The interface between people with a mental illness and mental health services – focusing the role of public stigma and self stigma in staff-patient relationships

Lars Hansson

An important focus in research on the staff-patient relationship in mental health services has been the therapeutic relationship or treatment alliance on the individual treatment level. Departing from corresponding research within the field of psychotherapy, there is some evidence that certain aspects of the staff-patient relationship are related to a better outcome of and satisfaction with treatment also in mental health services in a more general perspective.

However, focusing the importance of treatment processes in order to facilitate and support a more beneficial outcome of treatment and rehabilitation efforts may benefit from also including a more societal perspective. We know from stigma research that stigma and discrimination of people with a mental illness still constitute a major problem. Self stigma is an aspect of stigma which may be related to various parts of the treatment process. Self stigma may lead to avoiding contact with service as well as withdrawing from ongoing contacts. Further, self stigma has implications for ongoing treatment or rehabilitation efforts since it involves shame, guilt and a lowered self-esteem, which may have negative implications for the therapeutic relationship as well as for outcome of interventions and satisfaction with treatment. Such aspects of the treatment process are largely overlooked but need specific attention and interventions in order to foster a beneficial staff-patient relationship.

The other side of this coin is that there is evidence that people with mental illness feel patronised, humiliated and punished in contact with services and that patients point out mental health staff as one of the groups which are the most stigmatizing. Studies on mental health staff's attitudes have mainly focused on the prevalence of stereotypes and desire for social distance from people with mental illness, and a recent review of studies revealed that negative beliefs or attitudes are widespread among mental health care staff, and similar to those of the general public. If such negative beliefs are reflected in the actual delivery of treatment and rehabilitation, and in treatment planning as well, this may reduce ambitions of recovery and prospects of future life situation on behalf of the patient, and instead induce pessimism and hopelessness. On a service level, this may also prevent the implementation of evidence-based interventions. Consequently, negative beliefs in staff may also on a more general level be an important obstacle to the implementation of an evidence-based practice in various intervention domains.

Mental health professionals are also exposed to what has been labelled associative stigma or stigma by proxy, by working in a discipline with low status and being less valued than staff working with other patient groups in the health care system. It is still unclear to what extent this situation may carry over to actual behaviour in the daily work with patients. However, awareness that this phenomenon exists and may affect the wellbeing of patients. It has been suggested that interventions empowering patients may be a way of action to reduce perceptions of stigma and discrimination. In a similar way it may also be necessary to intervene among mental health care staff in order to empower them and provide a consciousness of how stigmatizing attitudes may impact on their work with patients.

The implementation of evidence-based services for people with mental illness is regarded as an essential factor in the development of high quality services, with relevance also for the quality of treatment relationships. One of the critical issues in practicing evidence-based care is to take into account that an evidence-based practice is based not only on scientific evidence, but equally on professional expertise as well as on patient values and preferences. This again puts an emphasis on treatment processes and decision making in various phases of treatment and rehabilitation in order to create a treatment situation which in reality considers the patient's views and involving the patient. Models of shared-decision making constitute a tool for establishing this and pave the way for the development of a beneficial therapeutic alliance and a recovery oriented perspective on treatment and rehabilitation.

Keywords: Therapeutic alliance, stigma, staff attitudes.