Being Stalked--An Occupational Hazard?

July 2006, Vol. XXIII, No. 8

Even though psychiatrists and other mental health professionals are more likely to be stalked than the average person, they receive little training in the concept of stalking or its management, according to a recent editorial in the British Journal of Psychiatry.¹

"Stalking of health care professionals is a common occupational hazard, yet it remains underresearched and underreported and can lead to significant distress and psychiatric morbidity," said Ronan McIvor, MB, BCh, MRCPsych, consultant psychiatrist at Maudsley Hospital in London, and forensic psychiatrist Edward Petch, MB, MRCPsych, DFP, of the West London Mental Health National Health Service Trust.

Several studies point to the risk of both stalking and harassment.

Galeazzi and colleagues² surveyed mental health professionals operating in the public and private sectors of Modena Province in Italy, and found that 40 of 361 respondents (11%) said they had been stalked, and in 90% of those cases the stalker was a client under the direct care of the clinician.

In Australia, health care professionals were overrepresented in a sample of 100 self-referred stalking victims (9 general practitioners, 3 psychiatrists, 2 gynecologists, 1 rheumatologist, 1 medical resident, 1 psychologist, 1 nurse, and 1 occupational therapist).³

In the United States, Romans and colleagues⁴ surveyed a random sample of counseling centers that were accredited by the International Association of Counseling Services. Responses from 178 counseling center staff members showed that 5.6% of the sample had been stalked by a current or former client, 8% had had a family member stalked, and 10% had had a professional under their supervision stalked.

Earlier, Lion and Herschler⁵ had surveyed clinicians attending the annual meeting of the Oregon Psychiatric Society about stalking. Twenty-six (29%) of the 90 respondents had been subjected to behaviors that met the authors' definition of stalking, and 37 (41%) reported having experienced other forms of distressing intrusions.

Forensic psychiatrists may be at greater risk. One survey of forensic psychiatrists looking at harassment outside of court found that 171 (42%) of the 408 respondents had been harassed in some way: 68 (17%) reported threats of physical harm, 13% reported nonviolent threats (such as a lawsuit), and 3% had been physically assaulted.⁶

When Sandberg and colleagues⁷ surveyed all clinical staff employed in an urban, university-based psychiatric inpatient unit, 33 of the 62 respondents (53%) reported having been the target of stalking, threatening, or harassing behavior outside of the hospital or other locked settings during their careers. More specifically, 2 respondents (3%) said they had been stalked (defined as willfully, maliciously, and repeatedly followed and harassed in a way that threatened the clinician's safety) by a psychiatric patient and 5 (8%) reported obsessional following (defined as more than 1 overt act of unwanted pursuit that was perceived by the professional as being harassing).

One of the study coauthors, psychiatrist Renee Binder, associate dean for academic affairs at the University of California, San Francisco, School of Medicine, told Psychiatric Times that harassment behaviors are more common than stalking.

There have been several cases, Binder said, in which patients write inappropriate letters about being in love with their psychiatrists and wanting to get together with them. The patients fantasize about how their psychiatrists reciprocate their love. Often, they know personal information about their psychiatrists, such as names of family members and where the psychiatrist lives.

"I have also been consulted on cases where a patient shows up at an office or parking lot, or is watching the psychiatrist at home; that can be pretty scary stuff," said Binder, a trustee of the American Psychiatric Association.

Stalker characteristics

J. Reid Meloy, PhD, a board-certified forensic psychologist in independent practice and associate clinical professor of psychiatry at the University of California, San Diego, School of Medicine, told Psychiatric Times there are some general characteristics of patients who harass or stalk psychiatrists and other mental health professionals. They tend to be primarily male with a major mental disorder (Axis I) as well as an Axis II personality disorder, he said, which is very consistent with the general literature on stalking. While males predominate as stalkers, Meloy added that in his experience of consulting in about 30 cases since the early 1990s, there were instances in which female patients stalked their male doctors--and, in one case, a female psychiatrist.

Another characteristic noted by Binder is a history of stalking.

"It may not be stalking of another psychiatrist, but may be of a friend or colleague or a professor that they have had," she said. "If there is any kind of stalking behavior, that information is invaluable, particularly if there is information on what has been effective in the past in stopping this behavior. . . . Some people respond well to limits, some people don't. Some people respond well to restraining orders, some people don't."

The average length of a stalking case is about 1.5 to 2 years, based on a compilation of all the data, Meloy said.

"I don't think there [are] any specific data on duration of stalking of mental health professionals, but I would say that it is likely to be a long-term project on the part of the stalker," particularly if the stalking exceeds 2 weeks, he said.

In one case, Doreen Orion, MD, a psychiatrist, was stalked for 10 years by a former patient she had treated for 2 weeks.⁸

Meloy, who wrote Psychology of Stalking: Clinical and Forensic Perspectives (Academic Press, 1998), warned that often mental health professionals will engage in both minimization and denial of their patient committing criminal acts against them, including stalking. Yet stalking is a crime under the laws of all 50 states, the District of Columbia, and the federal government.⁹

"One of the toughest things I have had to overcome in my consults is to convince the doctors that there is a real threat and that they need to look at their own defensive posture in relationship to the patient and to not deny that it is occurring and to also not minimize the risk," he said. "We know in stalking cases that the risk of physical violence is quite high. It ranges from 25% to 35%."

Education and strategies

Because awareness of stalking is limited, according to McIvor and Petch,¹ health care organizations should consider adopting formal educational programs, particularly for staff in the early stages of their career.

Such programs would center on increasing awareness of the problem, highlighting increased risk for mental health professions, and summarizing the current literature on the subject, McIvor told Psychiatric Times. This could be followed by general ways to reduce the risk of being stalked and advice on what to do if it actually begins.

McIvor emphasized that it is vital to take any stalking behavior seriously from the beginning.

"After receiving the first letter or contact, tell the patient clearly and unambiguously that their behavior is unacceptable and should stop. This will often be enough. If it continues, inform colleagues and have no further contact with the patient, ensuring that their care is transferred appropriately," he said. "Do not initiate further contact with the patient; it will simply reinforce the stalking behavior. Get the police involved sooner rather than later, [because] a verbal warning may be enough to stop further harassment."

McIvor, Binder, and Meloy each offered some strategies to reduce the risk of being harassed or stalked by a patient or ex-patient and to address such behaviors. A compilation of their suggested strategies includes the following:

• When working with a new patient, set limits early. Define what a therapeutic relationship is and what boundaries are.

• Minimize risk by using a work or post office address rather than home address in directories of professional or community organizations; by removing yourself from online search engines; by using pseudonyms when expressing opinions via the Internet in bulletin boards and online discussions; by shredding personal and domestic documents; and by not disclosing personal information to patients or having family pictures in the office.

• Carry out a risk assessment (risk factors, history, etc).

• If you are the target of criminal behavior of a current patient, attempt to terminate the case in a professional way, such as by making appropriate referrals. Don't be overly concerned about treatment abandonment issues.

• Pay close attention to how your behavior could unwittingly reinforce the stalker's pursuit.

• Let colleagues know you are being harassed and/or stalked and alert others in the building in which you work.

• Carefully document all incidents, including transcribing messages left on your phone rather than just erasing them.

• Retain any evidence (eg, letters with envelopes: DNA samples can be extracted from the back of a postage stamp).

• Get advice from experts in stalking behaviors. This is particularly helpful should the patient file a complaint with a state licensing board, alleging treatment abandonment or some other misconduct.

• Contact police, but recognize that this does raise issues of confidentiality. An initial contact might be: "I think I am being stalked but I'm not free to identify who it is. I want to at least report this incident and talk with somebody in my jurisdiction about this threat toward me."

• Seek help for the psychological consequences, including feelings of fear, anxiety, guilt, helplessness, anger, frustration, and disenchantment with the profession. References
  1. McIvor RJ, Petch E. Stalking of mental health professionals: an underrecognised problem. Br J Psychiatry. 2006;188:403-404.
  2. Galeazzi GM, Elkins K, Curci P. The stalking of mental health professionals by patients. Psychiatric Services. 2005;56:137-138.
  3. Path, M, Mullen PE. The impact of stalkers on their victims. Br J Psychiatry. 1997;170:12-17.
  4. Romans JSC, Hays JR, White TK. Stalking and related behaviors experienced by counseling center staff members from current or former clients. Profess Psychol: Res Practice. 1996;27:595-599.
  5. Lion JR, Herschler JA. The stalking of clinicians by their patients. In: Meloy JR, ed. The Psychology of Stalking: Clinical and Forensic Perspectives. San Diego: Academic Press; 1998:163-173.
  6. Miller RD. The harassment of forensic psychiatrists outside of court. Bull Am Acad Psychiatry Law. 1985;13:337-343. Cited by: Norris DM, Gutheil TG. Harassment and intimidation of forensic psychiatrists: an update. Int J Law Psychiatry. 2003;26:437-445.
  7. Sandberg DA, McNiel DE, Binder RL. Stalking, threatening, and harassing behavior by psychiatric patients toward clinicians. J Am Acad Psychiatry Law. 2002; 30:221-229.
  8. HealthyPlace. Stalking and Obsessive Love Transcript. Available at: www.healthyplace.com/ Communities/Abuse/Site/Transcripts/stalking_and_ obsessive_love.htm. Accessed May 30, 2006.
  9. National Center for Victims of Crimes. Stalking Fact Sheet. Available at: www.ncvc.org/src. Accessed May 30, 2006.