SCIE Guide 21: Commissioning and providing mental health advocacy for African and Caribbean men

Providing advocacy services: Translating principles into practice

1. Culturally appropriate advocacy

It is self-evident that advocacy services have to be culturally sensitive. It means:

Framing advocacy in a way that is relevant to black minority ethnic (BME) communities and ensuring that the way in which advocacy is defined does not inadvertently disadvantage BME communities.
Identifiable and sustainable investment to meet the advocacy needs of these communities.
The opportunity to have an advocate that shares your cultural heritage.
That the advocacy service has roots in the community and an understanding of discrimination, racism and black history. This will build confidence in the ability of the service to accurately listen, understand and act on the service user’s behalf.

2. Independence from statutory provision

Independence from service provision is a guiding principle for the majority of mental health advocacy services, reflected in the standards and guidelines for mental health advocacy. It is important to qualify this as independence from statutory provision, as provision for African and Caribbean men is often provided as part of a broader range of services, developed by community organisations.

3. Increasing access

A proactive approach is needed to engage with African and Caribbean men on their terms. This means developing advocacy services that are accessible to – and visible in – the local community. Strategies to increase access can be further developed by engaging service users and the community in the process. In addition, the following strategies are important:

The distinctive African and Caribbean identity of advocacy provision through the profile of the staff, and being in the same place as mental health services serving African and Caribbean or BME communities. The co-location with other interventions and forms of support that promote personal development and empowerment also facilitate the uptake of advocacy.
Messages targeted at African and Caribbean men and their communities to enable them to access and make use of advocacy services. Key messages are:
- advocacy means speaking up for yourself (self-advocacy)
- advocacy services are independent of mainstream mental health services and are culturally appropriate
- advocacy services exist to protect people’s rights in relation to the mental health system and to support people to access the most appropriate treatment and support
- that what happens between you and the advocate is confidential.
Mental health trust staff providing information on advocacy, its value and how to access it. This should happen on admission and be supported by written information. Staff need to be aware of and demonstrate an understanding of the importance of advocacy in relation to critical decisions, such as hospitalisation, detention, treatment and medication, and discharge arrangements.
Having service level agreements or contracts in place with advocacy services that are capable (with demonstrable evidence) of delivering culturally specific advocacy for African and Caribbean men.

4. Promoting choice

Choice is an important principle. However organisations often find themselves constrained by capacity and, as a consequence, unable to offer real choices. Service users often (but not always) express a preference for choice in terms of ethnicity and gender. Some men will also have definite preferences in terms of sexual orientation or whether the advocate has experience of using mental health services. However, it is also clear that the quality of relationship between advocate and partner is important.

Choice is a particularly pressing issue in secure services, where access to more broadly-based community resources can be severely limited. Advocacy provider organisations contracted to serve secure mental health units should be staffed appropriately, to take account of the over-representation of African and Caribbean men in these services.

Ideally there should be the opportunity to access different types of advocacy and at least the potential for self-advocacy, casework and collective advocacy.

5. Promoting choice and protecting rights

Advocacy needs to be available at times when African and Caribbean men are facing critical decisions. This applies particularly at the following times:

First point of contact with mental health services, in order to support an individual in seeking accurate information about care and treatment, and gaining access to appropriate services.
During detention under the Mental Health Act, to:
- help people understand their rights, what is happening, why they are being detained and their care and treatment
- support and help people engage with care planning
- help prepare and debrief people for Hospital Manager’s Hearings and Mental Health Review Tribunals
- plan discharge arrangements.
Appointments and meetings with key personnel such as consultant psychiatrists and care coordinators, to discuss treatment options, leave arrangements and moves to alternative treatment facilities.
In relation to seclusion and restraint by supporting appropriate care and treatment.
Advocacy interventions will be enhanced by being built on an existing relationship of trust. Solely providing advocacy at these key times is unlikely to be successful.

6. Promoting self-empowerment

A major aim of advocacy is the empowerment and self-determination of individual advocacy partners. This will be facilitated by:

Prioritising and promoting self-advocacy.
Access to peer advocacy.
Service user involvement in the management and delivery of advocacy services.

7. Ensuring competence and capacity to deliver

Advocacy providers need to ensure that they have the capacity to provide a quality service. This means:

adequate staffing, with staff who have advocacy as their main role
access to appropriate training and supervision that includes providing advocacy for black and minority ethnic communities, as well as other minority groups. Training should also equip advocates with the interpersonal resources. This will help advocates cope with difficulties in the relationship between advocacy and mental health service providers and their staff. It will also help advocates understand how best to promote positive changes on behalf of the advocacy workforce. The development of a national qualification in advocacy is underway and the Department of Health has commissioned the development of training materials to support this. Capacity-building organisations, such as Action for Advocacy, also provide training and information on training that may be relevant. Many advocacy providers, particularly those in the black and community voluntary sector develop their own training. See for example Link: The Advocacy Project, Liverpool.
understanding and knowledge of African and Caribbean dialects, languages and cultures
understanding of discrimination and how to tackle racism, including institutional racism
access to supervision to ensure practice development and the provision of a quality service
standards of good practice. These have been developed but in general have little to say about specific provision for BME communities, and therefore may need to be adapted. The following are particularly worth looking at:
- Kapasi, R., and Silvera, M. (2002). A Standards Framework for Delivering Effective Health and Social Care Advocacy for Black and minority ethnic Londoners. King’s Fund: London
- A standards framework for delivering effective health and social care advocacy for black and minority ethnic Londoners. This is a tool that offers a set of standards for health and social care advocacy for BME communities and a process for implementing them. It can be used by advocacy providers, commissioners, and service users to develop a code of practice, as a good practice checklist, or as a guideline for developing services. It is underpinned by an inclusive approach that aims to bring advocacy for BME communities into the mainstream. It provides a basis for quality assurance in relation to advocacy provision for African and Caribbean men.
- Action for Advocacy (2006), Quality Standards for advocacy schemes. Based on the Advocacy Charter, this provides a set of quality standards for advocacy organisations and a code of practice for advocates. These also provide a basis for quality assurance but will need some adaptation to ensure that they are suitable for advocacy providers in the black community and voluntary sector.

8. Monitoring and evaluation

Advocacy providers need to ensure that data on service usage by ethnicity are routinely monitored and evaluated. In addition, data on outcomes needs to be collected and the previous section on outcomes provides a basis for negotiation with commissioners.