Advocacy is a process or intervention that ensures vulnerable people have a voice within services that are characterised by power inequalities between providers and users. Mental heath issues, and the social and statutory service response to them, can mean that individuals can find it difficult to speak up for themselves and be heard. This can impact on decision-making and the opportunities to exercise choice. It can also result in marginalisation and social exclusion and place an individual’s rights in jeopardy.
In addition to this, people from minority ethnic communities may also experience racism and discrimination. For people from specific ethnic minorities, notably African and Caribbean communities, this means diversion to less restrictive services, reducing the risk of admission and detention under the Mental Health Act or via the criminal justice system. For other communities, for example Chinese communities, it means increased engagement and access to support, as people from these communities are typically under-served by mental health services.
There is a growing body of evidence for the negative relationship between mental health services and African and Caribbean men. This negative relationship can result in a lack of inclination to seek help or comply with treatment, leading to relapse and readmission and further social exclusion. The Better Health Briefing on African and Caribbean men and Mental Health from the Race Equality Foundation provides an overview of the key issues and examples of positive service developments.
This evidence provides information on the role of advocacy and addresses:
● The failure of services to understand and meet needs, including misunderstanding of African and Caribbean modes of self-expression.
● Fear and expectation of negative treatment, including not having needs understood or met, being stereotyped or ignored, concerns about treatment (particularly medication), detention, leave arrangements, day-to-day living, access to appropriate treatment and practical support.
● Low uptake of services and less desirable pathways into care.
● Lack of awareness of mental health and service provision.
● Lack of choices in relation to treatment offered – for example more likely to receive physical treatments and less likely to get psychotherapy.
● Experiences of coercion, discrimination and racism in mental health services.
● Social disadvantage and exclusion, particularly homelessness, poor housing, unemployment and over-representation in prison.
Assessing need for mental health advocacy is an essential task for both commissioners and providers. This assessment ensures that the services provided meet needs effectively, and do not disadvantage particular groups. This process needs to:
● Ensure that the heterogeneity and diversity of need of BME communities is understood.
● Draw on existing data to illuminate the need for mental health advocacy.
● Build on methods, particularly community engagement, to develop a detailed understanding of needs in relation to advocacy, barriers and facilitators to service use and preferences for service provision.
● Critically examine the extent to which mainstream mental health advocacy services are meeting the advocacy needs of people from diverse local communities.
Evidence suggests that commissioners need to adopt a strategic approach to the development of mental health advocacy ensure equality of access through investment in building capacity engage service users and communities in commissioning and provide sustainable funding for advocacy.
Reflecting local needs
Funding and commissioning of advocacy provision needs to reflect local demography, ethnic diversity and need. The provision of mental health advocacy with African and Caribbean communities will therefore differ, for example between city, urban and rural areas as the population of African and Caribbean communities varies. This implies:
● In urban areas where there are larger African and Caribbean communities, it would make sense for mental health advocacy to be provided as part of African and Caribbean mental health services.
● Where the population is much smaller but there are other, larger ethnic minorities, advocacy could be provided as part of a ethnic minority mental health service or advocacy-focused organisation.
● In rural areas where the population and demand from African and Caribbean communities is likely to be small, mental health advocacy could be provided as part of a generic mental health advocacy service. Alternatively, the area could be covered by outreach from an African and Caribbean mental health advocacy service in a neighbouring urban area.
In arriving at a decision, commissioners will need to map provision to need and available resources. They will need to demonstrate a clear relationship between demographic profile, needs and the service provided. But a focus solely on numbers must be avoided and whatever the population size, arrangements will need to be in place to ensure culturally appropriate provision for African and Caribbean men. This is pertinent to secure services where African and Caribbean men in general might be over-represented but will find themselves in the minority.
The diversity of needs, demand on mental health services, the over-representation of African and Caribbean men and women (and indeed under-representation of other groups) within mental health services and pathways into services also need to be considered. The engagement of communities and mental health service users in this process is essential.
● Resource guide 10: Commissioning and providing mental health advocacy for African and Caribbean Men.
● Knowledge Review 15: Mtetezi – Developing Mental Health Advocacy with African and Caribbean Men.