Stigma Influences Trust in Mental Health Providers

Laurie Scudder, DNP, NP


September 08, 2011

Stigma and Trust Among Mental Health Service Users

Verhaeghe M, Bracke P
Arch Psychiatr Nurs. 2011;25:294-302

Study Summary

Background. The quality of the interaction between a mental health provider and client is important to achieving a positive outcome for the patient. Verhaeghe and Bracke review earlier research conducted in general healthcare settings that stresses the importance of interpersonal trust in the provider-patient relationship. Trust in the context of mental health services is defined as a belief that the professional will care for the patient properly, be honest and competent, and protect private information. The investigators examined the relationship between stigma experiences in mental health clients and the development of trust in mental health nurses and other professionals.

Methodology. This study, conducted in Belgium, recruited participants from 36 mental health facilities, including psychiatric and general hospitals, day activity centers, rehabilitation centers, and community mental health services. From these settings, a total of 650 patients completed an extensive questionnaire that took approximately 45 minutes. In addition to demographic information and items designed to measure the severity of disease, the questionnaire included items that measured trust variables related to 3 stigma experiences:

  • Self-stigma -- associated with greater feelings of shame and inferiority;

  • Public stigma -- associated with actual discrimination; and

  • Stigma expectations -- associated with fear of devaluation and discrimination.

Results. Mental health service patients who had higher expectations for stigma and those with more self-stigma had less trust in their providers. Public stigma experiences, however, were not found to have an independent effect on trust. Several variables were significantly related to trust and satisfaction with care. Older patients had more satisfaction with the services they received; this appeared to be the result of having greater trust in their clinicians. More ill patients, including those with psychotic disorders and those receiving more intensive care, had less trust, which translated to lower satisfaction with care. However, the relationship between symptoms and trust was no longer significant after the introduction of the variable of stigma into the analysis. Clients with more symptoms had less trust because they had more expectation of stigma and more self-stigma. Patients with more self-stigma related to the experience of seeking mental health services were significantly less satisfied with the services they received because they had less trust in their providers. The researchers concluded that trust was the most important determinant in patient satisfaction with mental health services.


The relationship between stigma and trust is an interesting one that cannot be ignored as providers seek to form relationships with inherently fragile patients. Of interest, public stigma was a less important part of that equation than the patient's own feelings of shame or expectation of shame. This study does not lessen the importance of the ongoing struggle to remove stigma and the resultant bias against those with mental illness, but it is an interesting finding. Although nurses and other mental health professionals may not be able to alter a patient's own expectation of stigma at the onset of a therapeutic relationship, this large and well-done study underscores the need for these professionals to be aware of this dynamic, recognizing how much of it is generated by the patient rather than the environment.