To advocate is to speak on behalf of someone else. Peer advocacy, as defined by the UK Advocacy Network (UKAN), is “support from advocates who themselves use or have used mental health services” (Reference ConlanConlan et al, 1994). This is an important provision, especially for those detained under a section of the Mental Health Act because of the powers given to staff. Under these circumstances advocacy is valuable, and has an important ethical function (Reference Thomas and BrackenThomas & Bracken, 1999). Peer advocates are independent of mental health service staff and have usually had first-hand experience of using mental health services themselves. They can therefore be seen as working for the patient rather than the staff. UKAN has written a Code of Practice for advocates, defining peer advocacy:

At present psychiatric patients only have access to advocacy if they specifically request it, a method of recruitment that tends to reinforce the paternalism of mental health services, which advocacy is there to challenge. For this reason it has been argued that new mental health legislation should include a statutory right to advocacy as part of the principle of reciprocity, given that compulsory treatment in the community represents a significant erosion of civil liberties. The Green Paper proposing reform of the Mental Health Act recommends that a “statutory right to advocacy is created at the earliest opportunity”, specifically for those “subject to compulsory powers” (Secretary of State for Health, 1999). If implemented, this would have significant resource implications and result in changes to the way mental health services manage compulsory patients. The difficulty is that there is a belief that advocates are ‘anti-psychiatry’ and undermine the work of mental health professionals (Reference GambleGamble, 1999). Such negative attitudes are likely to stand in the way of any potential benefits of advocacy, so it is important that we clarify the attitude of psychiatrists and other mental health professionals towards advocacy. For this reason we interviewed junior medical and nursing staff to establish how much they knew about advocacy, their attitudes towards it and the effect it had on their practice.

Methods

Five senior house officers (SHOs) in psychiatry, five staff nurses working on an acute psychiatry in-patient unit in Bradford and four community psychiatric nurses (CPNs) were invited to participate on the basis of their availability at the time of the study. Nobody declined to be interviewed. These three groups were chosen because they represent the staff groups most likely to encounter mental health advocacy in their daily work. They are also the groups who have most contact with patients, and are thus in a good position to be able to discuss the role that advocacy may play in patient care. The junior doctors had worked in psychiatry for between 12 and 36 months. All the participants were interviewed by means of a semi-structured interview to establish their knowledge of advocacy, their experiences of it and their opinions about it. These key issues were represented by a series of questions (Appendix 1) to enable the subjects to explore the issues as fully as possible. These questions were formulated following discussions about the training and work of advocates with the manager of the Bradford and Airedale Mental Health Advocacy Group, and the co-chair of UKAN.

UKAN is the principal organisation in this country that has taken a lead in developing and extending the work of peer advocacy (that is, advocacy for patients by people with experience of using mental health services), although some advocacy services are provided by other organisations such as Mind and the National Schizophrenia Fellowship. UKAN has produced a Code of Practice for advocates (Reference ConlanConlan et al, 1994), as well as a training manual. Training is patient-led and deals with the Mental Health Act, patient rights and the principles of advocacy, as well as local issues. There is no qualification for advocates because UKAN considers that this may discourage those who have the potential to be good advocates, but who may have anxieties about formal study. UKAN acknowledges that there is much national variation in the way in which advocates are trained. The Bradford and Airedale Mental Health Advocacy Group, who are responsible for training the advocates that staff in this study would have encountered, offers a 30-hour course over 15 weeks, which involves external speakers (P.T. has spoken about the role of the consultant psychiatrist in mental health services), videotapes, role play, visits to the local psychiatric hospital and case discussions. The group uses the UKAN Code of Practice and training manual.

The SHOs were interviewed by Y.L. in the junior doctors' mess, and staff nurses in interview rooms on the in-patient unit. The CPNs were interviewed in the resource centres where they worked. No names were recorded, to allow anonymity, so the subjects felt more at liberty to speak openly. The interviews with the SHOs were conducted when there were as few people around as possible, and those with nurses in total privacy. Each interview lasted up to 10 minutes. Ideally interviews should have been tape recorded, but shortage of resources meant that it was not possible to transcribe and analyse the interviews, so written notes of subjects' comments were made instead. The notes were subsequently examined by Y.L. using a simple form of content analysis in which the keywords and points made for questions 1-4 and 7-9, and all details recorded for questions 5 and 6, were extracted (see Appendix 1). These were summarised by profession to compare each group's responses. This made it possible to compare the subjects' knowledge with the way in which advocates were trained and worked locally. A part-time advocate working on the in-patient unit for Bradford and Airedale Mental Health Advocacy Group was interviewed to find out how he felt staff understood his role, his experiences of working with staff and his opinions on the impact of advocacy for staff and clients. He was interviewed in an interview room on a ward in Lynfield Mount Hospital.

Results

Discussion

The study was limited in that we were only able to interview 14 subjects on the basis of their availability at the time. We have no way of knowing how representative the views and experiences presented here are of their colleagues, either locally or nationally. The results do suggest that larger national comparisons are indicated, especially given the high level of interest in advocacy at the moment. Only two of the staff interviewed had no experience of working with advocates and seven said they had much experience. Bradford and Airedale Advocacy Group has a part-time advocate working at Lynfield Mount Hospital and others work in the community. In defining the role of the advocate, most subjects regarded objectivity and representation as key points. Relatively little was said about enabling clients to speak for themselves — the key objective as far as the advocate was concerned. There was also a poor level of understanding of the background, training and Code of Practice of advocates. Despite this, experiences with advocates were generally positive and advocacy was seen as helpful to both staff and clients. This was confirmed by the advocate, who felt that most staff were positive about his role. Despite this, there were fears that advocates might work to their own agendas and thus cause problems for staff. The advocate acknowledged this as a potential problem if advocates do not adhere to the Code of Practice but in his view this is rare and advocacy services usually detect such individuals and deal with them.

Some subjects, especially staff nurses, expressed the idea that advocacy involves mediation between staff and patients. Mediation implies acting as a go-between for two parties in dispute, in which case an advocate would be expected to represent both the professional's and patient's positions. The UKAN Code of Practice states quite clearly that this is not the role of an advocate, and stresses the representation of the patient's position. This accords with the advocate's experience that some staff nurses did not understand this role. There was also a suggestion that advocates bring their own opinions into clinical situations, despite the fact that advocates are specifically trained to represent the patient's view and not their own. Campbell and Lindow (Reference Campbell and Lindow1997), in a publication for the Royal College of Nursing, point out that nurses should “understand the difference between acting in the person's best interest and acting to enable the person to say what they want”. This distinction is important. By representing the client rather than trying to work in their best interests, or mediating between staff and clients, advocates are combating the “dangers of unchecked medical paternalism in psychiatry” (Reference Thomas and BrackenThomas & Bracken, 1999).

Although SHOs made some negative comments, there was no evidence of widespread fears that advocates would “promote their own anti-medical establishment political agenda” (Reference GambleGamble, 1999). We have worked hard in Bradford to establish good relationships with local user groups, such as Mind and the Bradford and Airedale Mental Health Advocacy Group. These efforts have been rewarded by the active involvement of patients in the locally organised training scheme for SHOs (P.T. is one of the college tutors). In the academic term preceding this study (Autumn 1999) patients gave presentations on advocacy, self-injury and electroconvulsive therapy to the postgraduate psychiatrists in Bradford. The junior doctors interviewed here had probably had more exposure to patient perspectives than their colleagues elsewhere, yet despite this there is clearly room for improvement in their understanding of advocacy. In general, there would appear to be no grounds to be sanguine about psychiatrists' attitudes towards advocacy, and in view of the increasing prominence that advocacy will play in the future it is essential that the Royal College of Psychiatrists takes steps to ensure that all junior doctors are exposed to advocates in their training.

Appendix

What do you know about advocacy?

1. 1 What is the role of an advocate?

2. 2 Who are advocates?

3. 3 How are advocates trained?

4. 4 What do you know about their code of practice?

Experience with advocacy

1. 5 Have you had any experience of working with advocates?

2. 6 If yes, could you describe an example of a situation where an advocate was involved?

Opinions about advocacy

1. 7 Is advocacy helpful to staff?

2. 8 Is advocacy helpful to clients?

3. 9 Is it unhelpful at all?