Trust in psychotherapists plays a key role in help-seeking behavior (Cavanagh et al., 2022). It is also strongly linked to better treatment outcomes, particularly when patients regularly communicate with their psychotherapist about whether they feel respected and trust in their relationship (Connolly Gibbons et al., 2023). Trust ratings of psychotherapists in their patients and vice versa do not necessarily have to correlate, but therapists’ evaluations of being congruent and empathic correlate with patients’ trust ratings (Peschken & Johnson, 1997). It remains questionable whether one can really speak of interpersonal trust between patient and practitioner. It may be a question of trust between two representatives of two groups who meet (Sousa‐Duarte et al., 2020).

Trust measures can either refer to psychotherapists in general or to one's own psychotherapist with whom one is undergoing treatment. While there is a larger number of survey instruments available for measuring trust in one's own treating psychotherapist, which is a time critical event that must be completed during psychotherapy (e.g., Crits-Christoph et al., 2019), there is a lack of questionnaires that focus on general trust in psychotherapists (Kassebaum, 2004), which this study investigated.

The concept of interpersonal trust is understood as trust in strangers or trust in people in general (Beierlein et al., 2012; Naef & Schupp, 2009; Rotter, 1967; Yamagishi & Yamagishi, 1994). There are different definitions, which contain (a) a subject, (b) an action, and (c) an expectation concerning the future. “Trust, however, involves present decisions, often based on another person’s past behavior, that require anticipating some action that hasn’t yet happened” (Borum, 2010, p. 8). Lower levels of interpersonal trust are associated with reduced economic performance as lower income or higher rates of unemployment (Lichter et al., 2021; Nikolova et al., 2022). Individuals with higher interpersonal trust values are happier and more socially integrated (Rotter, 1980). Furthermore, greater interpersonal trust is linked to higher quality of life (Tokuda et al., 2008) and better mental health (Folkman et al., 1986).

Institutional trust is typically measured using scales that assess the level of trust in specific institutions (Hudson, 2006; Schupp & Wagner, 2004), which are evaluated by residents of a country (González & Smith, 2017). Institutional trust can be separated into three categories: political trust (e.g., in the parliament), trust in impartial institutions (e.g., the healthcare system), and trust in control institutions (e.g., the media). Among these, the healthcare system generally achieves the highest scores in comparison with other institutions, such as the media (Rothstein & Stolle, 2002). Trust is also a crucial factor in both private and social contexts, which are highly relevant for psychotherapy: Higher levels of institutional trust have been linked to enhanced social cohesion and mental health outcomes (Defeyter et al., 2021; van Prooijen et al., 2022). Moreover, institutional trust can act as a protective factor against the negative impact of adverse life events on well-being (Glatz & Eder, 2020; Lee, 2022). It also appears to play a significant role in the economic management of a country and for coping with crises (Chen et al., 2024; Eitze et al., 2021; Lichter et al., 2021; Reinemann et al., 2022).

Studies on the measurement of trust in (healthcare) systems, healthcare practitioners and the trust between practitioners, and patients primarily rely on questionnaires focused on the patient-practitioner relationship (Aboueid et al., 2023; Ozawa & Sripad, 2013). Thereby, these instruments neglect to address system trust (Ozawa & Sripad, 2013).

Notably, interpersonal and institutional trust appear to be distinct concepts as they differ according to their relationship to other constructs and attitudes (Krastev et al., 2023) and can be distinguished in factor analysis (Naef & Schupp, 2009). A causal influence of institutional trust on interpersonal trust has been proposed (Sønderskov & Dinesen, 2016). On the other hand, interactions with practitioners are still considered an interpersonal factor in the development of institutional trust (Campos-Castillo et al., 2016). It is important to clarify these connections as they affect the effectiveness of psychotherapy.

Several factors identified in the literature as influencing the utilization of psychotherapy overlap with those associated with higher levels of institutional trust: The sociodemographic factors such as biological sex (female), higher education, not living together with a partner, income and age appear to be relevant in understanding the likelihood of psychotherapy utilization (e.g., Hahm et al., 2020; Petrowski et al., 2014; Vessey & Howard, 1993). Similarly, the sociodemographic factors gender, high school diploma, age and income have been identified as significant factors for institutional trust (Baroudi et al., 2022; Campbell, 2004; Campbell, 2023). This may indicate that there are the same influencing factors and possibly conceptual similarities of trust in psychotherapists and institutions. Since the present cross-sectional study design is exploratory, further relationships will be recorded here. Psychotherapy is embedded within the healthcare system and is regulated by institutional frameworks in Germany. As such, trust in psychotherapists may not only reflect interpersonal evaluations but also institutional trust that governs and provides psychotherapy.

Linking trust in psychotherapeutic settings to institutional trust could offer valuable insights into the factors influencing therapy effectiveness and accessibility. Understanding this connection can help identify barriers to treatment, improve patient engagement, and highlight the broader societal impact of institutional trust on health behaviors.

In this study, we aimed to investigate the relationships between the three different forms of trust: in psychotherapists, others, and institutions. Based on the literature, we assumed a stronger connection of trust in psychotherapists to institutional trust than to interpersonal trust.

Patients come to therapy with varying backgrounds, including experiences of trauma, resilience, personality traits, and beliefs. For this reason, the results were further contextualized in terms of factors relevant to psychotherapy: Associations between trust patterns and traumatic life events (Goenjian et al., 1997) were also investigated, as they contribute to psychological burden and psychotherapy usage. Differences in psychological resilience factors, such as general resilience (Bartholomew et al., 2022), belief in a just world (Furnham, 2003), and willingness to forgive others – a resilience factor for traumatic life events (Wade et al., 2005) – were examined. Personality traits were also analyzed as introversion and neuroticism may be risk factors for psychological disorders (Zinbarg et al., 2008).

An online cross-sectional study was conducted in Germany in December 2022 by two projects¹1

The two projects ‘SiSaP’ (University Hospital Jena) and ‘DDR-Psych’ (University Hospital Mainz) investigated the history of psychotherapy in the GDR (German Democratic Republic) and the psychological consequences of the former GDR.

The analyses were carried out using the statistical software IBM SPSS (Version 21). Analyses concerning gender issues included only male and female respondents due to the small number of people who selected the category ‘diverse’ or ‘other’. Results were considered significant at α = 0.05.

Trust in psychotherapists and institutional trust correlated on a significant level of r = 0.259 (p < .001). Trust in psychotherapists and interpersonal trust also correlated significantly r = 0.226 (p < .001). Multiple linear regression analysis (R² = 0.089 (adj. R² = 0.088); F(2, 1297) = 63.64, p < .001) confirmed the relevance of both, with institutional trust showing a slightly stronger connection as standardized β reached a higher value (Table 2).

The hierarchical clustering resulted in a 3-cluster solution for those participants that have gone through psychotherapy. The trust-profiles for each cluster can be seen in Figure 1. Each cluster of the exploratory study design showed its own trust-profile. Based on the mean values of the three trust categories (trust in psychotherapists, institutional trust, interpersonal trust) the clusters 1-3 can be described the following way: low trusters (Cluster I; n = 391, 30%) with low scores for all trust measures, high trusters (n = 642, 49%) with highest interpersonal trust values and high trust values in psychotherapists and institutions and system trusters (n = 267, 21%) with highest trust scores in psychotherapists and high levels of institutional trust, but lower interpersonal trust values.

In order to assess the separation between the clusters, a discriminative analysis was examined and confirmed the three clusters. A total of two discriminant functions was obtained for the three cluster categories. Their Wilk’s λ values were 0.229 and 0.821, all reaching significant levels with p < .001. The eigenvalue of the first discriminant function was 2.582, which could explain 92.2% of the variance. The eigenvalue of the second discriminant function was 0.219 and explained 7.8% of the variance (Table 3). On the two discriminant functions, the structural load of institutional trust and interpersonal trust were highest (Table 4). The centroid of each cluster in the discriminant function is shown in Table 5. The reclassification results reached an accuracy rate of 87.2% (Table 6). In sum, the discriminant analysis indicated a clear separation between the three clusters but should be interpreted as a descriptive assessment rather than an independent validation of the cluster solution.

The three trust groups differed according to all of the classification variables – expect conscientiousness (Table S3 Appendix): System trusters were less willing to forgive others, were less agreeable and extroverted, than the high trusters, who reached highest scores in these categories, but showed higher values than the low trusters. Both system trusters and high trusters more often believed in a just world. High trusters showed higher resilience scores and experienced less critical and potentially traumatic life events in comparison with the low trusters. The high trusters reached the highest score for openness and low trusters showed higher values of neuroticism (Figure 2 & Figure 3).

The representativeness of this study is limited due to the non-random sampling and the inherent characteristics of panel surveys. The results of these correlational analyses suggest the potential for the formulation of causal hypotheses regarding trust in psychotherapists, which should be investigated further. The analysis can only be described as exploratory. Given the diverse definitions of trust in psychotherapists, it cannot be ruled out that different questionnaires might yield varying cluster solutions. A combined analysis incorporating multiple trust questionnaires could provide further information and strengthen our findings. Furthermore, a limitation of this study is that it assesses general trust in psychotherapists rather than trust in a specific therapist, which may differ in important ways. Also, the concept of epistemic trust – the capacity to understand others’ and one’s personal behavior according to mental states, which is relevant in the psychotherapeutic relationship – was not measured (Fonagy & Allison, 2014). In addition, the identified clusters represent statistical groupings based on the included trust variables and should not be interpreted as clearly distinct psychological types. Besides, the data used is only based on self-reports. Furthermore, the experience of psychotherapy was quite broad: It included participants who are currently in therapy, have completed therapy, or have discontinued therapy. These experiences can vary and may be related to trust in psychotherapists. Finally, the results refer to the German healthcare system, which is characterized by relatively high institutional regulation and broad access to psychotherapeutic services. Given cultural differences, no generalizations can be made. These structural features may contribute to comparatively higher levels of institutional trust, which in turn could influence trust in psychotherapists. Research suggests that the relative importance of interpersonal versus institutional trust may vary across cultural contexts (e.g., Sikorski & Albrecht, 2025). Therefore, the generalizability of the present results to other countries and healthcare systems may be limited and should be examined in future cross-cultural studies.

Trusting the psychotherapist may imply trusting the system: This perspective emphasizes the need for an adjustment of the conceptualization of psychotherapy as a relationship embedded within an institutional framework. In the therapeutic relationship, a third entity – the institution or system – plays a role alongside the patient and the psychotherapist. This underscores the importance of evaluating not only the patients’ trust in the psychotherapists but also their perception of the (healthcare) system as perceived by both the psychotherapist and the patient. This approach may help optimize the efficacy of psychotherapeutic treatments.