Soc Psychiatry Psychiatr Epidemiol (2006) 41:843852

DOI 10.1007/s00127-006-0123-6

ORIGINAL PAPER

Richard Laugharne Stefan Priebe

Trust, choice and power in mental health

A literature review

Accepted: 6 September 2006 / Published online: 27 October 2006

j Abstract Trust, choice and empowerment of patients are emerging as important issues in mental
health care. This may be due to an increasingly consumerist attitude amongst patients and as a consequence of postmodern cultural changes in society.
This study aimed to find evidence for the influence of
trust, patient choice and patient empowerment in
mental health care. A literature review was undertaken. Six searches of PubMed were made using the
key terms trust, patient choice and power combined
separately with psychiatry and mental health. The
literature search found substantial research evidence
in the areas of trust, choice and power including
validated scales measuring these concepts and evidence that they are important to patients. Trust in
general health clinicians was found to be high and
continuity of care increases patients trust in their
clinician. However, only qualitative research has been
found on trust in mental health settings and further
quantitative studies are needed. Patient choice is
important to patients and improves engagement with
services, although studies on outcome show varying
results. Empowerment has impacted more at an organisational level than on individual care. Innovative
research methodologies are needed to expand on the
present significant body of research, utilising qualitative and quantitative techniques.
Both authors are psychiatrists working in the UK.
R. Laugharne, MRCPsych (&)
Cornwall Partnership Trust and Peninsula Medical School
Mental Health Research Group
Wonford House Hospital
Exeter EX2 5AD, UK
Tel.: +44-1392/403421
E-Mail: [email protected]

Introduction
Modern medical practice is a multifaceted task.
Medical treatments have become increasingly technologically complex and there is an expectation that
they are justified by scientific evidence. However,
neither clinicians nor patients have forgotten the
importance of a more traditional part of medical
practicethe relationship between clinicians and
patients. In this relationship three concepts are being
increasingly examinedtrust between clinicians and
patients, giving patients more choice in their medical
treatment and the empowerment of patients. These
issues are relevant for the whole of medicine, none
more so than mental health. The relationship between
psychiatrists and patients is vital because psychotherapies are an integral part of treatment, the therapeutic relationship can predict long-term outcome
[1], and because power differentials can be exacerbated by the possibility of compulsory assessment
and treatment for the mentally ill.
Trust, choice and power may be emerging as
important areas of research for several reasons. The
political and social phenomena of consumerism and
market economics are impacting on health. Patients
may approach health care from a consumerist approach in which they expect to have more of a say in
their treatment, and governments are looking for
competition between service providers to improve
quality of care and, perhaps, to reduce costs. This has
led to a movement away from a more paternalistic
relationship between doctors and patients towards
giving patients more autonomy in the therapeutic
relationship. There is an increased emphasis on
identifying patient wishes in their health care. The
availability of information on the internet has in-

SPPE 123

S. Priebe, MD
Unit for Social and Community Psychiatry
Barts and the London School of Medicine
Newham Centre for Mental Health
London, UK

j Key words trust choice power psychosis

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creased patient knowledge and changes in the

financing of health care may lead to patients having
more financial involvement in their care.
We also feel that these issues are fuelled by postmodern cultural changes in society. Postmodern
criticisms of a scientific worldview [2, 3] have grown
throughout the twentieth century and have impacted
on medicine [4]. In mental health, a scientific model
has been criticised as emphasising the biological aspects of illness over the psychological and social
factors, as the former are easier to measure and
therefore establish a clear evidence base [5]. A holistic
view of experience has been elusive, as it is easier to
measure reductionist models of human experience.
The scientific method used in mental health emphasises knowledge gained through controlled
observation and measurement. The professionals who
gain this knowledge are given the power to influence
services through evidence-based medicine. However
the objectivity of these professionals has been questioned, as commercial interests (through the pharmaceutical industry) and the importance of academic
authority can both influence objective judgement [6].
Therefore, knowledge, power and trustworthiness of
clinicians are issues thrown up by postmodern criticisms of scientific psychiatry. If the power of clinicians to determine services is questioned, the logical
next step is to give more power to patients to make
treatment decisions, and hence patient choice enters
the debate. Recent UK government documents often
presume that patient choice is a good thing and patient empowerment is a reality that can improve care
[7]. However, the evidence for these presumptions in
mental health is not established.

j Aims of the study

We sought to complete a literature review to address
the following research questions. Is there a research
base for the influence of trust between patients and
mental health clinicians? What is the evidence for the
importance of choice in mental health care? Has patient empowerment had an impact on mental health
delivery?

Material and methods

For the literature review we aimed to examine trust, patient choice
and power. We performed a computerised search of the PubMed
database (19802005). The searches included the key terms trust,
patient choice and power. These were combined with psychiatry and
mental health in separate searches. Therefore a total number of six
searches were made. Some titles were clearly not relevant to the
study area. If the title of the paper suggested that the article might be
relevant, for example to the issue of trust in clinicians in mental
health, then the abstracts were reviewed for the content of the
article. Then if the abstract described conceptual ideas, research or
reviews of research in the areas of trust, choice and power from the
perspective of the care of the severely mentally ill, a copy of the full
article was read, interpreted and included in the review. Any rele-

vant papers or books cited by papers not previously found were

reviewed and included if judged to be relevant. In addition, two
publications not indexed on Medline, the Journal of Mental Health
and the Psychiatric Bulletin were hand searched. Trust and psychiatry identified 349 articles whilst trust and mental health identified 279 (with an overlap in articles). From these papers, those
found in the hand search and citations from these articles, 29 abstracts were reviewed. A total of 21 papers were included in the final
literature review on trust. Patient choice and psychiatry identified
227 articles and patient choice and mental health identified 241
articles (again with significant overlap). Forty-seven abstracts were
reviewed and a total of 21 papers were included in the final literature
review on patient choice. For power the corresponding figures were
449, 587, 45 and 28.

Results
j Trust
There has been debate and concern that public trust
in institutions as a whole has been declining [8] and
some have suggested that this loss of trust has extended to health professionals. However, patients
trust in their clinicians is recognised as vital to
healthcare as it is the basis for a positive therapeutic
relationship. Yet the notion of trust can be difficult to
define and to investigate [9].

Connotation of trust
Numerous definitions of trust have been put forward,
in both general and medical contexts [10]. The
majority stress the optimistic acceptance of a vulnerable situation in which the truster believes the
trustee will care for the trusters interests [11, p. 615].
This care includes a belief in the trustworthiness of the
intent of the clinician, often includes an emotional
element as it is relational, and involves a feedback
loop, where experience can reinforce trust or lead to a
sense of betrayal.
Trust can have multiple dimensions, summarized
by Hall et al. [12] as follows:
1. Fidelity. Pursuing the patients interests above the
interests of other relevant parties.
2. Competence. Avoiding mistakes and achieving the
best possible outcomes, both technically and in areas
of communication.
3. Honesty. Telling the truth and avoiding falsehoods.
4. Confidentiality. Protecting private information.
5. Global trust. The holistic aspect of trust inherent to
the relationship between people.

Trust is not only relevant to individual clinicians

but is also relevant to how patients relate to institutions and larger health care systems in medicine.
Patients will have relationships of trust in British
mental health care with their individual psychiatrist,
their local community mental health team, psychiatrists in general and NHS mental health services as a
whole. These contrasting aspects of trust can interact.

845

Whilst someone who trusts their personal clinician

may as a consequence trust an institution more, faith
in clinicians as a group will help a patient to trust a
clinician he or she is meeting for the first time [13].

Measuring trust
At least four rating scales have been developed in
medicine to measure trust in individual clinicians [12,
14 (Trust in Physician Scale), 15, 16]. There has been
a scale to measure trust in the medical professional
body as a whole [13] and other scales to measure trust
in hospitals generally [17]. According to Hall et al.
[12] all these scales have adequate psychometric
properties and are broadly consistent with the
dimensions of trust described above. Goudge and
Gilson [9] observed that few of the scales used qualitative work to measure validity or reliability, instead
relying on internal consistency and factor analysis.
However, the Trust in Physician Scale has been shown
to have adequate testretest reliability and predicted
some clinical outcomes, such as medication adherence [18] and the Wake Forest team [12, 13] described
their method of trust scale development in detail.
Scale development and empirical testing are more
advanced for the scales for individuals than those for
institutions. None have been specifically validated or
used with mental health patients.

Evidence for trust

It is often thought that trust in the medical profession
is waning [19]. However, studies examining trust in
individual physicians does not bare this out. Using
the Trust in Physician Scale, where 1 = strong distrust and 5 = strong trust, at least three studies show
consistent average scores of 4 or more [12, 14, 18]. In
contrast trust in institutions seems lower, although
direct comparison is difficult as different concepts are
involved [17, 20]. These studies used telephone
interviews with the public or patients attending primary care in the USA.
A study interviewing primary care patients in both
the USA and in the UK, using the Trust in Physician
Scale, also showed high levels of trust in individual
clinicians, similar in both countries [21]. The most
significant factors associated with trust in the doctor
were older age of patients and length of time of the
relationship between patient and clinician. Gender,
ethnicity, education, income levels and chronicity of
illness were not associated with the strength of trust.
The importance of continuity of care is supported by
a US study [22]. However rather than the length of
time of the relationship, the number of times the
patient had seen the doctor was associated with increased trust, along with adequacy of choice and the
degree of control in decision making. In another US

study, Kao et al. [16] found the length of relationship

and more choice of the physician was associated with
greater trust.
We could find no quantitative studies on trust in
mental health. A qualitative study in the UK, using in
depth interviews, demonstrated that for 34 patients
with an enduring mental illness, trust is important
in building positive therapeutic relationships [23].
Emerging themes emphasised the importance of continuity of care in maintaining trust. Another UK study
used focus groups of mental health service users to
establish their views of services [24]. Service users felt
a trusting clinician-user relationship was central to a
good quality service.
Mechanic and Meyer [25] examined concepts of
trust using qualitative interviews with three groups of
patientsthose with breast cancer, Lyme disease and
mental illness in the US. Patients with mental illness
stressed the importance of trusting the clinician to
understand and minimize side effects of medicationthis was more important to them compared to
patients with the two physical diseases. Those with a
mental illness also put more emphasis on the importance of confidentiality in trusting doctors, and also
reported withholding information on substance misuse, dangerous behaviour and non-adherence to
medication. The authors felt the mental health patients
emphasized the importance of time with the clinician
and the continuity of care with the same clinician.
One randomised controlled trial in the US attempted to teach family physicians to build and
maintain trust with their patients using communication skill training [26]. The intervention group made
no measurable difference in terms of patient trust,
satisfaction and treatment adherence.
It is important to remember that the concept of trust
should not be limited to patients but should include
clinicians trust of their patients and, perhaps unique to
psychiatrists who can treat patients against their will,
the publics trust of psychiatrists applying compulsory
treatment. A study of the publics attitudes to compulsory treatment of the mentally ill in Switzerland
indicated a high level of trust in psychiatrists [27].

j Choice
Connotations of choice in healthcare
The issue of choice in mental healthcare has become
an important issue but has differing aspects. First,
there are philosophical and ethical arguments for
more patient choice. In the spectrum of patient
involvement in care, at one end of the spectrum lies
an attitude of paternalism, where the doctor knows
what is best for the patient and decides treatment. At
the other end of the spectrum is autonomy. Autonomy denotes the freedom from external control and
right of self-determination. In healthcare an autonomous position suggests patients should have control

846

over healthcare decisions. Another key ethical concept in patient choice is informed consent: a competent person has the right to refuse treatment.
Whilst over the last 20 years medical ethicists have
stressed the importance of the principles of autonomy
[28], the situation is complex. In emergency and life
threatening situations, a paternalistic approach is
more practically reasonable and perhaps desirable. In
more elective procedures and situations where treatment decisions are more controversial, autonomy is
argued for more. Mental health is unique to medicine
in that some patients are treated against their will.
Whilst this can be seen as the ultimate paternalistic
position within medicine, most mental health patients
are treated on a voluntary basis, and it may be possible to offer patients who are treated involuntarily
some degree of autonomous choice in their treatment
plan.
A second argument for patient choice is economicthe application of free market concepts to
human services makes the case for more consumer
choice in mental health care which may increase
standards through competition between health care
providers [29]. It is easy to confuse the two arguments
for increased patient choicephilosophical and economic. For example the UK governments promotion
of more patient choice focuses on patients having a
choice between several hospitals competing to deliver
a service for them, which follows an economic model
but does not necessarily offer greater autonomy for the
patient in their individualised treatment plan, as all the
hospitals may all offer a paternalistic approach to care.
On the other hand, increasing patient involvement in
their individual treatment plan, for example through
shared decision making, is seeking to offer greater
autonomy for the patient, although actual choices for
the patient may be extremely limited by resources. In
summary, the term patient choice is used widely to
debate philosophical and economic arguments for
choice, and autonomy is just one of the philosophical
concepts used to argue for more patient choice. This
review focuses on the latter aspectthe autonomy of
patient choice in their individual care.
In examining patient choice and the evidence for
services in mental health, Salem [30] made the
observation that in controlled trials patients are
usually passive recipients of which service or treatment they receive. As such, these trials do not take
into account how patient preference may influence
how effective services might be in real life settings.
Self-help groups and consumer run services for people with severe mental illnesses have been criticised as
being self-selective, but rather than a weakness this
may be a strength in emphasising that patients should
be able to select the treatment they want.
In focussing on patient involvement in care, it is
important to differentiate between desire for information and desire for treatment choice. Coulter [31]
makes this observation and describes three different

approaches to clinical decision making in general

health care:
1. Professional choicethe clinician decides and the
patient consents.
2. Shared decision makinginformation is shared and
both decide together.
3. Consumer choicethe clinician informs and the
patient makes the decision.

Coulter argues that different models may be

appropriate at different times. The middle model,
shared decision making, is often preferred and there is a
growing body of research in this area, although relatively little has been done in psychiatry [32]. She found
that studies varied in how much choice patients want,
with age, clinical situation, educational status and
cultural background being possible factors leading to
the variance in findings. This pattern has also been
found in specific mental health settings in the US [33].
Choice may, in theory, improve treatment outcomes [34]. This may be by improving patient attitudes to the treatment they have actively chosen, by
increasing the patients sense of control, or by the
patients successfully matching their needs to the
appropriate treatment.

Measuring autonomous choice

Ende et al. [35] developed the Autonomy Preference
Index (API) as a measure of desire for information and
a desire for decision making. This instrument had
adequate validity and reliability and was used on 312
general medical patients in the US. They found that, on
the whole, patients wanted to have information about
their illness but did not want to be principle decision
makers. Desire for information was not correlated
with preference for decision making. Patients were
more likely to want to be part of the decision making
process if they were less ill or younger, but individual
characteristics were more important than sociodemographic factors in determining desire for decision
making. The authors felt their results reflected a desire
for paternalism with permission.
Other scales have been used to measure the degree
of involvement that patients want in decision making,
including the Control Preferences Scale [36] and the
Patient Preferences for Control measure [37]. Both
require patients to pick a role description. Using these
two scales, Entwistle et al. [38] found that patients
picked the same roles for differing reasons, and some
picked differing roles for similar reasons when compared to their narrative accounts, and hence questioned the validity of these scales.

The evidence for choice

Two recent studies using the API in mental health to
measure patients desire to be involved in treatment

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decisions suggest mental health patients want a significant say in their care. Hamman et al. [39], in a
study of 122 inpatients with schizophrenia, found a
desire for shared decision making which was slightly
greater than patients in primary care from the original
US study [35] and very similar findings were found
amongst 105 community mental health patients in
Cornwall, England [40]. However, neither study suggested patients want a consumerist approach, where
the clinician gives the patient options and the patient
makes a fully autonomous choice. Most patients want
a partnership with the clinician in deciding treatment.
In both studies, younger patients were more keen on
having a say in treatment.
Are patients actually given choices in their mental
health care in the UK? Rycroft-Malone et al. [41]
examined nursepatient interactions in different
patient groups including mental health using qualitative methodology. In practice patient choice was
restricted, although less so in mental health compared to acute medical and general practice patients.
More choice was offered to mental health patients in
terms of medication administration times, and the
time and venue of appointments. Psychiatric patients
have been interviewed in the UK about what they
wanted from nursing staff caring from them. A key
desire for patients was for nurses to give them
information about their condition to empower patients to have a degree of control over treatment
interventions [42].
There is evidence that giving patients choice increases patient engagement in mental health. In primary care in the US, Dwight-Johnson et al. [43] gave
depressed patients in an intervention group a choice
between medication and talking therapy. They compared these patients with a control group who had
usual care with no choice. More patients in the
intervention group entered treatment (50%) compared with the control group (33%). No outcome data
were given for the 742 patients. Rokke et al. [34]
studied 40 patients with depression. Two types of selfmanagement treatment were available (cognitive or
behavioural). Individuals given a choice of treatment
were less likely to drop out of treatment prematurely.
There was no difference in treatment outcome between patients given a choice and patients assigned to
treatment, although the number of patients was small.
The effect of giving patients choice on mental health
outcomes is not clear. Some studies suggest a positive
effect on outcome. Alcoholic consumers given treatment choices had better treatment outcomes than
consumers with fewer choices [44]. A study on 32 patients with a snake phobia gave 16 patients a choice
after seeing videotapes of four different behavioural
therapies whilst 16 patients were randomly assigned.
Despite the small number of patients, those who chose
were significantly better on a behavioural scale after
therapy [45]. However, other studies have not demonstrated a definite positive effect. Cocaine users given

a choice between group and individual therapy did no

better than patients given no choice in most symptom
measures, although surprisingly the authors did not
emphasise that those who chose their treatment were
using cocaine on fewer days per month nine months
later [46]. Patient preference randomised controlled
trials have not shown a clear effect of patient preference
on outcome, possibly due to the low power of the trials
[47, 48]. Bedi et al. [49] assessed the effectiveness of the
treatment of depression in primary care in a well-designed partially randomised preference trial. This was
one of the few quantitative studies in this literature
review that included a power calculation. Patients were
either randomised (n = 103) or chose (n = 220) between medication and counselling. The patients who
chose between the two treatment options did not have
better outcomes than those who were randomised to
treatmentoutcome measures were for symptoms and
functioning. This finding was consistent with another
preference trial in depression [50]. A study in modified
assertive community treatment gave homeless patients
with psychosis either a choice of treatment programme
or no choice [29]. Of those having treatment at the ACT
programme, there was no difference between patients
who had had a choice and those that did not in terms of
clinical outcome, other than the former group visited
the programme more. Manthei et al. [51] gave some
patients referred to a community mental health centre
in the US a choice of individual therapist whilst others
were assigned a therapist. There was no difference in
treatment outcome using standardised rating scales,
although again the study may have lacked power as only
42 patients were included.
Calsyn et al. [29] suggested that these mixed
findings might indicate that giving patients choice
results in the patients engaging better and making
greater effort in the treatment process. However
choice may improve outcomes in patients who are
functioning relatively well, but not in patients with
more pervasive and severe mental illnesses.

j Power
Connotations of power
Postmodern thought questions the concept of objective knowledge. This challenges the idea of clinicians
as disinterested observers of evidencethey can use
medical knowledge to augment their own power. The
issue of power in mental health can be separated into
three overlapping areas. First, there is the way the
state uses its power in addressing mental health
problems. The mentally ill are often the only group of
patients who can be forced to receive treatment. The
recent proposed reforms of mental health legislation
in the UK have led to debates on many relevant issues,
including treatability and reciprocity [52], capacity
[53] and discrimination of the mentally ill as compared to the physically ill. Thomas and Cahill [54]

848

have suggested that psychiatric patients are so disempowered that many do not feel able to take steps
towards empowerment.
Second, there is a more general issue of the power
balance between clinicians and patients. As well as the
charge that clinicians exert a paternalistic power over
patients [55], there are also power differentials between professions often reflecting a dominant model
of mental illness. The alleged imbalance of power
between clinicians and patients has led to movements
critical of psychiatry such as the anti-psychiatry
movement, consumer-led services, the alternative
treatment movement and critical psychiatry network.
Third, there is the movement for the empowerment
of patients. This emphasises the rights of patients to
self-determination and their economic situation as
consumers of services. Detailed descriptions of the
multiple conceptual components of empowerment
have been described elsewhere (e.g. [56]). Clearly
these three aspects of power in mental illness are not
distinct and overlap. In this review we shall not
examine the issues around state legislation as this has
been explored extensively elsewhere.

Measuring empowerment
In a US study designed to develop an empowerment
scale for patients, a group of 10 leaders in the consumer-survivor movement devised a 28-item questionnaire [57]. They found that the items could be
grouped into five themes: self-efficacyself-esteem;
powerpowerlessness; community activism; optimismcontrol over the future; and righteous anger
(listed in order of their importance in the variance of
the scale). This rating scale was completed by 271
patients participating in self-help programmes. Age,
gender, ethnicity, education level, employment status
and number of hospital admissions were not associated with a greater sense of empowerment. Community activism was related to greater empowerment,
and use of services to less empowerment. The scale
had a high degree of internal consistency. Wowra and
McCarter [58] used the scale on community mental
health patients in the US, with 283 patients (a response rate of 16%) completing the questionnaire.
They confirmed the order of significance of the five
areas described by the first study. Age, gender and
race were not associated with the degree of empowerment. However, they found that employment status
and level of education were associated with a greater
sense of empowerment. The mean score in this study
was 2.74, where a score of 4 is most empowered. The
average score in the first study was 2.94. It is not clear
if this scale is sensitive enough to show change in
intervention studies.
Corrigan and Garman [59] have suggested that
empowerment includes two factorsempowerment
of the self (with higher self-esteem and efficacy) and
empowerment within the community (leading to

more community confidence). Therefore their research team tested the Empowerment Scale developed
by Rogers et al. [57] to evaluate its construct validity
[60]. They approached 35 patients with severe mental
illness, and also measured symptoms, functioning,
intelligence, quality of life, social support and level of
need. They found that the scale could be interpreted
as dividing into two superordinate factorsself-orientation (associated with self-efficacy, self-esteem and
optimism/control of the future) and community orientation (associated with community action, powerlessness and effecting change). Greater community
orientation was associated with higher intelligence,
greater resources and minority ethnicity. Greater selforientation was associated with better quality of life,
fewer symptoms and better social support.
Three other empowerment scales were developed
by Segal et al. [61] with patients with severe mental
disabilities. These scales have not been extensively
used in the literature.

Evidence for empowerment of patients

Historical overviews of the developments in advocacy
and patient empowerment have been well described by
Foulks [62] in the US and Peck et al. [63] in England.
There is some evidence on empowerment at an organisational level. Geller et al. [64] surveyed mental
health services in all states of the US. With a 100%
response rate, about one third of states had policies for
consumer involvement, one half employed consumers
in central offices for mental health and one half employed consumers in field offices. Consumer empowerment was not associated with geographical region or
the size of the mental health budget, but was associated with larger sizes of population and better quality
of services. In Somerset, England, the development of
user involvement over 30 months was measured using
qualitative and quantitative methodology [63]. User
consultation was evident at management and planning
level, but there was little evidence of user control in the
system, and involvement at an individual patient level
depended on the attitude of individual staff members.
Of those patients involved in devising their care plan,
82% said the plan had made a positive impact on their
lives. For those who were not involved, the corresponding figure was 12%.
In the UK, national policy states that service users
should be involved in all levels of planning and
delivery of mental health care [7]. An audit of a
rehabilitation service in Nottingham using structured
interviews suggested high levels of user involvement
in staff recruitment, planning and organising services,
with less involvement in eliciting users views and
evaluation of services [65]. When 137 patients
receiving psychiatric care in North London, UK, were
asked how satisfied they were with their care, one
question asked was whether they had a say in the
treatment they received. Only 44% agreed that they

849

did have a say in their care. Younger patients were

less likely to agree [66].
Service users have been employed as health care
assistants in an assertive outreach team in London,
and 45 patients were randomised into having this
input or receiving standard care. Those patients
receiving help from these health care assistants had
better rates of attendance, participated more in social
activities, and had fewer social needs. There was no
difference in satisfaction with services and there was
concern with the amount of sick leave of these
workers [67, 68].
Clearly there is an overlap between patient
empowerment and interventions that seek to increase
the self-efficacy of patients and increase their independence. Fitzsimmons and Fuller [56] reviewed
studies showing the positive effect of certain psychosocial interventions that had increased patients
empowerment through increased self-help, meaningful participation in services, self-esteem and employment. They conclude that the research to date
indicates that empowerment interventions need to
occur at many levels throughout a system to be
effective.

Evidence in the power differential between patients

and clinicians
The research in this area has been qualitative and has
examined abuse, disengagement, alternative service
models and the interactions in community mental
health care. There has been a literature review of
patient empowerment and abuse in mental illness
[69]. This concluded that abuse can occur firstly because of power imbalances between patients and clinicians and secondly because conditions that can lead
to physical and sexual abuse in general society can
occur in mental health services.
A qualitative study examined assertive community
treatment in mental health from the viewpoint of 12
patients interviewed using a grounded theory approach. They found that previous disengagement
from mental health services was linked with previous
coercive interventions. All felt that their voice had not
been listened to and had an increased level of arousal
around issues of power [70].
The patient empowerment movement led to the
development of alternative service models, including
consumer-led services. However in a study interviewing users of such a service, McClean [71] concluded that the founding principles had been lost in
the growth of these organisations. She concludes that
this has lead to a crisis in the movement that has
replicated standard mental health agencies, particularly in the divide between providers and receivers of
a service. A residential centre set up as an alternative
to hospital admission in North Wales was also evaluated by qualitative interview [72]. The centre was

intended as a person centred environment. They

found that however person-centred the approach, issues around the power differential between staff and
patients persisted. However patients still valued aspects of the new service.
Colombo et al. [73] examined how decisions are
made in multidisciplinary mental health teams in the
UK. They interviewed 100 participants, including
psychiatrists, nurses, social workers, patients and
carers using specific questions to establish what
model of mental illness participants used and how
decisions are made in clinical care. Whilst different
groups emphasised different models of illness, the
decisions made were felt to be influenced by the sick
role of the patient. The authors stated, On the one
hand patients are unconsciously encouraged, via the
sick role, along with its associated rights and obligations, to become passive recipients of care. On the
other hand, via notions such as patient empowerment
and social inclusion, they are being subjugated to
contradictory messages encouraging them to take on
more responsibility and to see this as an important
civil right... Underlying beliefs about the need to
recognise patient rights and autonomy do not sit
comfortably along-side structural and implicit support for the sick role. They conclude that for effective care, patients need to be recognised as part of the
multi-disciplinary team.

Discussion
Researchers have examined the connotations of trust,
choice and power, developed tools to measure all three
and there is a significant research base stressing that
they are important to patients. The literature review
was limited to PubMed, which may have biased the
findings to anglophone journals. Due to the large
number of articles identified, they were screened by
article title and then abstract, which may have missed
some relevant research. However some articles not
identified in the search were picked up by references in
the identified papers. Whilst we reviewed trust, choice
and power as three distinct areas, there were several
papers identified by two or three of the different
searches, emphasising how these areas overlap. For
example research on trust emphasised the importance
of clinicians giving patients information and a role in
choosing treatments in building trust (e.g. [22]).
Most quantitative research on trust has taken place
in the US amongst community population samples or
on patients attending family doctors. Trust in individual clinicians has been shown to be high and robust to pressures on this trust [18]. Important
variables associated with higher levels of trust are
older age of patients and greater continuity of care,
both in terms of length of time the patient has known
the doctor and the number of consultations. In mental
health, qualitative studies in the UK suggest that trust

850

is important to patients, and that again continuity of

care is an important aspect to build trust [23, 24]. A
study in the US suggests that attention to patients
concern about medication side effects, confidentiality
and continuity of care are important to mental health
patients in building trust [25]. Overall the current
evidence suggests that trust has not been significantly
eroded in health care and is valued by mental health
patients in their relationship with clinicians. However
quantitative studies on mental health patients are
needed including on interventions that might build
trust.
There is significant research evidence on patient
choice suggesting that patients value choice in their
interactions with staff [42] and being given information on their illness and a say in treatment decisions
[39, 40]. There is some evidence that in routine care,
mental health patients are offered more treatment
choices than other areas of medicine [41]. In general
and mental health, sociodemographic factors can
influence how much choice patients want, but individual variation is also important [31, 33, 35]. Patients
given choice of treatment in mental health may be
more likely to enter treatment and stay in treatment
[34, 43]. The effect of patient choice on clinical outcome is variable. Limited evidence may suggest that
in less severe illnesses choice has a positive effect on
outcomes, whilst this is not so in more severe conditions. However the number of studies is small and
of varying quality.
Empowerment scales have been developed in
mental health and have suggested multiple domains
[57, 59]. It is unclear if these scales can be used in
intervention studies, as their sensitivity to change is
not established. There is a research base examining
power issues in the relationship between patients and
clinicians and it is mostly qualitative in nature. The
issue of a power imbalance matters to at least some
patients, and can be a factor in patients disengaging
from services [70]. The ideological conflict between
the patient in the sick role and patient empowerment
is evident when different stakeholders are interviewed
[73]. Setting up patient-led services and patient-centred services to try to overcome this power imbalance
is not necessarily successful at achieving that aim, as
new power imbalances can emerge [71, 72]. Studies
on patient empowerment suggest that practical steps
have been introduced at a managerial and planning
level, but this is harder to implement at an individual
care level, despite some evidence that patients feel it
improves their care [63]. Employing users of services
as health care assistants is a relatively new development and may improve outcomes [67, 68].

Conclusions
There is a substantial research base in trust, choice
and power in mental health care. The methodology

used has often been qualitative, but quantitative

studies have also been fruitful, and empirical measures of trust, autonomy and empowerment have
been developed, although for trust not validated in
mental health. Qualitative methodology, whilst in
some aspects more consistent with postmodern
thought, seeks to reflect individual experience rather
than population probabilities. Nevertheless, qualitative research often aims to find generalisable conclusions, partly to justify funding and publication.
The research methodology has been disparate,
needs developing, and would benefit from being
consistent and coherent. Quality standards of methodology do not mean identical methodology, but
standards need to have clear definitions and operationalised approaches. The studies that have been
described have met these criteria to a varying degree.
In the introduction it was postulated that the debate
about trust, choice and power may have been influenced by postmodern cultural change. There is an
inherent tension in studying postmodern ideas using
clearly modernist methodologies. Is the paradigm of
postmodernism an excuse for not researching ideas?
We would argue that it is acceptable to use both
empirical and non-empirical evidence to evaluate
mental health care. Furthermore funding bodies and
journals will demand agreed consensual quality
standards in research methodologies.
The issue of trust in mental health clinicians has
not been as well researched as it has in other areas of
medicine. Trust in doctors appears to be robustly
high in other medical disciplines and we need to
discover if this is the case in psychiatry, as well as the
importance of continuity of care and age in influencing trust. The area of patient choice has had more
evaluation in mental health. Offering patients choice
appears to be what patients want. However, in general
health care and mental health, they do not appear to
want a consumerist system but rather a partnership
with their clinician where the knowledge of the expert
is utilised by the patient. Giving patients choice seems
to increase engagement with services, but effects on
outcome are variable. International comparisons of
patient choice may well be enlightening, as some
consumerist systems offer much more patient choice
than others. Patient empowerment in mental health
has developed at an organisational level. The challenge is to empower patients in their individual care
as currently the evidence suggests that this has not
been established.

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