"A lot of people don't understand the mental health system until they encounter it themselves."

All it can take is for someone to say they are unwilling to go along with treatment and try to walk out the door, to find they are prevented from leaving, Ms Carr said.

"They will say to the advocate 'I came in here because I was asking for help - I volunteered to come to hospital'," she said.

There were not enough advocates in those people's corner, a new report into the Independent Mental Health Advocacy service has found.

The RMIT report has called for everyone forced into treatment to have access to an IMHA advocate through an opt-out system, as well as a funding boost to help those slipping through the cracks.

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The main issue for the IMHA advocates covering five mental health services out of the Bendigo office was the tyranny of distance, Ms Carr said.

"From Bendigo we are dealing with the big empty top half of Victoria," Ms Carr said.

"We do the best we can, and we try to get there when we can, but there is a limitation because of the resources we have got."

In some parts of the region advocates can only arrive at hospitals every six weeks and they are forced to rely on phones to work with clients.

On average patients stayed in mental health inpatient units for about a week, study author Chris Maylea said.

"So if you've only got an advocate coming in every few weeks most people aren't going to have access to them. That was really our key finding, that there needed to be enough advocates so that everybody has access to one," he said.

When people finally made their way to mental health hospitals they were in the midst of a chaotic period in their life, often one in which bridges with family members were burnt or at least badly damaged, Ms Carr said.

"So there is this sense of isolation in which they feel everyone is against them, including those who would usually be there to support them," she said.

"My feeling has always been that to have an advocate, who by definition is there to be on that person's side to support them ... until they can reform those networks is critical and I believe life-saving."

Patients who had needed advocates since the service started in 2015 really valued them, Dr Maylea said.

"People told us 'having an advocate saved my life' or 'I would still be in hospital if it was not for the advocate',"  Dr Maylea said.

Often, though, it was the little things that patients most valued.

"Somebody we spoke to in Bendigo was quite happy to be in hospital. But he just wanted to go to church and they wouldn't let him out, so the advocate was able to present his case to the doctors," Dr Maylea.

"That was really important to him - and he was able to go to church."

Advocates' work could be challenging, Ms Carr said, in part because of resistance from some medical professionals.

At some services advocates had been made to feel unwelcome, Ms Carr said, and barriers had on occasion been put in place that made it harder for them to help patients.

"I've had the experience myself of being yelled at and dressed down in a psych unit corridor by a nursing unit manager. All we are trying to do is our job to support people to get better health outcomes, but sometimes it's not really seen in that way," she said.

Ms Carr recalled a nurse punching the air in victory in front of one of her clients when a treatment order was upheld.

"Those kinds of behaviors creep in. Though I have to say, that's very much the minority. I think we are moving on from those kinds of behaviours," Ms Carr said.

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In some cases the problem was that rushed poor clinicians were not taking the time to explain everything that was happening, Ms Carr said.

That could include for incredibly traumatic experiences, like being forced to have injections or being placed in seclusion or another form of restraint.

"I don't want to make excuses for mental health services, but they are a scarce resource and they are under the pump," Ms Carr said.

"Sometimes their practice is pretty appalling, really, in terms of making sure they are taking the extra time to support that person to make sure they know what their rights are and support people to be as involved as possible.

"This culture has developed because of issues around shortages of staff."

Changes to the mental health act in 2014 reframed how services were expected to help people be as involved as possible in their own treatment and care, even when forced into medical treatment.

That meant clinicians needed to make sure people were supported, as much as possible, to make their own decisions or to be involved in the decisions being made by treatment teams, Ms Carr said.

"If you can sort of work out ways to work with people, rather than impose things on them against their will, it makes sense that people are more likely to engage better with services," she said.

Advocates worked hard to educate medical staff about how to work better with patients.

That included training programs geared to help bring clinicians along.

"We are showing we are part of a system that can add value for clinical staff, that we can support patients to understand what is going on and what their options are ... and to deal with some of their fears. It's a critical role that can also make clinicians' jobs easier," Ms Carr said.

All services had embraced advocates to some extent over the three years the IHMA had run. Some had done it better than others.

"Bendigo Health is great, their service is very embracing of advocates coming in and out of there service, which we are all the time," Ms Carr said.

"I think they have done a great job in terms of getting on board and enabling us to talk with their staff about making these cultural changes."

Bendigo's health service had some of the lowest numbers of patients put in seclusion or restrained in Victoria, Dr Maylea said.

And while some patients had "mixed experiences" at Bendigo Health, lower seclusion rates seemed to go hand-in-hand with a culture of being more open with advocates, he said.

"The one everybody agrees on with mental health in Victoria is that the system needs fixing, it needs reforming and it needs a new culture," Dr Maylea said.

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