Right to independent advocacy

There has been debate over the advantages, if any, of the Mental Health (Scotland) Act 2003 compared with the Mental Health (Scotland) Act 1984. One of its introductions has been the right for any patient with a mental disorder to access an independent advocate, ‘a person who enables the patient to express their views about the decisions being made about their care and treatment by being a voice for the patient and encouraging them to speak out for themselves’ (Scottish Executive, 2005). It is noteworthy that this definition of the remit of the advocacy workers precludes the peddling of an anti-psychiatry agenda independent of the wishes of the patient. However, as advocacy workers are employed by organisations not directly funded or run by the Health Board or local authority, their activities are not open to the scrutiny of the Mental Welfare Commission for Scotland which refers complaints to the commissioning agency.

In principle, independent advocacy for vulnerable people who may have communication difficulties is an excellent idea but in practice it can give people with no health service training the opportunity to pursue a mission to find fault with services regardless of the welfare of the patients. Some advocacy workers misrepresent themselves as working for the benefit of the patient when their stated purpose is to assist them in expressing views about care and treatment decisions, however harmful or self-destructive these views may be. In contrast, all professionals who make up the multidisciplinary team are employed for the health and welfare of the patient, and are bound by codes of ethics and ever-increasing demands for evidence, accountability and governance.

Unnecessary interference with the patient's confidence in the service being provided undermines the trust which is so often crucial in a therapeutic relationship, whereas cultivation of suspicion and mistrust can leadtoan increase in aggressive and threatening behaviour towards psychiatric staff. When deescalation efforts by staff are then impeded by advocacy workers, either because they are enjoying the spectacle or because they see it as part of the patient's right to be freely abusive and threatening to staff, their presence moves from being unhelpful and time-consuming to being dangerous. Do other organisations employ skilled professional staff to perform a function and then employ unskilled, untrained staff with a remit to undermine that function and to foster hostility and mistrust? I suspect that businesses interested in profit would not seek to damage consumer confidence and satisfaction by provoking complaints and creating an atmosphere in which morale and productivity will decline.

When time has been spent with someone who has severe communication difficulties to ensure that their views are properly represented it is occasionally possible to see why independent advocacy is considered in principle to be beneficial and why some of the individual practitioners of the function are an asset to the service, usually when they do not adhere too closely to their stated remit. Unfortunately, the damage to therapeutic relationships and interactions, and to the planning and implementation of treatment programmes means that any benefits are greatly outweighed. Until there is a major revision of the Act with significant input from clinicians, it is to be hoped that the aims and methods of advocacy services are redefined to minimise the damage to the health and welfare of the people for whom they are supposed to speak.