successful. Only one team closed down since we began implementing MST in 2003. We attribute this sustainability to adherence and collaboration with the managers from our MST teams.

Another success? We have had no experts’ turnover since we became a Network Partner in 2007, and we have doubled in size to 12 teams. 

Lessons learned 

Throughout the years, we learned to humbly embrace questions by responding with facts and positive stories. Often, families tell their side of a positive change. We also follow families up to 18 months after treatment to track results. This allows stakeholders see the benefits of working with MST. We have always tried to be transparent about how we do things and value the QA CQI process to identify strengths but also what we can do better.

This has created opportunities for ongoing dialogue as we continue to answer the question with “Yes, evidence-based programs can be helpful to the Swedish young people and communities.”

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Topics: MST implementation

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