Journal of Mental Health, 2013; 22(6): 570–574 © 2013 Informa UK, Ltd. ISSN: 0963-8237 print / ISSN 1360-0567 online DOI: 10.3109/09638237.2013.841877
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards: What are they, and do they impact on safety in acute ward settings?
SONYA LIPCZYNSKA Institute of Psychiatry, Library, London, United Kingdom
RESPECT http://www.respecttrainingsolutions.co.uk Starwards http://starwards.org.uk/ Press guidelines for reporting suicide in the media, handling dramatic enactments of suicide, etc. http://www.samaritans.org/media-centre/media-guidelines-reporting-suicide Safety on psychiatric intensive care units (PICU) is of paramount importance both for the patients and for the staff. Patients admitted to these units will often be suffering from disorders with challenging behavioural symptoms such as aggression, delusions, paranoia or self-harming and when these behaviours present a threat to other patients and staff on the unit, or to themselves, then a range of containment measures may be put in place including administering of drugs, transfer to a locked ward, or mechanical containment such as net beds, or strapping (although as Bowers et al. (2004) found, these latter practices are disliked by mental health nurses from a range of countries, and in fact, not administered in the UK at all. The implementation of safety and containment policies can have an adverse effect on the well-being and recovery of intensive care patients (Anderson et al., 2013; Dack et al., 2013) increasing the risk of fear, unpredictability and mood swings. To counteract this, recent programmes have been devised and implemented to encourage a more holistic approach. These are care pathways for in-patient mental health care, which practise models of patient autonomy and self-determination, forging alliances with staff and engaging in creative activities. Data suggest that patients can flourish in this kind of environment (Gunasekara et al., 2013; Maguire et al., 2013; Ward & Bailey, 2013), but is there a risk that implementing these programmes could impact negatively on safety measures, or do these programmes actively reduce the instances of containment on a unit? I will be looking at two websites which offer this kind of programme – RESPECT, which originated in North-East Lincolnshire, and Marion Janner’s programme, Starwards, which Correspondence: Lipczynska Sonya, Institute of Psychiatry, Library, De Crespigny Park, London SE5 8AF, United Kingdom. E-mail: [email protected]
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards
571
she devised after her own experiences as a service user on a PICU ward. Additionally, I will be looking at the Samaritans web pages on suicide, particularly those which deal with media reporting and asking if media reporting can have a knock on effect on safety. RESPECT comes from Navigo, a mental health service based in North-East Lincolnshire. The company offers training programmes for mental health staff, which is designed to promote support instead of control. RESPECT focuses on the patient as a person, rather than a problem to be managed – the introductory page explains the ethos as treating patients as you would like your loved ones to be treated. The idea behind the programme, as detailed on the website, is that trainers will train staff members at the relevant institution with the aim that some of those staff members will become certified RESPECT instructors in their own right and thereby embed the programme and practices into the everyday culture of the institution. The website is not just a repository for information about the training programmes but also has short articles about the history, progress and future of the programme. The history of RESPECT is outlined, from its beginnings in 1985, focusing on prevention rather than reaction, changing the culture of care for in-patient mental health facilities and has been developed in consultation with service users. The principles of the programme are also outlined, including an emphasis on “care not control”, giving patients roles, acting proactively, avoidance of labelling and abuse and de-escalating potential harmful or violent situations. There is also a précis and link to a 2009 inquiry by Mind into acute mental health care, which found that patients interviewed want to be treated with kindness, warmth and respect, and detailed their negative experiences with restraining techniques and the effect that this had on their wellness and recovery. Service users are also an important part of the programme, and there is information on how these groups were involved both in the planning of the programme and the teaching of the programme by sharing experiences and perspectives with RESPECT trainees. There are also five case studies where the programme has been implemented in institutions or trusts. For example, Coed du Hall Mental Hospital in Mold, Flintshire, reports reduction in instances of physical aggression after RESPECT training was implemented. So far, this initiative seems to be based in the northern counties, Ireland and the Caribbean. There are details about the four courses available and a contact email, although more information about practical considerations such as costings may also be useful. Similar to RESPECT is the Starwards programme that was set up by Marion Janner, after her experience as a service user. In an article from 2007, Janner invokes the spirit of Philippe Pinel, the eighteenth century French doctor who revolutionised care for mentally ill patients and goes on to talk about the spirit of Starwards that “acute ward stays shouldn’t be characterised mainly by containment and pharmacological intervention. Talking therapies should be a standard provision” (Janner, 2007). She also acknowledges the need for ward safety and identifies the biggest barrier to achieving “freedom within psychiatric care” first pioneered by Pinel as the expectations of both patients and staff. Janner also cites the National Audit of Violence study from the Royal College of Psychiatrists in 2005 which identified boredom as a key factor for outbreaks of aggression or harm in acute wards, as does the study from Ward and Bailey (2013). Janner refers to “fluffy” ideas for improving patient engagement and relationships with ward staff, and the Starwards website embraces this philosophy full on. The text and tone of the website is jokey, informal and occasionally a little bit arch as if someone is nudging you in the ribs while you are reading. Feedback about Starwards communications to members (newsletters, etc.) reproduced in the 2009/2010 Annual report (which can be
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
572
S. Lipczynska
found in the Publications section of the website) shows that some found this approach a little bit difficult, but others felt that it made the whole process of patient care and staff-patient alliance much less intimidating. In terms of content, the core aim of the Starwards programme is a list of 75 suggestions for acute patient care and engagement ranging from bringing animals in and personalising bedrooms to promoting a culture of empathy on the wards. These suggestions are listed on “Wardipedia”, an online encyclopaedia to which members of Starwards are encouraged to contribute, so that underneath each of the core suggestions, trusts and institutions add examples of what they have done to implement the particular suggestion. For example, under no. 56 “mealtimes made special”, real life suggestions include catering staff listening to individual patient preferences, placemat competitions and patients attending food safety courses in advance of preparing a special meal for the rest of the ward. As well as blogs and newsletters that can be downloaded; two other tools available are “Ward Buddy”, a kind of diary/record for patients to fill in as they wish and includes prompts about patient rights, recording of feelings, goals and achievements. There is also a self-directed learning programme for staff called “Talkwell”, which encourages work and exercises around effective communication with patients. What is noticeable about all these tools is the collaborative work behind them. Service users contributed towards the Talkwell and the Ward Buddy tools, and Wardipedia is a crowd sourced information bank along the Wikipedia lines, which aims to collect best practice information from practising health professionals, service users and mental health organisations. Starwards is also a repository of information and best practice from different, official organisations. From the website, you can view and download documents such as the Starwards response to the recent Care Quality Commission consultation, a regular newsletter, blog postings from members and a selection of free to download articles from Mental Health Today. Not everyone will agree with the approach or the tone of the website, but there is an enormous amount of information and collaborative ideas that aim to promote wellness through alliance and engagement. Criticism of the Starwards programme includes concerns about patient and staff safety; but on secure and acute wards, it is impossible to introduce these suggestions without compromising the primary work on the wards, and that, according to one particular email that was reproduced and responded to in the Starwards annual review by Marion Janner, the Starwards programme was attempting to tell nurses how to do their jobs. Janner refutes this and reiterates that these 75 ideas are suggestions that can be implemented or not as required. She also points out that one trust Cheshire and Wirral Partnership managed to implement all 75 suggestions in all their 18 acute wards thereby winning Starwards “Full Monty” award, and thus feedback from them and other places that have used the Starwards programme has been extremely positive. However, it is also worth noting from the 2009/2010 Annual Report that some members had found Starwards programmes difficult to implement due to the unpredictable nature of their patients’ disorders, a lack of motivation from some staff and patients and poor environmental design. However, overall, I think it is certainly worth a look even as a starting point to evaluating current care for patients on acute wards and whether this could be improved. Another organisation that promotes talking and engagement is the Samaritans. Whilst issues of containment may not be relevant when discussing this, issues of safety certainly can be, not just in terms of suicide prevention but also when reporting suicide events in the media, the main source of information for the general public (Whitley & Berry, 2013). Chapple et al. (2013) cite a study from New Zealand by Collings et al., who found that
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards
573
instances of suicide did rise in the wake of a widely reported suicide, particularly if the person concerned was well known. In Bridgend, Wales, a spate of suicides of young people between 2007 and 2009 led press to speculate about a “suicide cult” and one bereaved parent accused the media of glamourising the initial reports and triggering more deaths.1 The Samaritans have media guidelines in place for the reporting of suicides as well as a press team who can offer advice to journalists and media outlets on the presentation of a story, either in real life or as part of a TV programme. The guidelines are available in full from the Samaritans website, containing facts about suicide, common myths, the copycat effect as a result of media reports and how the media can present these incidences in a sensitive and non-sensational manner (e.g. leaving out the specific details of the death). On the media page, there are also a few key points to remember when approaching this subject matter, including providing the contact information of support services and acknowledging the complex nature of these issues. Other links on this page include tips for journalists writing on this topic, how to work with bereaved families and how to present dramatic portrayals of suicide. There is also an article on copycat behaviour that cites several studies showing a correlation between media-presented suicides and a subsequent rise in other incidents, which mirror the reported or dramatised suicide. Care pathways for in-patient mental health care are moving towards models of patient autonomy and self-determination, boosted by activities designed to alleviate boredom, create a sense of trust and agency for the patient. Studies overall show that this approach has a positive, rather than a negative effect on safety issues and that they may reduce the need for containment by medication or other methods. We cannot, of course, generalise about the effectiveness of programmes such as Starwards or RESPECT on acute wards – as pointed out by Starwards members, the working environment, the engagement of the staff as a whole, the issue of staffing levels and how much time they have and the nature of the patients’ disorders will all impact positively or negatively on their effectiveness. The Samaritans website emphasises the need for understanding and respect when dealing with mental health issues in the media, and this also seems to be at the heart of the programmes considered here. They may not be able to be implemented fully, but they may be a good place to start. Declaration of Interest: The author reports no conflict of interest.
Note 1. http://news.bbc.co.uk/1/hi/wales/7253788.stm retrieved 6/8/2013.
References Anderson, K.K., Fuhrer, R., & Malla, A.K. (2013). “There are too many steps before you get to where you need to be”: Help-seeking by patients with first-episode psychosis. Journal of Mental Health, 22(4), 384–395. doi: 10.3109/09638237.2012.705922 Bowers, L., Alexander, J., Simpson, A., Ryan, C., & Carr-Walker, P. (2004). Cultures of psychiatry and the professional socialization process: The case of containment methods for disturbed patients. Nurse Education Today, 24(6), 435–442. doi: 10.1016/j.nedt.2004.04.008 Chapple, A., Ziebland, S., Simkin, S., & Hawton, K. (2013). How people bereaved by suicide perceive newspaper reporting: Qualitative study. The British Journal of Psychiatry, 203(3), 228–232. doi: 10.1192/bjp.bp.112.114116 Dack, C., Ross, J., Papadopoulos, C., Stewart, D., & Bowers, L. (2013). A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatrica Scandinavica, 127(4), 255–268. doi: 10.1111/acps.12053
574
S. Lipczynska
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
Gunasekara, I., Pentland, T., Rodgers, T., & Patterson, S. (2013). What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing. doi: 10.1111/inm.12027 Janner, M. (2007). From the inside out: Star Wards – Lessons from within acute in-patient wards. Journal of Psychiatric Intensive Care, 3(2), 75–78. doi: 10.1017/S1742646407001136 Maguire, T., Daffern, M., & Martin, T. (2013). Exploring nurses’ and patients’ perspectives of limit setting in a forensic mental health setting. International Journal of Mental Health Nursing. doi: 10.1111/inm.12034 Ward, J., & Bailey, D. (2013). A participatory action research methodology in the management of self-harm in prison. Journal of Mental Health, 22(4), 306–316. doi: 10.3109/09638237.2012.734645 Whitley, R., & Berry, S. (2013). Analyzing media representations of mental illness: Lessons learnt from a national project. Journal of Mental Health, 22(3), 246–253. doi: 10.3109/09638237.2012.745188
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards: What are they, and do they impact on safety in acute ward settings?
SONYA LIPCZYNSKA Institute of Psychiatry, Library, London, United Kingdom
RESPECT http://www.respecttrainingsolutions.co.uk Starwards http://starwards.org.uk/ Press guidelines for reporting suicide in the media, handling dramatic enactments of suicide, etc. http://www.samaritans.org/media-centre/media-guidelines-reporting-suicide Safety on psychiatric intensive care units (PICU) is of paramount importance both for the patients and for the staff. Patients admitted to these units will often be suffering from disorders with challenging behavioural symptoms such as aggression, delusions, paranoia or self-harming and when these behaviours present a threat to other patients and staff on the unit, or to themselves, then a range of containment measures may be put in place including administering of drugs, transfer to a locked ward, or mechanical containment such as net beds, or strapping (although as Bowers et al. (2004) found, these latter practices are disliked by mental health nurses from a range of countries, and in fact, not administered in the UK at all. The implementation of safety and containment policies can have an adverse effect on the well-being and recovery of intensive care patients (Anderson et al., 2013; Dack et al., 2013) increasing the risk of fear, unpredictability and mood swings. To counteract this, recent programmes have been devised and implemented to encourage a more holistic approach. These are care pathways for in-patient mental health care, which practise models of patient autonomy and self-determination, forging alliances with staff and engaging in creative activities. Data suggest that patients can flourish in this kind of environment (Gunasekara et al., 2013; Maguire et al., 2013; Ward & Bailey, 2013), but is there a risk that implementing these programmes could impact negatively on safety measures, or do these programmes actively reduce the instances of containment on a unit? I will be looking at two websites which offer this kind of programme – RESPECT, which originated in North-East Lincolnshire, and Marion Janner’s programme, Starwards, which Correspondence: Lipczynska Sonya, Institute of Psychiatry, Library, De Crespigny Park, London SE5 8AF, United Kingdom. E-mail: [email protected]
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards
571
she devised after her own experiences as a service user on a PICU ward. Additionally, I will be looking at the Samaritans web pages on suicide, particularly those which deal with media reporting and asking if media reporting can have a knock on effect on safety. RESPECT comes from Navigo, a mental health service based in North-East Lincolnshire. The company offers training programmes for mental health staff, which is designed to promote support instead of control. RESPECT focuses on the patient as a person, rather than a problem to be managed – the introductory page explains the ethos as treating patients as you would like your loved ones to be treated. The idea behind the programme, as detailed on the website, is that trainers will train staff members at the relevant institution with the aim that some of those staff members will become certified RESPECT instructors in their own right and thereby embed the programme and practices into the everyday culture of the institution. The website is not just a repository for information about the training programmes but also has short articles about the history, progress and future of the programme. The history of RESPECT is outlined, from its beginnings in 1985, focusing on prevention rather than reaction, changing the culture of care for in-patient mental health facilities and has been developed in consultation with service users. The principles of the programme are also outlined, including an emphasis on “care not control”, giving patients roles, acting proactively, avoidance of labelling and abuse and de-escalating potential harmful or violent situations. There is also a précis and link to a 2009 inquiry by Mind into acute mental health care, which found that patients interviewed want to be treated with kindness, warmth and respect, and detailed their negative experiences with restraining techniques and the effect that this had on their wellness and recovery. Service users are also an important part of the programme, and there is information on how these groups were involved both in the planning of the programme and the teaching of the programme by sharing experiences and perspectives with RESPECT trainees. There are also five case studies where the programme has been implemented in institutions or trusts. For example, Coed du Hall Mental Hospital in Mold, Flintshire, reports reduction in instances of physical aggression after RESPECT training was implemented. So far, this initiative seems to be based in the northern counties, Ireland and the Caribbean. There are details about the four courses available and a contact email, although more information about practical considerations such as costings may also be useful. Similar to RESPECT is the Starwards programme that was set up by Marion Janner, after her experience as a service user. In an article from 2007, Janner invokes the spirit of Philippe Pinel, the eighteenth century French doctor who revolutionised care for mentally ill patients and goes on to talk about the spirit of Starwards that “acute ward stays shouldn’t be characterised mainly by containment and pharmacological intervention. Talking therapies should be a standard provision” (Janner, 2007). She also acknowledges the need for ward safety and identifies the biggest barrier to achieving “freedom within psychiatric care” first pioneered by Pinel as the expectations of both patients and staff. Janner also cites the National Audit of Violence study from the Royal College of Psychiatrists in 2005 which identified boredom as a key factor for outbreaks of aggression or harm in acute wards, as does the study from Ward and Bailey (2013). Janner refers to “fluffy” ideas for improving patient engagement and relationships with ward staff, and the Starwards website embraces this philosophy full on. The text and tone of the website is jokey, informal and occasionally a little bit arch as if someone is nudging you in the ribs while you are reading. Feedback about Starwards communications to members (newsletters, etc.) reproduced in the 2009/2010 Annual report (which can be
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
572
S. Lipczynska
found in the Publications section of the website) shows that some found this approach a little bit difficult, but others felt that it made the whole process of patient care and staff-patient alliance much less intimidating. In terms of content, the core aim of the Starwards programme is a list of 75 suggestions for acute patient care and engagement ranging from bringing animals in and personalising bedrooms to promoting a culture of empathy on the wards. These suggestions are listed on “Wardipedia”, an online encyclopaedia to which members of Starwards are encouraged to contribute, so that underneath each of the core suggestions, trusts and institutions add examples of what they have done to implement the particular suggestion. For example, under no. 56 “mealtimes made special”, real life suggestions include catering staff listening to individual patient preferences, placemat competitions and patients attending food safety courses in advance of preparing a special meal for the rest of the ward. As well as blogs and newsletters that can be downloaded; two other tools available are “Ward Buddy”, a kind of diary/record for patients to fill in as they wish and includes prompts about patient rights, recording of feelings, goals and achievements. There is also a self-directed learning programme for staff called “Talkwell”, which encourages work and exercises around effective communication with patients. What is noticeable about all these tools is the collaborative work behind them. Service users contributed towards the Talkwell and the Ward Buddy tools, and Wardipedia is a crowd sourced information bank along the Wikipedia lines, which aims to collect best practice information from practising health professionals, service users and mental health organisations. Starwards is also a repository of information and best practice from different, official organisations. From the website, you can view and download documents such as the Starwards response to the recent Care Quality Commission consultation, a regular newsletter, blog postings from members and a selection of free to download articles from Mental Health Today. Not everyone will agree with the approach or the tone of the website, but there is an enormous amount of information and collaborative ideas that aim to promote wellness through alliance and engagement. Criticism of the Starwards programme includes concerns about patient and staff safety; but on secure and acute wards, it is impossible to introduce these suggestions without compromising the primary work on the wards, and that, according to one particular email that was reproduced and responded to in the Starwards annual review by Marion Janner, the Starwards programme was attempting to tell nurses how to do their jobs. Janner refutes this and reiterates that these 75 ideas are suggestions that can be implemented or not as required. She also points out that one trust Cheshire and Wirral Partnership managed to implement all 75 suggestions in all their 18 acute wards thereby winning Starwards “Full Monty” award, and thus feedback from them and other places that have used the Starwards programme has been extremely positive. However, it is also worth noting from the 2009/2010 Annual Report that some members had found Starwards programmes difficult to implement due to the unpredictable nature of their patients’ disorders, a lack of motivation from some staff and patients and poor environmental design. However, overall, I think it is certainly worth a look even as a starting point to evaluating current care for patients on acute wards and whether this could be improved. Another organisation that promotes talking and engagement is the Samaritans. Whilst issues of containment may not be relevant when discussing this, issues of safety certainly can be, not just in terms of suicide prevention but also when reporting suicide events in the media, the main source of information for the general public (Whitley & Berry, 2013). Chapple et al. (2013) cite a study from New Zealand by Collings et al., who found that
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
RESPECT and Starwards
573
instances of suicide did rise in the wake of a widely reported suicide, particularly if the person concerned was well known. In Bridgend, Wales, a spate of suicides of young people between 2007 and 2009 led press to speculate about a “suicide cult” and one bereaved parent accused the media of glamourising the initial reports and triggering more deaths.1 The Samaritans have media guidelines in place for the reporting of suicides as well as a press team who can offer advice to journalists and media outlets on the presentation of a story, either in real life or as part of a TV programme. The guidelines are available in full from the Samaritans website, containing facts about suicide, common myths, the copycat effect as a result of media reports and how the media can present these incidences in a sensitive and non-sensational manner (e.g. leaving out the specific details of the death). On the media page, there are also a few key points to remember when approaching this subject matter, including providing the contact information of support services and acknowledging the complex nature of these issues. Other links on this page include tips for journalists writing on this topic, how to work with bereaved families and how to present dramatic portrayals of suicide. There is also an article on copycat behaviour that cites several studies showing a correlation between media-presented suicides and a subsequent rise in other incidents, which mirror the reported or dramatised suicide. Care pathways for in-patient mental health care are moving towards models of patient autonomy and self-determination, boosted by activities designed to alleviate boredom, create a sense of trust and agency for the patient. Studies overall show that this approach has a positive, rather than a negative effect on safety issues and that they may reduce the need for containment by medication or other methods. We cannot, of course, generalise about the effectiveness of programmes such as Starwards or RESPECT on acute wards – as pointed out by Starwards members, the working environment, the engagement of the staff as a whole, the issue of staffing levels and how much time they have and the nature of the patients’ disorders will all impact positively or negatively on their effectiveness. The Samaritans website emphasises the need for understanding and respect when dealing with mental health issues in the media, and this also seems to be at the heart of the programmes considered here. They may not be able to be implemented fully, but they may be a good place to start. Declaration of Interest: The author reports no conflict of interest.
Note 1. http://news.bbc.co.uk/1/hi/wales/7253788.stm retrieved 6/8/2013.
References Anderson, K.K., Fuhrer, R., & Malla, A.K. (2013). “There are too many steps before you get to where you need to be”: Help-seeking by patients with first-episode psychosis. Journal of Mental Health, 22(4), 384–395. doi: 10.3109/09638237.2012.705922 Bowers, L., Alexander, J., Simpson, A., Ryan, C., & Carr-Walker, P. (2004). Cultures of psychiatry and the professional socialization process: The case of containment methods for disturbed patients. Nurse Education Today, 24(6), 435–442. doi: 10.1016/j.nedt.2004.04.008 Chapple, A., Ziebland, S., Simkin, S., & Hawton, K. (2013). How people bereaved by suicide perceive newspaper reporting: Qualitative study. The British Journal of Psychiatry, 203(3), 228–232. doi: 10.1192/bjp.bp.112.114116 Dack, C., Ross, J., Papadopoulos, C., Stewart, D., & Bowers, L. (2013). A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatrica Scandinavica, 127(4), 255–268. doi: 10.1111/acps.12053
574
S. Lipczynska
J Ment Health Downloaded from informahealthcare.com by Universitat de Girona on 11/10/14 For personal use only.
Gunasekara, I., Pentland, T., Rodgers, T., & Patterson, S. (2013). What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing. doi: 10.1111/inm.12027 Janner, M. (2007). From the inside out: Star Wards – Lessons from within acute in-patient wards. Journal of Psychiatric Intensive Care, 3(2), 75–78. doi: 10.1017/S1742646407001136 Maguire, T., Daffern, M., & Martin, T. (2013). Exploring nurses’ and patients’ perspectives of limit setting in a forensic mental health setting. International Journal of Mental Health Nursing. doi: 10.1111/inm.12034 Ward, J., & Bailey, D. (2013). A participatory action research methodology in the management of self-harm in prison. Journal of Mental Health, 22(4), 306–316. doi: 10.3109/09638237.2012.734645 Whitley, R., & Berry, S. (2013). Analyzing media representations of mental illness: Lessons learnt from a national project. Journal of Mental Health, 22(3), 246–253. doi: 10.3109/09638237.2012.745188
