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:
- To identify the unique problem of a patient stalking a psychiatrist and how to cope.
- To address what every stalking victim (including a patient) can do to protect herself or himself.
- 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*
| Type | Features | Assault potential | Response to legal interventions | Response to mental health interventions |
|---|---|---|---|---|
| Rejected | Response to an unwelcome end to relationship Seeks to maintain the relationship Long duration | Along with Predatory, the most likely to assault | Will usually curb behaviors | Typically not responsive to therapy |
| Resentful | Response to a perceived insult Seeks vindication Self-righteous and self-pitying | Most likely to threaten, least likely to assault | Will usually stop behaviors | Difficult to engage in therapy Focus on ruminations that drive stalkers |
| Intimacy seeking | Belief that they are loved or will be loved by the victim Satisfies need for contact and feeds fantasies of eventual loving relationship | May assault | Impervious to legal interventions | If erotomanic delusions are present, they are resistive to change |
| Incompetent | Intellectually limited Socially incompetent Desires intimacy but lacks sufficient skills in courting rituals | Low assault potential | Will stop Typically has previous stalking victims Responsive to restraining orders | May benefit from basic social skills and courting rituals education |
| Predatory | Desire is for sexual gratification and control Rehearsal for violent sexual fantasies and satisfaction of voyeuristic and sadistic desires | High assault potential | Cannot determine before an attack | Poor candidate for therapy |
| *Mullen P, Pathe M, Purcell R, Stuart G. Study of Stalkers. Am J Psychiatry. 1999; 156:1244-1249. | ||||