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Journal of Psychiatric and Mental Health Nursing, 2001, 8, 315–321

Mass media, ‘monsters’ and mental health clients: the need for
increased lobbying
J. R. CUTCLIFFE 1 rmn rgn bsc (hons) ph d & B. HANNIGAN 2 ba(hons) ma pgce rmn rgn dpsn
1
Senior Lecturer in Mental Health Nursing and Practice Development Co-ordinator, University of Ulster, Belfast,
and RCN Institute, Oxford; and 2Lecturer, School of Nursing and Midwifery Studies, University of Wales College
of Medicine, Wales, UK

Correspondence: CUTCLIFFE J.R. & HANNIGAN B. (2001) Journal of Psychiatric and Mental Health
J. R. Cutcliffe Nursing 8, 315–321
School of Health Sciences Mass media, ‘monsters’ and mental health clients: the need for increased
University of Ulster lobbying
Cromore Road
Coleraine
A review of the limited empirical and theoretical literature indicates that current mass media
Co. Londonderry
representations of mental health service users appear to emphasize violence, dangerousness
BT52 1SA
and criminality. This is despite the empirical evidence that indicates a decline over the last
UK
40 years in the number of homicides carried out by people identified as suffering from
mental health problems. Such inappropriate representations do much to increase stigma,
ostracism, harassment and victimization of these individuals by the public. Furthermore, it
can be argued that there is another repercussion of these representations and that is the
subsequent government position/policy and the resulting legislation concerning care of
people with mental health problems. Consequently, this paper argues that there is a clear
need for psychiatric/mental health (P/MH) nurses to become more mindful of the wider,
socio-political environment in which their practice occurs, particularly if psycho-social
approaches to practice are adopted in their fullest sense, and as a result increase their politi-
cal lobby. Such increased lobbying should occur on behalf of, and in collaboration with,
service users, and accordingly the authors describe a range of activities under the broad
headings of pro-active and reactive lobbying. Furthermore, it is incumbent upon P/MH
nurse educationalists to prepare aspirant P/MH nurses for this lobbying role and equip
them with the skills necessary to do so.

Keywords: lobbying, macro-context of care, mass media, mental health policy, misrepre-
sentation, repair procedures

Accepted for publication: 12 December 2000

policy has taken on an increasingly coercive appearance.


Introduction
This trend has been witnessed most recently in proposals
It is rare that a single week elapses without some story, or from the present United Kingdom (UK) government on the
reference to, users of mental health services or mental reform of the English and Welsh Mental Health Act, and
health issues appearing in the mass media. Moreover, a on proposals for the management of dangerous people
substantial body of evidence exists to suggest that mental with severe personality disorders. The authors of this paper
health issues are poorly represented in the mass media. At posit an implicit relationship between these two phenom-
the same time as acknowledging this, it should be noted enon, and consequently, argue that such a relationship war-
that from the mid-1990s onwards, mental health care rants further investigation.

© 2001 Blackwell Science Ltd 315


J. R. Cutcliffe & B. Hannigan

As a result, our aims in this paper are as follows. First what were the language and assumptions about mental
we aim to review key evidence relating to mass media health and illness used by the press. The key findings of the
representation of mental health and illness. Secondly, we study indicated that almost 46% of all press coverage was
consider the complex relationship between mass media about crime, harm to others and self-harm, with 54% of
representations of mental health users and mental health tabloid coverage devoted to these issues and almost 43%
issues and we then argue that these (mis)representations in the broadsheets. Both broadsheets and tabloids made a
not only appear to have direct negative repercussions clear link between mental ill health, criminality and vio-
for some mental health service users, but additionally, lence, and stories that reported this link were given greater
may have been one important factor in influencing the prominence than more ‘positive’ pieces. The key findings
development of current mental health policy (and emerg- also indicated that 40% of the tabloid articles and 45% of
ing policy initiatives) and law in the UK. the Sunday tabloid articles about mental health contained
Having done this, we observe how mental health nursing stigmatizing words, such as ‘nutter’ or ‘loony’.
practice is (and has been) invariably affected by the politi- Other empirical evidence that suggests a link between
cal and sociological context in which it is delivered. Given media accounts and public attitudes includes the study by
this awareness of the macro-context of P/MH nursing prac- Appleby & Wessely (1988). In this paper, the authors were
tice, in the final part of this paper, we make the case for guided by two questions: does media reporting strengthen
increased social and political awareness on the part of the public’s tendency to link violence and mental illness,
P/MH nurses. We then suggest a range of practical strate- and, if so, does this attitude make the mentally ill less
gies or ‘repair procedures’ for challenging negative images accepted in the community? Nine hundred and sixty-five
of mental ill-health, and for lobbying towards more members of the public said whether they either agreed or
accurate portrayals of mental health issues in the media. disagreed with a series of statements, including the state-
ments that ‘mentally ill people are likely to be violent’, and
‘people who commit horrific crimes, such as the murder of
Mass media representations of mental
children or old people, are likely to be mentally ill’. Three
health clients
months after this first round of surveying, Michael Ryan
In 1993, the Scottish Mental Health Working group, con- killed 15 people in Hungerford, a town in Berkshire. A
cerned about the extent to which the portrayal of mental short time after this event, the same statements were put
illness in the mass media contributed to the stigma felt by to another stratified sample of 998 people, with a final
people with mental health problems, commissioned the survey of 989 people taking place some four months
Glasgow University Media Group to undertake a study of later. Approximately one third of respondents on each
the mass media representations of mental health and occasion agreed with the statement that mentally ill people
illness. A content analysis of 562 items, which were iden- are likely to be violent. Interestingly, whilst the number
tified within the local and national media over the space of of people agreeing with this statement did not change
one month, highlighted five main categories of themes. significantly in the wake of the Hungerford massacre, there
These were titled: violence to others (62%), harm to self was a significant increase at the second sampling point in
(13%), sympathetic coverage (18%), criticism of accepted the proportion of those who agreed that people who
definitions of mental illness (1%) and ‘comic’ images (2%). commit horrific crimes are likely to be mentally ill. Possi-
They noted that by far the most common type of coverage ble explanations for this finding, Appleby and Wessely
was that which linked mental illness with violence to suggest, include the way in which the media associated
others. In the second component of the study, over 40% of Michael Ryan with mental illness, despite the fact that no
a sample of 70 members of the public reported that they clear evidence of this existed. As they put it, ‘Our results
believed mental illness was associated with violence, and suggest that either the Hungerford massacre or the media
stated that the media was the source of their beliefs account of it strengthened the public view of extreme
(Glasgow University Media Group 1993). violence as a product of mental illness’ (Appleby & Wessely
A more comprehensive study carried out by the Health 1988, p. 294).
Education Authority (Ward 1997) monitored the national However, it needs to be acknowledged that the relation-
press coverage of mental health issues throughout 1996. ship between negative media reporting of mental health
Articles and press cuttings were collected and analysed in issues and public perceptions of people with mental ill-
order to address the four questions: what is the quantity nesses is a complex one. First, negative public attitudes
of mental health coverage, what type of stories received the towards people with mental illnesses clearly predate the
most attention, how positively did the coverage communi- arrival of the mass media. Bhugra (1989), in a review of
cate a number of key messages about mental health, and the literature on attitudes towards mental illness, noted

316 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 315–321
Mass media, ‘monsters’ and mental health clients

that, historically and in different parts of the world, mental images of mental illness portrayed in the mass media are
illness has typically been accompanied by negative atti- the stigmatizing, damning or ‘negative’ images described
tudes and, often, harsh or punitive treatment. Already above, or for that matter that accurate reports of incidents
negative or prejudiced public attitudes may, however, be involving users of mental health services should not be
particularly susceptible to further influence by a powerful published. There is evidence of some ‘positive’ images
mass media. As those who design and purchase television being portrayed and there are times when legitimate and
and newspaper advertisements are well aware, the media balanced reporting of incidents involving users of mental
can be a powerful tool in shaping public perceptions on health services does occur. In Ward’s (1997) study, it was
any number of topics. McKeown & Clancy (1995) suggest reported that more than 20% of the coverage promoted
that the relationship between media images and attitudes the messages that mental health problems are treatable and
towards mental illness is a circular one. Negative media that people with mental distress lead worthwhile lives.
images promote negative attitudes, with further media cov- Similarly, stories about politics, funding and services relat-
erage tending to feed off already-negative public percep- ing to mental health accounted for 20% of all coverage.
tions. Complex sociological and psychological processes, The MIND (1999a) report indicated that the respondents
McKeown and Clancy therefore suggest, moderate the felt their local and regional media reported mental health
effects of the media in shaping individuals’ attitudes. stories in a more balanced way than the national media
Although the relationships between media images and and Brindle (1997) reported his gratification in being able
public attitudes are complex, there is nonetheless a to present an award to a journalist (Euan McGrory) who
growing literature supporting the view that negative wrote a series of articles on the practice of burying people
accounts of mental illness promote and reinforce negative who die in long-stay psychiatric hospitals in unmarked
public perceptions. Glasson 1996) argued that mass media graves.
sensationalization has reinforced the public’s already nega- Despite these ‘positive’ examples, however, it is accurate
tive view of mentally ill people and Repper (1997) pointed to conclude that the current mass media representations of
out that the public’s understanding of mental health prob- mental health service users appear to emphasize violence,
lems is developed by national and local media coverage. dangerousness and criminality. Thus, it is important that
The MIND (1997) report Tall Stories from the Back Yard, people (including mental health nurses and users) continue
a survey of attitudes to people who use community mental to make the case for more balanced, ‘fair’ and accurate
health facilities, revealed ‘shocking’ levels of public coverage. This is an argument supported by David Brindle,
ignorance and misunderstanding. Further, the report noted the Social Services correspondent of the Guardian news-
that even though local opposition to community mental paper, who states, ‘It is vital, though, that people keep
health facilities is common and, what’s more, appears to making the case for positive coverage and keep protesting
be increasing, such opposition was not grounded in per- when it stigmatises, or when is just plain wrong’ (Brindle
sonal experiences of violence. The report indicated that 1997, p. 16).
there were no incidents of violence at any of the facilities
against which the opposition was raised. Respondents
Accurate images?
could not cite any specific incidents that had led to their
fears and opposition. Similarly, Kelly & McKenna’s (1997) It is clear, then, that there is a growing body of evidence
quality of life research in Northern Ireland discovered that indicating that the mass media propagates negative images
over half of the community-based long-term mentally ill of people with mental health problems. In particular, there
population they surveyed reported that they had experi- is evidence that the media often alleges links between users
enced harassment/victimization. Additionally, Kelly and of mental health services and violence, dangerousness and
McKenna argued such harassment/victimization resulted, crime. Additionally, evidence also exists that such inap-
at least in part, from the hyped-up media reports which propriate representations do much to increase stigma,
focus on negative experiences associated with people with ostracism, harassment and victimization of individuals
mental health problems living in the community, thus with mental health problems by the public.
serving to fuel existing misconceptions (Kelly & McKenna However, there is also another repercussion of these
1997). More recently, a further study titled Counting the negative representations. This relates to the effect that the
Cost (MIND 1999a) indicated that negative media report- media’s handling of mental health issues has had, and con-
ing of mental health issues increased the mental health tinues to have, on the development of government policy
problems of people living in the north-east and generated and legislation. Holloway (1996), for example, makes the
more social exclusion. point that supervision registers, supervised discharge and
However, it would be inaccurate to imply that the only the appearance of a generally more controlling mental

© 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 315–321 317
J. R. Cutcliffe & B. Hannigan

health policy framework in the 1990s emerged, in part at Psychiatric Nurses’ Association, a series of challenges were
least, as a result of media-fuelled ‘moral panic’. Particularly raised to the thinking behind the proposed move towards
significant in this respect were the powerful effects of the increased compulsion in the provision of community care.
media’s treatment of mental health issues in the wake of the One of the arguments in this leaflet which MIND and other
death of Jonathan Zito at a London underground station organizations used to challenge the prospect of compulsory
and the mauling of Ben Silcock by a lion at London zoo. treatment in the community was the lack of evidence that
Despite the recent European Convention for Human such a shift in policy was warranted.
Rights and the Human Rights Act coming into force in Perhaps the most compelling pieces of evidence regard-
October 2000 (Grey & Tucker 2000), some developments ing the dangerousness of people with mental health prob-
in British mental health care appear to be moving away lems are the studies undertaken by Taylor & Gunn (1999)
from the position that upholds, wherever possible, the indi- and the National Confidential Enquiry into Homicides and
vidual’s personal freedom as sacrosanct, towards a posi- Suicides by Mentally Ill People (Appleby 1997). Whilst
tion more concerned with minimizing risk to others. This acknowledging that there are methodological difficulties in
trend is evident in a number of policy and legal initiatives discerning trends in rates of homicide (Taylor & Gunn
that have emerged from the present government since its 1999), both of these investigations indicated that, contrary
election in 1997. The consultation paper, Managing Dan- to the images portrayed in the mass media, the percentage
gerous People with Severe Personality Disorder (HO & of homicides committed by mentally disordered people has
DoH 1999), for example, included the option that new declined over the last 40 years. Taylor and Gunn examined
powers could be introduced to provide for the indetermi- the statistics collected between 1957 and 1995. These illus-
nate detention of some individuals based on their potential trated that in 1957, 35% of homicides were committed by
risk to others (Byrt 2000). This trend towards a more con- mentally disordered people; by 1985 that percentage had
trolling mental health policy and legal framework can also declined to under 20% and since 1984, the percentage had
be detected in parts of last year’s Green Paper on review- further declined to 11.5%. The authors also point out that,
ing the Mental Health Act 1983 in England and Wales (Sec- of an estimated total population of 12 000 or 13 000 users
retary of State for Health 1999). This document introduced of mental health services, an average of 40 individuals per
the prospect of compulsory care and treatment for indi- year are responsible for a homicide. They draw a parallel
viduals living in the community. If enacted, the document with these figures to the figures for dangerous, drunken or
stated that a compulsory order of this sort could: drugged driving, or aggravated vehicle taking and ‘acci-
• stipulate a client’s place of residence; dents on the road’ and report that there is a total number
• define the proposed care and treatment plan; of 3500–4000 deaths per year arising from these incidents.
• oblige the patient to allow access and to be present for The researchers conclude:
planned visits by identified professionals; ‘Confining people with a mental illness to Hospital to
• oblige health and social services to comply with save 40 or so lives would be analogous to abolishing
arrangements set out in the care plans; and motoring to prevent the 4000 or so road deaths’ (Taylor
• stipulate the consequences of non-compliance, which & Gunn 1999, p. 10).
could include powers to: If the empirical evidence to support this shift towards a
• enter premises; more coercive and controlling mental health policy and
• convey the patient to a stipulated place for such care legal framework does not exist, then alternative explana-
and treatment as is prescribed in their care plan; and; tions for this shift need to be considered. We argue that
• convey the patient to Hospital. the shift towards a coercive policy has, in part at least,
(Secretary of State for Health 1999, p. 38). much to do with the Government’s attempts to pander to
In the period surrounding the work of the Richardson inaccurate public perceptions, reactions, and intolerance.
Committee (DoH 1999), which made recommendations to Furthermore, we suggest that, at least in part, the public
Government on reform of English and Welsh mental health may have been ‘whipped up’ into this position of intoler-
law, and in the subsequent period following the publica- ance as a result of misleading, inaccurate mass representa-
tion of the Green Paper, many professional and service user tions of mental illness and mental health issues.
groups raised serious concerns over the prospect of com-
pulsory treatment in the community. In a campaigning
What can psychiatric/mental health
leaflet titled 10 Questions about Compulsory Treatment
nurses do?
in the Community (MIND 1999b), produced by and on
behalf of a number of organizations which included Nursing is, for the most part, a discipline that focuses on
MIND, the Royal College of Nursing and the Community micro-level concerns. This is entirely appropriate, given

318 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 315–321
Mass media, ‘monsters’ and mental health clients

that nurses typically work with individuals and families in


Suggestions
order to improve their health and well being. Macro-level
concerns, such as the social and political context in which
Pro-active
care is provided, may often seem rather remote – and even
irrelevant – to the practice of ‘everyday care’. We challenge 1 Invitations should be offered to members of the
this assumption, however, and suggest instead that politics local/national press to attend seminars, open days, and
and policy are absolutely central in influencing what presentation of research findings.
nurses do in their everyday practice, and how they do it 2 Local and national radio and television that feature
(Masterson & Maslin-Prothero 1999). news, current affairs and human interest stories could be
This encompassing of a social and political dimension to contacted by P/MHs and made aware of relevant
nursing suggests a need to re-examine what is understood research findings, outcomes of reports, and human
by ‘nursing care’, ‘nursing action’ and the ‘nurse’s role’. interest stories involving users of mental health
‘Nursing’ does not occur, and never has occurred, in iso- services.
lation (Pearson 1983). Care is organized and delivered in 3 Local and national television shows that feature politi-
a wider context. This context impacts not only on the client cal and policy debate programmes, e.g. Question Time,
and on the individual nurse, but also on the ward they rep- BBC Radio Five Morning Debate, could be contacted by
resent, the unit they work on the community they work in P/MHs who would be willing to contribute to such
and with and the discipline of psychiatric/mental health debates.
nursing as a whole (Cutcliffe 1997). Importantly, a ‘macro’ 4 P/MH nurses could consider forming networks
perspective on mental health nursing involves a recognition and working relationships with local and national
that views on how people with mental health problems reporters and media groups.
should be cared for have a social and political dimension.
We suggest, too, that this awareness of macro-level issues
Reactive
might usefully be extended to encompass awareness of the
key issue we have been discussing in this paper – the role 1 Assist clients in writing, or write on behalf of the client,
of the mass media in (mis)representing people with mental to his/her Member of Parliament.
health problems, and the consequences this has for the 2 Assist clients in writing, or write on behalf of the client,
future shaping of mental health policy and law. to local/national newspaper, television and radio stations
There already exist limited examples of attempts to in response to media misrepresentations.
increase lobbying carried out by mental health service 3 Write to or lobby the Mental Health ‘Zsar’, Louis
users. For example, the National Association for Mental Appleby, and enquire how he intends to address the
Health, MIND, currently has a media guardian campaign issue of mass media misrepresentation (and offer
as part of their Campaign to Complain. In September of assistance).
1999, MIND (1999a) reported that the campaign had 4 Write to or lobby the Minister(s) for Mental Health
already recruited almost 300 ‘guardians’. Each guardian is and enquire how he/she intends to address the issue
contacted approximately once per month and provided of mass media misrepresentation (and offer assistance).
with a media alert sheet that provides details of the pro-
gramme, article or report. These sheets also contain details
Discussion
of who and where the complaint should go to. Addition-
ally, Harrison (1998) identifies Regional Public Education
Pro-active
Officers of the Royal College of Psychiatrists as being
strategically placed to influence and improve the coverage Perhaps part of the difficulty of this problem resides in a
of mental health issues in the media. Such endeavours are felt sense of ‘them and us’ scenario, in that there appears
laudable and should be supported. However, the authors to be only a limited reciprocal relationship between mental
of this paper argue that P/MH nurses have the potential health care users/workers and members of the mass media.
for a stronger and more influential lobby. We posit that one possible way to address this would be
Consequently, we outline some suggestions for increased to offer invitations to appropriate members of the media
lobbying activities or ‘repair procedures’, under the broad to seminars, open days, mental health conferences and pre-
headings of pro-active and reactive lobbying, and these are sentations of research findings. Not only could this provide
then discussed in more detail. The authors recognize that the opportunity for building relationships, but it also has
these are preliminary suggestions and hope that they will the crucial advantage of increasing awareness (and hope-
stimulate debate and thinking. fully reporting) of ‘positive’ mental health issues. For

© 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 315–321 319
J. R. Cutcliffe & B. Hannigan

example, the ongoing research by the Universities of Ulster, of the radio/television still have the potential to censor, edit
Sheffield and Newcastle, into how mental health nurses or present any response and thus the potential for misrep-
may bring about a change of heart in suicidal in-patients, resentation remains intact.
may well have a distinctly ‘positive’ appearance in addi- Perhaps individuals who have a vested interest in
tion to the clear ‘human interest’ element and therefore national mental health issues and indeed, policy, could
arguably warrants widespread reporting. also be contacted. This repair procedure perhaps has the
In addition to this face-to-face contact, there may be advantage of involving people who have a duty to respond
mileage in providing local and national radio and televi- to any correspondence in a fair and balanced manner. It
sion that features news, current affairs and human interest also has the secondary advantage of raising the profile of
stories with relevant research findings, outcomes of such issues further into the attention of these key
reports, and human interest stories involving users of individuals.
mental health clients. Given the extensive and varied range This shift in role, to one that embraces the macro
of news programmes that currently exist, it is entirely plau- endeavours in addition to the micro endeavours, is perhaps
sible that there may be adequate space and sufficient public an example of the expanding role of mental health nurses
interest in these matters. and is a more appropriate example of role expansion than
There may also be a case for contacting local and taking on board ‘cast-offs’ from medics, such as limited
national television shows that feature political and policy powers of medication prescription. Consequently, if this
debate programmes, e.g. Question Time, BBC Radio Five lobbying is to become a more common element on P/MH
Morning Debate, and making the producers of these pro- nursing practice then clearly there is a need for P/MHN
grammes aware of the experts in the field that already exist. training/education to include some theory and methods on
At the moment it appears that the producers of these shows how to do this. For example, such training might include:
have one or two ‘well known’ nurses who they call upon • simulated debates around a series of related topics;
each time health matters arise, irrespective of the expertise • awareness raising of local and national media
of these individuals in the subject matter. If genuine, well contacts;
informed debate is the real aim of such programmes, • construction of social/political arguments;
perhaps it would be wiser to have a range of individuals, • letter writing;
each with expertise and experience in particular substan- • sessions on how to handle the media.
tive areas.
Perhaps as a ‘spin-off’ of the first suggested repair pro-
Conclusion
cedure, P/MH nurses could consider forming networks and
working relationships with local and national reporters It would be indecorous and inaccurate of the authors to
and media groups. Arguably a more balanced approach to imply that the only images of mental illness portrayed in
the reporting of mental health issues is likely to be fostered the mass media are the stigmatizing, damning or ‘negative’
in a climate of trust, openness and warmth, and such images; there is evidence of some ‘positive’ images being
qualities perhaps need a working relationship in order to portrayed. However, it is accurate to suggest that the
flourish. current mass media representations of mental health
service users appear to emphasize violence, dangerousness
and criminality. This is despite the empirical evidence that
Reactive
indicates a decline over the last 40 years in the number of
Users of mental health services have an equal right to any homicides carried out by people identified as suffering from
other member of the community to be represented by their mental health problems.
local MP and therefore clients could raise issues of mis- Consequently, there is a clear need for P/MH nurses to
representation with their MP. However, it is rare that increase their political lobbying and become more mindful
such activity is prompted or encouraged by P/MH nurses. of the wider socio-political environment in which their
Furthermore, if the client is unable to do so independently, practice occurs, particularly if psycho-social approaches to
then P/MH nurses could provide the support necessary practice care are adopted in their fullest sense. Such
or alternatively, carry out such activity in the role of an increased lobbying should occur on behalf of, and in col-
advocate. laboration with, service users. The authors are not sug-
Similar activities, working with or on behalf of the client, gesting that each P/MH nurse needs to become a modern
could be utilized to contact and/or lobby local/national day 21st century equivalent of Demothsenes (being a
radio/television. The difficulty with this option is that, in renowned public orator). However, as Tilley (1997)
all probability, the editors of the newspaper and producers submits, perhaps P/MH nurses can already be regarded as

320 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 315–321
Mass media, ‘monsters’ and mental health clients

rhetoricians, individuals who can construct and deliver Harrison T. (1998) Climbing Mount Everest. tackling the media
arguments. Therefore, the movement towards a more bal- at a national and regional level. Psychiatric Bulletin 22,
111–112.
anced and accurate portrayal of mental health users and
HO & DoH (1999) Managing dangerous people with severe per-
issues by the mass media might be facilitated, at least in sonality disorder: proposals for policy development. Home
part, through the repair procedures described in this paper. Office & Department of Health, London.
Further, it is incumbent upon P/MH nursing educational- Holloway F. (1996) Community psychiatric care: from libertari-
ists to prepare aspirant P/MH nurses for this lobbying role anism to coercion: moral panic and mental health policy in
and equip them with skills necessary to do so. Britain. Health Care Analysis 4, 235–243.
Kelly L.S. & McKenna H.P. (1997) Victimization of people with
enduring mental illness in the community. Journal of Psychi-
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