When a Therapist Is Being Stalked

How can mental health professionals deal with patients who cross the line?

Posted Jan 20, 2014

Based on victim surveys, about 16 percent of women and 5 percent of men in the United States reported having been stalked at some point in their lives.

The legal definition varies, but stalking is usually defined as "repeated unwanted behaviors that reasonably cause the individual who is being stalked to experience fear of harm or death to self, family, or household," but many stalkers are careful enough to avoid breaking laws.

Even though the majority of stalkers are men, an estimated 12 to 22 percent are women, although the motivation often varies according to the intended target.

According to the research of Paul E. Mullen and his colleagues, there are five types of stalkers, although there can be considerable overlap among the different categories.  

  • Rejected stalkers who are seeking revenge following a perceived rejection (real or imagined).
  • Intimacy-seeking stalkers who are seeking to form a close relationship with their intended target.
  • Incompetent stalkers lack basic social skills and often engage in stalking behaviour in the hope of becoming intimate with their target.
  • Resentful stalkers are revenge-seekers who feel they have been somehow wronged by their target. They are often prone to paranoid ideation that is difficult to treat.
  • Predatory stalkers seek power and control over their targets and are most likely to intimidate their victims. These are the stalkers most likely to be charged for their offenses.

While most stalkers are not violent, the risk should not be overlooked despite the reluctance of many police officers to lay charges unless a clear criminal act occurs. Risk of violence usually rises in stalkers with a previous criminal history while nonpsychotic stalkers are more likely to become violent than psychotic stalkers.

Regardless of the actual risk of assault, stalking has a clear impact on the mental health of targets. Around 20 to 30 percent of stalking victims seek counseling because of the emotional distress caused by stalking and one in seven will change their residence. Stalking victims are also much more likely to arm themselves or take other defensive measures to ensure their safety. 

But what if the stalking victim is a mental health professional? Being stalked by a former patient is a potential threat for many therapists with studies of mental health settings in the United States suggesting that as many as 6 to 11 percent of therapists will be stalked by patients at some point in their careers. Studies of different medical specialties suggest that psychiatrists are the most likely to be stalked. One Australian study found that the incidence of psychiatrists who were stalked was as high as 19.5 percent.   

There is a long history of Incidents of violence directed against therapists by former patients  including the 1893 shooting of Dr. Gilles de la Tourette (of Tourette's syndrome fame) by a hysterical patient. More recent cases include the 2006 murder of Dr. Wayne Fenton by a patient he was assessing, the 2008 murder of Dr. Kathleen Faughey (by a patient who had targeted the psychiatrist she was sharing an office with), and the bizarre harassment campaign launched against Dr. Jan Falkowski by an amorous patient.  

Though there is rarely a consistent pattern to stalking of mental health professionals, the effect that it has on them can be extreme and long-lasting. A 2005 Italian study found that 8 percent of stalked professionals thought of changing their profession as a result of the stalking and 5 percent actually did so. One in four professionals who report having been stalked end up losing time from work in order to avoid their stalker or to get help from fellow therapists and attorneys.   

Stalking episodes can last as briefly as a few days or can persist much longer (the average length is about two years). During the time that the stalking occurs, professionals typically experience mental distress due to safety fears, lack of proper support from law enforcement and professional organizations, and the uncertainty over when and where the next confrontation will take place. Mental health professionals who are stalked often find themselves isolated from the people around them, many of whom develop fears for their own safety or who wonder if the targeted professional somehow "deserved" the harassment through their own actions.  

While professional organizations typically have procedures in place for dealing with various professional issues, they often fail to address the problem of mental health professionals being stalked by a current or former patient. As well, most clinical training programs tend not to address how to manage stalking behaviour and professionals, especially young professionals who are most likely to be stalked, are left floundering for answers when stalking occurs.   

Unfortunately, professionals being stalked by a patient find themselves in an ethical bind when it comes to pursuing legal options due to the need to respect patient confidentiality. While Tarasoff laws allow for breaking confidentiality when patients pose a threat to others, most ethical codes fail to take therapist stalking into account in permitting therapists to speak freely about their concerns. 

So what options are there for mental health professionals who find themselves being stalked?   Aside from increased security, greater vigilance, and generally following basic precautions recommended for stalking victims, a recent article published in the Journal of Threat Assessment and Management reviews the problem of professionals being stalked as well as providing guidelines for therapists to follow. Written by Malique L. Carr and Anders C. Goranson of Oregon's Department of Veterans Affairs and David J. Drummond of Oregon Health and Sciences University, the article reviews different strategies for managing stalking behaviour.   

By presenting two vignettes describing how patient stalking can escalate and the problems that can result from confronting patients over their actions, the authors then propose a management model focusing on primary prevention strategies that are used before the stalking occurs,  secondary prevention strategies to be used when patients violate professional boundaries and begin acting in ways that make the therapist uncomfortable, and tertiary prevention strategies to be used if the patient behaves in a way that causes harm or potential harm.  

These strategies can be applied by individual therapists or as part of the guidelines adopted by clinics or other agencies to protect therapists providing services under their employ. Since all stalking cases are different, there is no "one size fits all" solution for therapists feeling threatened by patients. Still, the different strategies described by Carr and her colleagues are flexible enough to be used as needed depending on the level of threat involved.

  • For individual therapists, primary prevention strategies usually focus on education so that they can learn to identify potential warning signs before they have a chance to escalate. That includes providing an expanded consent form describing inappropriate behaviours and the consequences of violating therapist safety. Mental health professionals are also advised to do a thorough review of the patient's previous interactions with therapists and identify potential "blind spots" that could affect patient and therapist safety. Therapists should also be careful about setting proper boundaries, i.e., accepting gifts, or allowing online personal contact on Facebook or Twitter. Therapists should also be sensitive to cultural norms that might send "wrong messages" to patients from traditional cultures who might have conflicting ideas about intimacy. Female therapists, especially younger females, are warned to be especially cautious about patients crossing boundaries. While formal guidelines may already be in place at a given clinic or agency, therapists should be completely familiar with them beforehand and also use their own judgment about what may make them uncomfortable.
  • Secondary prevention strategies usually involve consulting with colleagues, professional organizations, supervisors, legal counsel, and law enforcement. By consulting with colleagues and supervisors, therapists worried about being stalked can also protect themselves from charges of breaching confidentially without cause. This also means documenting every stalking incident in the patient record, i.e., all gifts, boundary violations, or other examples of behaviour that makes the therapist uncomfortable. The main question that needs to be asked at this point is whether the professional relationship can be salvaged or if the patient needs to be referred elsewhere. This can also mean referring the patient for psychiatric hospitalization if there are serious mental health concerns.  
  • If the secondary strategies are not enough, the next step is to refer the patient to law enforcement or to another therapist who might be better able to deal with the patient. Once the patient begins making threats of physical harm, then the therapeutic relationship is damaged beyond repair. This is especially hard for therapists who are not part of a larger practice since they cannot discontinue treatment without providing the patient with other options. Once again, there is no "one size fits all" solution and patients may respond even more aggressively to having treatment stopped abruptly. If the stalker feels humiliated or rejected by having the therapist cut off all ties with them, they may well transfer their anger to the new therapist. How the patient responds to having the treatment terminated should also be carefully documented. This can help with malpractice lawsuits and complaints to the police.

Mental health professionals being stalked by a patient often find themselves caught between their own ethical obligations and worries about their own personal safety and the safety of the people close to them. Unfortunately, they can also have trouble getting the support and guidance they need to deal with problem patients. As Carr and her co-authors point out, the three-step management model they describe in their paper is not meant to be seen as a complete solution for making therapists feel safe, but rather as a first step in getting help. 

It is still important for professionals being stalked to explore all possible options and to do whatever is needed to reduce the risk they face. Perhaps the most important lesson for professionals dealing with stalking is that they are not alone in facing this kind of problem and that consulting with fellow professionals can help deal with what has to be one of the most ethically charged problems a mental health professional can face.