brainscanIndependent mental health advocacy is about more than just an exercise in placating people with mental ill health, it can empower them. In this article, a group of leading mental health experts draw upon a 1952 paper by Erving Goffman, to provoke some critical thinking about the value of independent advocacy within modern mental health services:  

We start from a position that is appreciative of the efforts of practicing advocates and other supporters of advocacy in their struggles to establish access to independent advocacy for people compelled into treatment or detention in mental health facilities.

Advocacy is vital for ensuring that vulnerable people can get their voice heard and have their rights protected. But we do suggest that some of advocacy’s more transformative potential might be constrained, undermined or subverted in practice for various reasons.

At its best, advocacy has a crucial role in empowering people to become active and autonomous participants in their own care. Furthermore, advocacy can be seen to positively affect the very social space of mental health services, promoting rewarding and constructive relationships and opening up services to more equal and respectful communications. With the support of skilled advocates, patients detained under the Mental Health Act 1983/2007 in England and Wales can be enabled to increasingly master their own destiny, engage in shared decision-making about their treatment and progress through the mental health system. Similar arrangements have been in place in Scotland since the implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003.

In its ideal form, independent advocacy is associated with a democratisation of the social relations of care, and it is deserving of credit for its contribution to emancipatory goals. Even operating in circumstances where personal agency is very much curtailed by less than ideal environments, independent mental health advocacy helps to highlight different options and engender hope for people with limited rights and freedoms. For instance, having an advocate present can influence the behaviour of mental health staff, prompting more respect and honesty.

Tangible outcomes of advocacy
In a study of independent mental health advocacy in the UK (Newbigging et al, 2012a; Newbigging et al, 2012b) we explored the complexities of organising and delivering advocacy, the support and reception advocacy receives in services and the difference that it makes to the lives of service users. One particular thing we found was that many service users valued advocacy without necessarily achieving the outcomes they were looking for.

A distinction can be drawn between beneficial tangible outcomes on the one hand, and gains that are associated with the process or experience of advocacy on the other (see also Townsley et al, 2009). The latter are often a consequence of positive aspects of the advocacy relationship, such as being consistently respectfully listened to.

People relying on advocacy might not get exactly what they want but end up feeling better because of the experience of the advocacy process, or they manage to achieve some part of what they asked for, if not all. In effect, people can get their voice heard but this might not make a significant difference to the exercise of clinical or judicial power.

'Confidence tricks'
In one of his earliest papers, Goffman’s classic insight was to suggest that, while life was full of disappointments, society had developed some interesting processes for helping people adjust to their troubles and these could be illuminated using the metaphor of the ‘confidence trick’. In the classic confidence trick, key members of the ‘grifting’ team, skilled in conciliation, would remain on the scene after the ‘sting’ and intervene with the hapless ‘mark’ so that s/he would not cause too much fuss. These personnel are deployed to ensure that the confidence tricksters can exit the scene quietly, creating as few ripples as possible in the social fabric while simultaneously allowing the victim to ‘save face’. This is essentially an exercise in consolation: hence the argot ‘cooling out the mark’.

Goffman identified professions such as psychotherapy as part of a broadly-based ‘cooling out’ enterprise within society, along with priests, friends, workplace supervisors and shop assistants; more or less anybody who may have occasion to pacify individuals struggling to adapt to failure, loss of a social role or sense of self.

Mental health advocacy, in these terms, comprises interventions which are designed, or effectively operate to, placate individuals who are upset by their perceptions of inadequate care and treatment. As such, independent mental health advocacy could be perceived as helping detained psychiatric patients to adjust to their disappointments and multiple losses, such as liberty, social role and identity.

Increasing rates of psychiatric compulsion
Ultimately, this might make detention or treatment more bearable, returning the mental health system to a stable status quo. In this sense, arguably, independent mental health advocacy might potentially function as a conservative, rather than emancipatory force, merely enabling individuals to acclimatise to the liberty-curtailing features of psychiatric regimes.

Keeping alert to the possibility that a satisfying experience of advocacy may well also have helped to keep a lid on legitimate grievances is a valuable strategy, and one that could energise us all to do more to challenge or resist the oppressive features of psychiatric services. Whatever the case, at this time of ever increasing rates of psychiatric compulsion in the UK (Bentall, 2013), it would be unwise to dismiss advocacy as a mere sticking plaster.

Instead, we propose a more considered and critical view of its practice and effectiveness in tandem with greater effort to deliver independent mental health advocacy services that are properly supported to empower those individuals who are currently so disempowered within services.
Without a critical approach such as this to independent mental health advocacy and without efforts to realise some of its more emancipatory potential, one wonders whether we will simply be, perhaps in perpetuity, cooling the mark out.

About the authors
- Dr Mick McKeown, School of Health, University of Central Lancashire
- Dr Dina Poursanidou, honorary research associate, University of Manchester, Centre for Women’s Mental Health
- Laura Able, member of the IMHA research team
- Karen Newbigging, senior lecturer, School of Social Policy, University of Birmingham
- Julie Ridley; senior research fellow, School of Social Work, University of Central Lancashire
- Michelle Kiansumba, research and training assessor, Intraining

References
Bentall R (2013) Too much coercion in mental health services. The Guardian 1 February. Available at: http://www.theguardian.com/commentisfree/2013/feb/01/mental-health-services-coercion (accessed November 2013)
Goffman E (1952) On Cooling the Mark Out: Some Aspects of Adaptation to Failure. Psychiatry 15 (4) 451–463.
Newbigging K, Ridley J, McKeown M, Machin K, Poursanidou K, Able L, Cruse K, Grey P, de la Haye S, Habte-Mariam Z, Joseph D, Kiansumba M & Sadd J (2012a) The Right to Be Heard: Review of the quality of independent mental health advocate (IMHA) services in England. Research report. Preston: University of Central Lancashire.
Newbigging K, McKeown M & Machin K (2012b) The right to be heard: independent mental health advocacy services in England. Mental Health Today, September/October, 24–27.
Townsley R, Marriott A & Ward L (2009) Access to Independent Advocacy: An evidence review: Report for the Office for Disability Issues. London: HM Government Office for Disability Issues.

Disclaimer: This study was funded by the Department of Health Policy Research Programme. The views expressed are not necessarily those of the Department.