Brook Zitek, DO

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm