Multisystemic therapy in Chile: A public sector innovation case study

This study has a qualitative, case study design, due to its pertinence to analyze and report decision making processes in specific organizational and political context ( Baxter & Jack, 2008 ). This design is also appropriate to describe “how and why things happen, allowing the investigation of contextual realities and the differences between what was planned and what actually occurred” ( Anderson, 1998).

The study is also single case, descriptive, and intrinsic case study, as it prioritizes the description of a process itself, without considering it a mean to support or reject any hypothesis or theory ( Baxter & Jack, 2008).

The information used to report the case is limited to documental sources. Due my personal involvement in the case, I do not have authorization to disclose any informal details protected by ethical regulations regarding confidentiality. However, my participation in the decision to implement MST in Chile, as well as my work during the implementation process may be considered as a source of potential bias.

Case definition . The case studied is the decision making process of the Undersecretariat for Crime Prevention (SPD) which resulted in the implementation of Multisystemic Therapy (MST) in Chile.

Study question . May the implementation of MST be considered a case of public sector innovation in the context of Chilean policies and practices to prevent youth offending?

Crime is a major concern in Chile, according to the most relevant public opinion poll in the country, which positioned this issue as one of the top-three priorities over the last 12 years ( Centro de Estudios Públicos, 2015 ).

In response, the national government designed several public policy instruments, institutions, and programs in a process started with the release of the National Policy for Citizen Security by 2004. This policy, along with a formal diagnostic about the causes of crime in Chile, stated several principles and priorities which reveal valuable information about the technical and political consensus about the problem by that time.

Beyond the relevance of situational crime prevention policies, better policing strategies, and improved prosecution for the control of criminal activity, the document states the preeminence of social crime prevention practices. The first principle stated by the National Policy for Citizen Security was to “strengthen and empower the capacity of the families to promote prosocial behavior and reduce violence” ( División de Seguridad Ciudadana, 2004 , p. 19). The second principle included in the document was to “strengthen and empower the capacity of the schools to promote prosocial behavior and reduce violence” (División de Seguridad Ciudadana, 2004, p. 19). Both principles recognize the importance of family and school as socialization agencies responsible for the learning of values and practices needed for prosocial relationships among citizens.

By 2010, from a total of 519,236 people arrested at national level, 43,803 (8.4%) were 17 years old or less ( Instituto Nacional de Estadísticas & Carabineros de Chile, 2010 , p. 152); 15,521 youth entered different programs at the special correctional system managed by the National Service for Child Protection (SENAME) the same year ( Servicio Nacional de Menores, 2010 ). According to experts, “different kinds of theft, assault, homicide, and sex offenses are among the most frequent crimes committed by youth offenders” ( Dionne & Zambrano, 2009, p. 37).

Qualitative studies regarding the experiences and life trajectories of Chilean youth offenders stated valuable information about social and family issues associated with antisocial behavior. About this topic, Godoy said that youth offenders reported several structural and functional issues in their families, including parents abandoning home due to alcohol or drugs abuse, financial stress, and lack of adult supervision, while “most of the interviewed youth offenders said they do not have an actual parental role figure” ( Godoy, 2010 , p. 129). Other studies reported similar results: “Most of the times, the researchers found a conflicted family context when exploring the life-trajectories of youth offenders. Several issues where revealed, including dysfunctional parenting strategies, physical abuse or neglect at childhood, conflicts and violence among the parental couple” ( Mettifogo & Sepúlveda, 2005 , p. 40). But social issues were not only affecting families, since the youth also reported experiencing school as a non-supportive institution. Failure at school is often associated with behavioral problems and academic underachievement (Metti-fogo & Sepúlveda, 2005).

The treatment of youth offenders, since 2007, is regulated by the Juvenile Criminal Responsibility Act No. 20,084. This law established different types of sentences, oriented to restitution to the victim, education and socio-education of the offenders, therapy, and the protection of the offender's rights, in the context of community and residential sanctions ( Ley 20,084, 2011 ). The system to deliver sanctions and correctional programs was criticized by academic experts due to its design, claiming that “correctional treatment allocation is often inappropriate, since it is not decided based on the youth's specific characteristics and requirements in order to progress in his re-adaptation process, which affects treatment program's effectiveness” ( Dionne & Zambrano, 2009 , p. 45). There were also criticism about the operational conditions of the system: “the caseload assigned to youth probation officers, as well as the high level of geographical dispersion of the treatment of these cases, does not allow to provide a service intensive enough to meet user's treatment goals” ( Dionne & Zambrano, 2009 , p. 45). Finally, “the lack of specialized practitioners at different levels […] does not contribute to the existence of uniformed criteria based on scientific research” ( Dionne & Zambrano, 2009, p. 45).

The concerns claimed by critics seemed to be worthwhile. A national study analyzed the reoffending rate of 1,667 youth offenders who completed different kinds of criminal sentences by 2008. This study found 39.4% recidivism in the 12-month follow-up, and 53.7% in the 24-month follow-up after completion of a custodial or community sentence ( CESC Universidad de Chile, 2012, p. 8).

The problems noted in correctional programs made it necessary a change in the design, operations, and funding schemes of the services provided to sentenced youth offenders, but the fact that the system is ruled by law required to draft extensive and detailed reform projects to be discussed at the Congress. The need to test new developments fast, within the purview of the executive branch, as well as the need to promote preventive (rather than punitive) practices, made it relevant to focus on the improvement of child protection services, as a way to prevent youth at-risk from being sentenced before entering the criminal justice system. The design of child protection programs is more flexible, as its change only required technical and administrative decisions at the executive.

New Life was based on the 24 Hours program, created by Carabineros de Chile (national uniformed police) to identify at-risk children and youth through the analysis of cases entered to every police station in the country, either as perpetrators or as victims (Ponce, Echeverria, & Garrido, 2011). The information of every case is recorded in a database, which is split by the commune of residence of the child or youth, and sent to local authorities in order to provide them with useful information to concentrate social and protection services on the cases that need it ( Dirección de Protección Policial de la Familia, 2007 ).

In order to strengthen the capacity of local governments (municipalities) to provide protection and preventive services for children, SENAME increased the allocation of financial resources to the first eight communes that a) concentrated a high number of kids entering police stations, and b) had authorities committed with the initiative to protect children. These communes had to use the extra resources to complete a new, improved standard of services, which included the implementation of ( Ponce et al., 2011):

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  A Children's Rights Protection Office [Oficina de Protección de Derechos – OPD] to diagnose and treat low complexity cases.

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  A Brief Intervention Program [Programa de Intervención Breve – PIB] to diagnose and treat medium complexity cases.

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  A Specialized Intervention Program [Programa de Intervención Especializada – PIE], to diagnose and treat high complexity cases, with the support of:

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  A local drug treatment program

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  A local school reintegration program

Additionally, New Life included two more components. One was the Case Management Team, designed to apply a standardized screening for psychosocial risks factors. The other one was the local board for case management, designed as a coordination scheme and an opportunity to enhance cooperation bonds among local protection service providers.

Compared to previous experience, the original version of New Life Initiative showed a clear potential to solve different pre-existing problems in the field of crime prevention focused on at-risk youth, such as weak service capacity at local level, lack of standardized screening procedures, and lack of coordination among local service providers ( Allende & Valenzuela, 2008 ). However, it did not solve other significant problems, such as time-consuming assessment process (over 3 months in some cases), confusing definition of “complexity” as core variable of the initiative (with the risk of mixing perpetrators and victims), lack of effective service for low-risk cases (OPDs were collapsed with mandatory assessment requirements from Family Courts, with no time to treat cases), and lack of effective service for high-risk cases (PIEs were showing problems to engage cases with greater needs) (Monreal, Neira, & Olavarría, 2012).

The evolution of crime prevention policies ended up with the creation of the National Strategy for Public Safety. Along with the release of the Strategy ( Gobierno de Chile, 2006 ), political authorities for the first time in the country established a clear, measurable goal for crime prevention management, in terms of an expected reduction on victimization. The definition of this overarching goal aligned further program developments to contribute to victimization reduction, creating a positive scenario to shift towards evidence-based crime prevention. At the offender treatment field, this created incentives to set reoffending reduction as a primary target.

At the following administration, started by 2010, the “Plan Chile Seguro”, a new edition of the national public safety plan, also defined specific measures of expected reductions on victimization, and openly subscribed the evidence-based approach on crime prevention ( Gobierno de Chile, 2010 ). This statement reinforced the need for policy developers to design programs in order to adhere to the principles of effective practices, and increase the chance of reducing reoffending.

The definition of clear goals in terms of reduction on victimization had an effect on the institutional framework of the executive office in charge of public safety. By 2011, the Undersecretariat for Crime Prevention was created under the Ministry of Interior and Public Safety. The role of this new Undersecretariat was to concentrate functions and accountability for crime prevention, and a coordinating role regarding any public safety driven effort made by other agencies at the government ( Ley 20,502, June 10th, 2015 ). The new institution meant the creation of the new position of Undersecretary for Crime Prevention, allowing a high level authority to focus exclusively on the reduction of victimization and to interact directly with technical teams specialized in different fields related to public safety, including youth antisocial behavior treatment.

The youth offending problem was re-defined by 2011, given some design and operational problems at New Life Initiative, and the positive context for the implementation of evidence based programs with the potential to contribute to the reduction of general victimization. This re-design process was led by SPD.

The new definition of the problem considered two elements:

a) the lack of appropriate service for youth offenders under 14 years old ( Allende & Valenzuela, 2008 ) and b) the doubts about the effectiveness of youth correctional programs within the criminal justice system, due to recent reports of high rates of recidivism ( CESC Universidad de Chile, 2012; Pantoja, 2014 ). These two elements were special concerns regarding high-risk youth offenders, who seemed not to engage available services.

The solution to be proposed had to comply with certain criteria, based on the prior analysis of the situation ( Monreal et al., 2012; Pantoja, 2014 ):

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  The program had to be based on a treatment model for youth offenders with extensive scientific evidence of effectiveness in terms of reoffending reduction.

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  The treatment model had to be pertinent to the Chilean's social and cultural reality.

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  The treatment model had to be feasible to deliver and be evaluated during the 4-year administration term. Instead of using time on large feasibility and diagnosis studies, the model had to be proven quickly.

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  The program cost had to fit SPD budget.

Several research reports and crime prevention program's websites were reviewed to gather details about different solution alternatives, including SAMSHA and the Washington State Institute for Public Policy. However, the main source of information consulted were the Blueprints for Healthy Youth Development website of the Center for the Study and Prevention of Violence Institute of Behavioral Science, University of Colorado Boulder. We noticed the development of the Blueprints project due the recommendation given by an expert on the field (Dodge, personal communication, November 07th, 2006), and devoted special attention to it due to its high level of methodological rigor.

Among the multiple solution options detected, the following were considered due to their fit to the target population ( Pantoja, 2014):

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  Multidimensional Treatment Foster Care (MTFC)

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  Functional Family Therapy (FFT)

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  Multisystemic Therapy (MST)

The selected choice was MST, a highly intensive family therapy model implemented mostly at-home, considering a series of characteristics, such as ( Pantoja, 2014):

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  Good fit with target population, described as 10 to 17 years old, high-risk youth offenders.

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  MST can be provided to families on a voluntary basis, does not require changes in the law to make the treatment mandatory. Because of this, the program was appropriate for the legal context.

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  MST met the evidence-based criteria. The program had evidence of effectiveness in different rigorous studies ( Borduin, Henggeler, Blaske, & Stein, 1990; Curtis, Ronan, Heiblum, & Crellin, 2009; Sawyer, 2008; Sawyer & Borduin, 2011; Schaeffer & Borduin, 2005 ), and a potential to maintain at least part of the positive effect on the youth even 20 years after treatment completion.

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  MST was considered a highly structured program in terms of its general design and philosophy, but not in terms of a specific curriculum of activities. This characteristic was considered positive because it made the replication of the program easier in a different cultural context.

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  Strong quality-assurance system.

Multisystemic Therapy involves an intensive psychological family therapy to address several behavioral problems, including drug abuse and offending in children and youth between 10 and 17 years old ( Subsecretaría de Prevención del Delito, 2015b ). The theory of change of MST is based on the assumption that there are many different risk factors present at different systems where the youth is embedded, so interventions need to be capable to address effectively those risk factors ( Henggeler, 2009 ). The emphasis is “on training parents/caregivers to control the behavior of their children, promoting the maintenance of youth at school, at home, reducing drug abuse and risk situations. The treatment is delivered at home and in the community environment, through face-to-face intervention and on-call support provided by a highly trained clinical and psychosocial team, available 24/7” (Subsecretaría de Prevención del Delito, 2015b, p. 27). It uses a combination of evidenced-based models including cognitive behavioral therapy, family therapy and behavioral approaches, as well as parent management training, all adapted for delivery within the MST model ( Ashmore & Fox, 2011 ). Lack of engagement of the young person in the treatment process would not prevent MST from being delivered; the parents need to consent to have MST, but the young person does not ( Ashmore & Fox, 2011).

MST is a highly structured model for family therapy, with clear definitions about clinical interventions that can be considered acceptable and useful in the treatment process ( Henggeler, 2009 ), but its permanent attention to the context – social ecology – where behavioral issues happen helps therapists to understand details about the sequences of situations that lead to dysfunctional conduct, which may be different not just for every family, but even for every different youth in the same family. This philosophy provides good conditions for transportability of MST, as its structured pre-defined analytic process allows highly individualized and cultural-sensitive treatments ( Bibi, 2014; Brondino et al., 1997 ).

Though some reviews of rigorous research have not found evidence of the effectiveness of MST compared to usual services ( Littell, Popa, & Forsythe, 2005 Littell, 2005 ), several studies have concluded MST is effective at reducing offending behavior and drug abuse, among other issues on at-risk youth ( Tiernan, Foster, Cunningham, Brennan, & Whitmore, 2015; United Nations Office on Drugs and Crime, 2013; Weiss et al., 2013 ), including a recent meta-analysis ( van der Stouwe et al., 2014 ), two longitudinal studies which reported positive results remain 14 and 21 years after treatment delivery ( Sawyer & Borduin, 2011; Schaeffer & Borduin, 2005 ), and a study that detected a long-term positive effect on the siblings of treated youth 25 years after intervention ( Wagner, Borduin, Sawyer, & Dopp, 2014 ). MST is also cost-effective. A recent study estimated that the long lasting impact of MST compared to individual therapy is associated with cumulative benefits of US$ 35,582 per juvenile offender. Every dollar spent on MST returned $ 5.04 to taxpayers ( Dopp, Borduin, Wagner, & Sawyer, 2014 ).

The municipalities in Chile usually have an excellent level of knowledge about the local territory in terms of social dynamics and existing resources, including institutional and informal sources of social support. Also, municipalities usually have good performance in executive and administration functions. Finally, the municipalities involved in New Life Initiative by 2012 were already receiving a weekly summary of youth who engaged in contact with police, either as victim or as perpetrators of violence or crime. However, several municipal teams have declared not having the appropriate training nor the resources to design and implement specialized programs to deal with high-risk youth offender at the community ( Allende & Valenzuela, 2008, p. 11).

The existence of valuable resources such us executive capacity and local knowledge of social dynamics, as well as specific demands for financial and technical support, made it necessary to subscribe agreements between the central and local government. Through these agreements, central government provided technical and financial assistance to implement MST, while the local governments managed the financial resources and undertake the administrative procedures to meet operational requirements including setting up a program office, hiring clinical teams, and making transportation arrangements to deliver MST to treated families at home ( Ilustre Municipalidad de Peñalolén, 2014 ).

The resources allocated by SPD for the development and implementation of MST were about USD $ 3 million by year, beginning with a 3-year program (2012-2014), to start operations in 14 sites, with one clinical MST team per site. Each team included one fulltime supervisor and four full-time therapist, generating a total case load capacity of 840 treated youth annually ( Monreal et al., 2012).

The central government made an agreement with Multisystemic Therapy Group to get access to technical assistance regarding the hiring of clinical teams, the training and on-going guidance of the clinical teams by MST experts, and the access to materials and assistance to run the quality assurance system. This agreement also made it possible for SPD to receive support on the program development process, including the visit to municipalities in order to a) perform seminars to inform local stakeholders and general community about MST and b) to have meetings with relevant agencies, including local offices in charge of Child Protection Services, Police, Local Administration for Public Education, and others.

This process involved the translation of MST training materials into Spanish, due the limited level of bilingual competence in the Chilean staff at the local level.

The clinical teams hired by the municipalities received training provided directly by MST Group, in order to get the basic orientation needed to begin treating cases. The teams also received on-going support from MST experts in case analysis and the definition of treatment strategies. The availability of a direct link between clinical teams and experts was considered highly valuable by several actors both at central and local level.

While MST Group was in charge of the development of clinical skills in the teams, the SPD as a funding institution was in charge of overseeing and management control. This role allowed it to supervise the effective administration of resources at the local level, and contributed to the generation of a good-enough working environment for the teams to focus their time on the process of learning the treatment model.

Due the expected progressive learning of the clinical teams, the total caseload was below capacity in the first months of operation. By month 1, only four teams were in place treating only 32 cases; by month 8, 14 teams were in place with a cumulated caseload (treated + under treatment) of 448. By month 16, the same 14 teams treated 944 at-risk youth ( Monreal et al., 2012).

To support the case flow of youth offenders to MST, SPD also funded one Risk Assessment Team (EER) for each site. This EER included a psychologist and a social worker, both with significant experience in community intervention, and training in actuarial screening of risk factors for offending behavior in children and youth. The EER had the following tasks ( Pantoja, 2014 ): receiving data on a weekly basis from the police through 24 Hours initiative; select cases involved on antisocial behavior; prioritazing cases based on variables associated with risk of antisocial behavior (previous arrests, severity of current offense, age, among others); visiting prioritized cases at-home to interview the parents or caregivers and run an onsite screening of risk. Finally, the result of the risk screening is used as a base to decide referrals. Only cases at higher risk band were considered for referral to MST.

The institutional SPD website reported an MST expansion plan to have up to 36 clinical teams in operation by 2016. Considering the process began by 2012, this may be one of the most extensive and faster MST implementation process ever. Also, the SPD website states that by June 2015 there is up to 2,574 treated and 1,400 discharged families, from whom 70% has not being re-arrested according to objective administrative data provided by Carabineros de Chile ( Subsecretaría de Prevención del Delito, 2015a ). The operation in the current 31 communes “generates an (MST) treatment capacity over 1,000 families every year” (Subsecretaría de Prevención del Delito, 2015b, p. 32).

According to the leading institution (SPD), “the implementation of MST in the country has been challenging in terms of public policy, demanding a sustained work from the Undersecretariat for Crime Prevention. This model has meant implementing new practices and understandings about social intervention, in a way that the treated youth are always part of a broader context, which is also part of the treatment” (Subsecretaría de Prevención del Delito, 2015b, p. 32).

Chile is currently facing increasing demands from the society to get access to better public goods like high quality education, public health services, and public safety, all in the context of a slowing-down economy. This combination of factors made it necessary a significant tax reform implemented since 2015. Innovation is especially important in the context of stressed public finances due to long-term issues such as ageing societies, social security and healthcare costs, and outdated public service infrastructure ( Bason et al., 2013).

Beyond the traditional understanding of the private sector and NGOs as sources of social innovation, the European Union is now understanding and promoting the need of public sector to engage in innovation process capable of creating valuable solutions for social issues. In this context, “a new vision for the public sector is required, whereby public managers become public entrepreneurs. This can only happen through a pervasive change of mindset, with more experimentation, controlled risk taking, and an agile and personalized response to new constituent challenges. This will help unleash the potential of an innovative public sector, which can be transformed into a much needed growth engine for the economy” ( Bason et al., 2013).

Public sector innovation can be defined as the “use (of) new approaches, from policy design to service delivery, for a high performing, more responsive public sector” ( OECD Observatory of Public Sector Innovation, p. 1); or as “the process of generating new ideas and implementing them to create value for society, covering new or improved processes (internal focus) and services (external focus). It takes on a variety of forms, ranging from smarter procurement, mobilizing new forms of innovation financing, creating digital platforms and citizen-centric services as well as driving a new entrepreneurial culture among public managers” ( Bason et al., 2013).

Social innovation is not always related to civil society leadership; some experts define it as “new solutions that simultaneously meet a social need and lead to new or improved capabilities and relationships and better use of assets and resources. In other words, social innovations are good for society and enhance society's capacity to act” ( European Commission, 2013 , p. 15). The goal of social innovation is to tackle social problems, no matter if those are long-lasting or new issues, faced by vulnerable groups ( European Commission, 2013).

If innovation is necessary and positive for public management, it is valid to consider why it is still infrequent. According to Bason and colleagues, the main barriers for public innovation fall into four major categories: weak enabling factors or unfavorable framework conditions, lack of innovation leadership at all levels, limited knowledge and application of innovation processes and methods, and insufficiently precise and systematic use of measurement and data ( Bason et al., 2013).

In order to overcome the barriers to innovation, a set of design principles has to be promoted at the public sector ( Bason et al., 2013):

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  Co-design and co-creation of innovative solutions (with other member states, other parts of government, businesses, the third sector, and citizens).

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  Adopting new and collaborative service delivery models (across public, private and non-governmental actors, both within and across national borders).

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  Embracing creative disruption from technology (the pervasive use of social media, mobility, big data, cloud computing packaged in new digital government offerings).

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  Adopting an attitude of experimentation and entrepreneurship (government itself needs to become bolder and more entrepreneurial).

It is possible to consider the case described as public sector innovation, based on the following criteria:

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  The implementation of MST in Chile occurred in a general context of evolution of crime prevention policy, which was shifting to results-oriented (victimization reduction) policy design. This shift from “process” to “results” in crime prevention began by 2006, 6 years before the implementation of MST and contributed cultural elements, which supported the importation of evidence-based practice.

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  The general, high priority issue (crime) was specified on an accessible problem that prioritized a vulnerable group of the Chilean society: youth exposed to harsh social and family conditions and who developed a high profile of offending risk.

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  The approach to the problem of youth offending in the process described was radically different from regular practices in policy-making. The regular approach to youth offending in Chile is based on the assumption that every youth offender is a victim of violations of his/her rights as a child or youth, so the solution has to be based on the restitution of the exercise of the violated rights. This assumption is true in most cases, but usually lead professional teams to focus on the youth (where “the damage is made”) rather than the family (where the damage can be prevented). This approach, which makes sense from the perspective of most practitioners, set the focus of public services on the consequences, rather than the causes of rights violations and problematic behavior. The decision of implementing MST was mainly based on its strong evidence-base, but also on the understanding of the role of the family as protective factor.

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  While it is true that MST has been existing for 30 years, it still can be considered an innovation in the Chilean context, due to its focus on the change of the social ecology of youth, and the interaction between youth and their context (family, peers, school, neighborhood) rather than the individual and the change of the meaning the subject assigns to his/her past experiences. In fact, the concept of innovation “[does] not need to be limited solely to new ideas that had never before been carried out in other places in the world or region” ( Marulanda & Tancredi, 2010, p. 10).

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  The most important thing, the implementation of MST allowed Chilean policy-makers to provide public value (safety), according to the high rate (70%) of high-risk treated cases that are not showing new arrests.

Notwithstanding the leadership of SPD, the participation of different institutions in this process, such as central government, local governments, and an international organization devoted to cutting-edge program development of crime prevention could be considered also a case of “collaborative innovation” ( Bommert, 2010 ). Indeed, “collaboration between public and private entities creates better and more effective public and private services and products […], enables the participants to exchange and share knowledge, experiences, know-how, and expertise ( Cankar & Petkovsek, 2013, p. 1597).