The Stigma of Having Psychological Problems: Relations With Engagement, Working Alliance, and Depression in Psychotherapy

The stigma of having psychological problems is a barrier to seeking mental health treatment, but little research has examined whether this stigma influences the experiences of those in treatment. In a sample of 42 psychotherapy clients, we explored links over the first few sessions between 2 facets of stigma (self-stigma and perceived public stigma) and 3 variables germane to the therapeutic process (depression, working alliance, and engagement). Initial self-stigma (SS) level was positively associated with initial depression, negatively associated with initial working alliance, and unrelated to initial engagement. Initial perceived public stigma (PPS) level was unrelated to initial levels in the 3 outcome variables. Initial SS and PPS levels were both generally unrelated to linear changes in the outcomes over the initial phase of counseling. Relations between stigma and outcome variables often differed within- and between-persons. For example, the association between PPS and engagement was negative at the between-person level but positive at the within-person level. Finally, on average, PPS decreased over the first few sessions but SS remained constant. Such findings may help therapists better understand the role of stigma in their clinical work, and stimulate research examining how to address stigmatization in psychotherapy.