Brady, Charlotte; (2024) Understanding drivers of the impact of diversion programmes and community mental health interventions on women's incarceration and wellbeing: a realist approach. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: The incarceration of women with mental health conditions has complex roots in multiple disadvantage and intersectionality. As the ‘criminalisation of mental health’ has attracted attention globally, several interventions, including ‘diversion programmes’, have been designed to direct women away from the criminal justice system and into health and social care systems. For diversion to achieve intended outcomes, both the diversion programme and the health and social care mechanisms need to function effectively, as an integrated system of tailored support. The aim of this PhD was to understand, for both of these areas of intervention, what works, in which contexts and for whom. / Methods: The project was guided by realist methodology and underpinned by intersectional and feminist theory. I organised my approach in two parts. First, I synthesised the available evidence on the effectiveness of diversion programmes using a realist methodology, to get a deeper understanding of the contexts and mechanisms that drive effectiveness of diversion programmes. Second, I undertook a realist evaluation of a community-based intervention named "It Takes A Village" (ITAV). ITAV represents an ambitious approach to working across systems to deliver integrated, interdisciplinary care in a London borough, for women with complex needs who are risk of incarceration and recidivism. The realist review of diversion programmes allowed me to develop an understanding of what works, in which contexts and for whom in the context of diversion, which I used to inform the design of my realist evaluation. Within the evaluation I applied case study methods to the realist evaluation cycle to explore the everyday workings of ITAV and define an explanatory model for the intervention. I completed 33 interviews with professionals, 13 interviews with service users, 74 hours of observation and 41 meetings over the course of 18 months. I used thematic network analysis to analyse qualitative data. / Results: The realist review highlighted four essential principles: that successful diversion requires connections and coordination between services across the healthcare system; that the development and maintenance of relationships should be incorporated within programmes to maximise their effectiveness; that major risk factors for recidivism remain relevant for offenders whether or not they have mental illness; and that diversion programmes provide an opportunity for stabilisation of an individual’s life, and effective programmes should enable this. The realist evaluation of the community-based intervention highlighted three complementary principles: effective service provision requires a developed understanding of women with complex needs; service users need to feel heard and supported by services to build trust in the system and foster engagement; and appropriate service delivery for women with complex needs relies on flexible, cross-agency collaboration. / Conclusions: The women directly involved in my research had slipped through the cracks in the system at multiple junctures and all required greater access to appropriate support. This was exacerbated by the lack of funding directed towards services, which drives a focus on firefighting when women are in crisis, rather than investing in preventative measures or treatment at earlier points of potential intervention. Two findings have practical implications. Firstly, designing effective diversion programs requires a critical focus on the 'system' element. Identifying and diverting women with complex needs from the criminal justice system is insufficient without a comprehensive system addressing their underlying issues. Secondly, support systems should be tailored to individual needs, emphasising flexibility rather than rigid pathways. This involves expanding eligibility criteria, improving service coordination, and implementing proactive, preventative outreach before a woman reaches a point of crisis. Further research is required to understand intersectional and gender-responsive considerations in the development of programmes designed to support women with complex needs.

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