Abstract

۱٫ Introduction

۲٫ Material and methods

۳٫ Theory

۴٫ Results

۵٫ Discussion

۶٫ Conclusions

Funding source

Author contributions

Declaration of comepting interest

Acknowledgments

Supplementary data

References

Abstract

Purpose
Women in prisons are known to suffer with mental health difficulties and many experience challenges prior to incarceration. Diversion programmes are initiatives designed to divert people with pre-existing mental illness from the criminal justice system into mental health services. The variability of effectiveness of interventions makes realist approaches particularly appropriate for diversion programmes, and this paper presents the first realist review to be undertaken across the breadth of this topic. This realist review aimed to explain the successes, failures and partial successes of these programmes as an intervention to improve the outcomes of women offenders with mental health issues.

Methods
We conducted a realist review of published literature explaining the impact of diversion programmes on participants with mental health issues. Consultations with six specialists in the field were conducted to validate the principles and hypotheses about key dynamics for effective programmes.

Results
The review included 69 articles. We identified four essential principles, developed through thematic groupings of context-mechanism-outcome configurations, to articulate key drivers of the effectiveness of diversion programmes: coordination between services; development and maintenance of relationships; addressing major risk factors; and stabilisation through diversion programmes.

Conclusions
The behaviour of women offenders is driven by need, and the complex needs of this group require individualised plans that incorporate relationships as vehicles for support and change. Although there is a role for gender-specific interventions, it is not fully understood and further research is required. Implications for future interventions are discussed.

Introduction

     Worldwide, more than 10 million individuals are in prison at any given time and more than 30 million circulate through prison each year (Fazel, 2016). The incarceration of people with mental health conditions is now drawing attention globally, with increasing concerns around the detrimental impact of incarceration and the lack of mental health interventions adapted for prisons, alongside policy issues including overcrowding and other failures to meet human rights in prison settings (Fazel, 2016). This has resulted in an increased focus on developing mental health interventions for prison populations—particularly in high-income countries—including pre-arrest diversion services, mental health referral while incarcerated, and mental health provisions on release.

     Rates of mental illness during incarceration have been found to be higher among women than men. Women are at greater risk of receiving a mental health diagnosis while incarcerated (Al-Rousan et al., 2017; James & Glaze, 2006), and diagnosis describes a wider variety of mental disorders (Al-Rousan et al., 2017). Studies that have compared men and women have found that, except for psychoses and alcohol abuse or dependence, mental health disorders are more common in women, with odds ratios of 2–۳ times those in men in prison samples (Maden, Swinton, & Gunn, 1990; Steadman et al., 2009; Teplin, 1990a, 1990b; Teplin, Abram, & Mcclelland, 1996). This suggests that female inmates may have different concerns from those of male inmates and, as a result, different needs. Evidence also suggests that prison results in a deterioration in mental well-being through factors such as overcrowding and isolation and the subsequent impact on levels of stress and distress. Incarceration is conceptualised as the fourth most upsetting event on the Holmes/Rahe Social Readjustment Rating Scale (Holmes & Rahe, 1967), and prison-related factors have also been found to be risk factors for suicide (Fruehwald et al., 2004; Hayes, 1989; Humber et al., 2013; Joukamaa, 1997).

Conclusions

     If an overarching objective of diversion programmes is to change behaviour, an individual’s needs have to be understood, including those which are not directly related to mental illness. This includes, but should not be limited to, mental health needs, particularly through addressing trauma.

     Our findings illuminate that care to promote mental health requires individual rather than agency-based plans. Programmes require flexibility to be able to prioritise services and interventions based on need, building connections with other resources in the community where they are based. Regardless of the way in which an individual comes into contact with a programme, they should be able to access the appropriate services, tailored to meet greatest and most urgent needs first.

     The findings also suggest that quality of relationships can enhance, or even define, an individual’s experience of a diversion programme. There are two aspects to this: the relationship an individual has with a programme, which should be based on trust, understanding and recovery; and the relationships an individual has outside the programme, which should be supported by diversion programmes, both through enabling ongoing contact with an individual’s support network, and more broadly, through nurturing an individual’s connection with the community they are part of.