Advocacy Awareness Week 2021 – Interview with Senior Independent Mental Health Advocate Kerryn Davey

For Advocacy Awareness Week 2021 we wanted to speak to some of our advocates that work alongside people in secure hospital settings. They often support people in difficult and traumatic circumstances where a person may have been sectioned under the Mental Health Act. We wanted to show the vital work advocates do in these situations and spoke to Senior Independent Mental Health Advocate Kerryn Davey about her role.

Could you tell us a bit about how you work alongside people in your role as an Independent Mental Health Advocate (IMHA) including the different ways you support people and what your focus tends to be as an advocate?

I work across medium and low forensic (secure) services for adults as well as the inpatient Child and Adolescent Mental Health Services (CAMHS), for those aged 12-18. This means I work with a range of individuals, from young people who are often in hospital for the first time, sometimes under a Mental Health Act (MHA) Section or informally, to adult patients who may have spent many years in a secure hospital environment. The people I work with have a wide range of needs and it is important that as an advocate, I tailor the service to meet these needs, taking into account how the individual is able to access and engage with it.

With the young people of the CAMHS service, much of my work is around supporting them with understanding their rights under a MHA Section, or understanding what it means to be there informally. When young people come into hospital, in addition to often being acutely unwell, they are perhaps away from home and their families/caregivers for the first time. With this group, I aim to work in way that provides them with reassurance that there is an independent adult there just to listen to them and help get their thoughts and needs heard by their care team. Because of their age, young people have limited rights to their own decision-making and can often feel powerless in an already frightening situation. My main focus is to support them to feel empowered over the elements they can have input into, such as utilising their appeal rights, attending and engaging with ward rounds and ensuring that they have an avenue to have their views heard.

At a time when a young person feels like all decisions have been taken out of their hands and that everything they say and do is being scrutinised by their team, advocacy needs to be available. As an advocate we’re able to give them that space to talk and work things out without them feeling judged or being told their perception of the situation is incorrect. When working with young people, it is really important for advocates to be a regular, visible presence on the ward so that they become familiar with the individual and can develop a rapport. Many young people will have social care involvement, may not be living at home and could have experienced many professionals coming and going and can be reluctant to open up to yet another new person. As a result, becoming a reliable, familiar face is a really important part of the role.

When working across medium and low secure services, whilst I employ the same principles of advocacy, my approach can be quite different. Many patients, some of whom have been in hospital several years, will have a clear understanding of advocacy and what support the service can offer, as well as a thorough knowledge of the mental health hospital system. Other patients may not have used advocacy before or not felt that there was anything an advocate could do to help them. It is those patients less familiar with advocacy in particular who will benefit from a thorough introduction to the service, as well as regular reminders at Community Meetings or drop-in sessions on the ward.

Whilst I do some work with these patients around their rights under MHA Section, I support people more around getting their views heard in relation to their care plans and the pathway they are on. That can relate to working towards discharge or be around changes they would like to see within the wards or to hospital policy and procedure. Common issues that arise are gaining leave, working towards discharge, access to restricted items such as mobiles, the internet or e-cigs, available activities and therapies and views on staff practice. Because many patients will be in hospital for a while, they often wish to raise more issues relating to their day-to-day experience than young people who tend to be on a shorter admission and less invested in this. I find one of the most important things to focus on with this client group is fostering hope. Many people who have been in hospital a long time lose hope that things will change, or that they will be listened to and advocacy can often support them to look at options or approaches they have not considered previously.

As an IMHA you work alongside people in a low secure facility at Nottinghamshire Healthcare NHS Trust who may have experienced trauma and mental distress and will often have been sectioned under the Mental Health Act. What are some of the things you’ve learned from your time as an advocate on engaging with people at a difficult time for them?

Within both the secure environments and the CAMHS ward, I work with many people who have experienced trauma – especially in women’s services – and the majority of those I work with have been detained in hospital under MHA Section. Many young people will be experiencing a high level of mental distress as they have come into hospital when acutely unwell and often for the first time. With adult patients, many will go through periods of mental distress throughout their admission, but will have more settled periods in between.

The levels of mental distress or acuity of the mental illness can have a major impact on an individual’s ability to engage with me in that moment. That means it is really important to gauge the distress their experiencing and to try to modify the way I am behaving accordingly. For example, sometimes an individual may find a cheerful and upbeat approach uplifting and friendly, but then at other times they might take this as lack of acknowledgement of their distress and the situation. Also, like all of us whether in hospital or not, people will have days where they just don’t want to talk to anyone. It is really important to keep coming back to offer, though never impose, support and to meet with the individual at a time they feel able to and working to their schedule rather than mine. For example, many of the teenage young people I work with are fond of day-napping and I have rarely had a successful session with someone I’ve had to wake up to talk to!

I have also learned the need to balance sensitivity with being direct and realistic. It is not my place to tell someone their view or wishes are wrong or unwise, or to pass any judgement. However, I also have a responsibility to be factual and realistic when presenting someone with the outcomes that are likely to come from the choices they make. By developing a space for discussion around why someone has the view they do, I can often encourage them to look at alternative explanations or ways of considering an issue. That can be particularly helpful around topics like diagnosis and medication to provide insight on how clinicians may view certain behaviours differently to the person and therefore why they may have reached the conclusions they have. It may well be they feel the same way they did at the start of the conversation, and if that is the case I will respect this and ensure their view is heard by their teams. That is my approach even when I know they are unlikely to get the outcome they want, because ultimately my role is promote their choices, not decide what is best for them. I have also learned that an individual’s views and their perspective on being in hospital can change greatly over the time they are in there. Those views can be dependent on the mental state they are in at a particular time and so I would never base my work with someone solely on the way they have used the service before.

An important part of Together’s approach to mental health support is service user leadership and that feels especially important in advocacy work to ensure a person’s voice is heard and they are fully involved in decisions relating to their rights and access to care. Could you tell us about the process of ensuring the person is fully involved in that process and looking to empower them to do so?

It is important to note that as an advocate, I will only work with someone who wishes me to do so. To decide that someone needed my help whether they wanted it or not would be the very antithesis of the role! The first step in supporting someone to voice their views about their rights, care and treatment is to see what support, if any, is necessary for them to be able to do so. For some people, it may be that they can to articulate their views well but just need a little help organising what they want to say and their thoughts in advance. For others, they might struggle to speak for themselves in front of health or social care professionals and may require an advocate to support them to put together their views and then communicate them to others. Throughout my work with a patient, my aim will be to empower them to build self-advocacy skills so that they can work towards having the confidence to express themselves effectively. I believe this is a crucial life skill that should hopefully benefit them beyond their time in hospital so they can be more independent situations in the future when they may not have an advocate at their disposal.

When working with someone, I will highlight the various ways they can be involved in their care. Some of those include engaging in named nurse sessions, attending ward rounds and Care Programme Approaches. Within those, they should always be offered the chance to chair their own meeting, and to give their own ‘report’ made up of their own feedback about how they think their care and treatment is going and how things have been for them since the last meeting. When it comes to voicing opinions about ward/hospital rules and environment, I would encourage individuals to attend their ward community meetings and any patient forums that are available. Within our service, advocates regularly attend community meetings and patient forums to lend support to those who find it more difficult to speak in front of others.

I will often work with people who tell me there is no point in them engaging with their care as they feel nobody listens to them anyway and that it won’t make any difference. It is always disappointing to hear when someone feels their team are not listening to them. In that situation, I will explore with the individual ways that they can interact with their teams differently or more effectively. We will also consider ways they can tangibly assess whether their teams are hearing them and whether they feel they are getting reasonable responses to their requests. Regular advocacy sessions are beneficial for some so that the advocate can support them to reflect on progress made and areas that they are still waiting for answers on to then provide support to chase things up. It is vital to keep people motivated towards being involved in their care as decisions about their support and treatment will be made with or without them. They have a greater chance of it meeting their needs and suiting their wishes if they have been involved in and fed into the decisions.

Recent reforms to the Mental Health Act looked at prioritising access to advocates for people in mental health services and a recent campaign called for access to advocate to become an opt out basis ensuring everyone has access and that it is properly funded. What are some of the reasons you think access to advocacy support should be made more widely available?

Most of my work is as an Independent Mental Health Advocate (IMHA), which is the provision of statutory advocacy to those detained under the MHA. Because provision of an IMHA is part of someone’s rights under the MHA, these are usually sourced for those who need it, as there is an obligation on the detaining body to provide this. That provision will depend on what the service has been able to fund and so it may range from advocates not based on site that only liaise with patients when referred, to more like how our Together services operate.

At the services I work at, we have advocates based at the services of the people we support who will attend community meetings and other wider hospital events. I would love to see every inpatient service receiving funding to have onsite advocates provided by an independent organisation, as I believe this is the gold standard for advocacy. We are accessible and build rapport with patients, which means technical teams get used to us supporting them, rather than being someone who just appears from time to time. Having advocates as a regular presence helps contribute to a culture of listening to the patient. I also feel there needs to be serious consideration to funding advocacy for those not detained under the MHA. In the difficult times we’re all facing with an increased need for mental health services, which is not being matched by increased provision, many people in the community do not know where to turn to get the help they need.

I believe that if people that needed to access mental health services had advocates to support them and ensure their views could be heard on what their needs are it would help them engage with professionals at difficult times. We could then form part of a more robust preventative system that could help to support them so they didn’t need to end up in hospital at all. It’s worth noting also that there is very little availability by way of advocacy for carers of people in hospital and they may also need support to raise concerns about their loved-one’s treatment.