Overview | Clinical Scenarios | Additional Tips | References

By Susan Hatters-Friedman, MD

OVERVIEW

General Principles

Stalking is defined as “engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others; or suffer substantial emotional distress” according to the Violence Against Women Act of 2005.

• It is critical to be aware that there is no single definition of stalking used legally across the American states. Therefore, one should be aware of their jurisdiction’s law and penalties and definition.

CLINICAL SCENARIOS

Scenario #1: A patient is angry that he has been civilly committed. He threatens the psychiatrist who civilly committed him, and after release from the hospital remains preoccupied with the psychiatrist, sending angry letters and threatening to report the psychiatrist to the medical board.

• It is first important to acknowledge that one is the victim of stalking behaviors. Surprisingly perhaps, psychiatrists often do not think of their own safety in the early stages of stalking behaviors, but rather focus only on their therapeutic stance toward the patient.
• Mullen and colleagues described various types of stalkers. These include:
  • The rejected stalker
  • the intimacy-seeking stalker
  • the incompetent stalker
  • the resentful stalker
  • the predatory stalker
• The first case scenario depicts a resentful stalker. They are acting on grievances against a specific person and they mean to frighten or distress their victim.
• The angry patient’s conduct is concerning for stalking. The psychiatrist should contact their supervisor and consider a forensic consultation. Other measures might include:
  • contacting the security services
  • contacting local law enforcement
  • parking one’s car near security or having security escort one to one’s car
  • only seeing patients when others are present in the office
  • planning a safe escape route
• Additionally, basic security measures both at home and at work are important, including locks and alarm systems where needed.
• The psychiatrist should document problematic behavior and all attempts at interventions. Ongoing risk assessment is also important.
• If a mental health professional becomes the target of a stalker, they should continue to guard their personal information carefully, including on social media. Boundary violations should be noted, such as requests for personal information, phone calls, gifts, messages, and contact outside of the work setting. These activities should be noted in the medical record. Finally, contact with supervisors or specialists is important.
• A protection order or restraining order may be considered. In some cases, these will help and in other cases less so. A restraining order is a step to potentially take subsequent to forensic consultation, depending on risk.

Scenario #2: A female patient develops erotomanic delusions about her psychiatrist. She leaves gifts at the psychiatrist’s office and notes under the car’s windshield wiper in the doctors’ parking lot. She attempts to follow the psychiatrist and to learn the psychiatrist’s home address. She can tell they have a special connection from the way the psychiatrist spoke to her. She is convinced that they are in love with each other.

• This is an example of Mullen’s category of intimacy-seeking stalker. These individuals have morbid infatuations or delusional disorder regarding a person, including their psychiatrist.
• While psychiatrists may initially minimize it when a patient appears infatuated with them, this may be an erotomanic delusion which can lead to stalking behavior. As such, it is important to recognize this early on to engage in primary prevention. Rather than disposing of any gifts in the second scenario, these should be documented. Measures followed in Example 1 are also of great utility here.
• The psychiatrist should also be aware that female stalkers can be as dangerous as male stalkers. They tend to target people who they know and may threaten their victims or become violent. It is critical not to underestimate a female stalker’s risk of violence just because of her gender.

Scenario #3: A new patient is demanding the prescription of a specific benzodiazepine medication. When the psychiatrist states that this is not the right prescription for the patient’s condition, the patient makes veiled statements about knowing where the psychiatrist lives.

• This patient, according to the vignette, has not yet engaged in a pattern of stalking, but rather may be threatening as a one-off in order to obtain the substance they desire.
• In cases like these, it is critical to set firm boundaries, as well as having preventive strategies in place should such a situation occur. Basic security measures at work and at home, as well as minimizing the online presence is important, as well as is contact with security.
• Of note, it is important to have a plan for termination of treatment in scenarios where the patient and the psychiatrist’s treatment goals do not align. Keep in mind the risk of abandonment.

ADDITIONAL TIPS

1. All issues related to stalking should be documented.
2. Any inappropriate gifts or communications should be documented as well as any threatening statements. All of this should be discussed in supervision as well.
3. Any forensic consults subsequent to the stalking should be documented, along with the safety plan.
4. Methods of stalking will continue to change over time as technology changes, and psychiatrists should safeguard their personal information as much as possible including on social media.

REFERENCES

1. APA Council on Psychiatry and Law. Resource Document on Stalking, Intrusive Behaviors and Related Phenomena by Patients. 2019. Available from: https://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/resource-documents
2. Pinals DA, editor. Stalking: Psychiatric perspective and practical applications. New York: Oxford University Press; 2007.
3. West SG, Friedman SH. These Boots are Made for Stalking: Characteristics of Female Stalkers. Psychiatry (Edgmont). 2008 Aug;5(8):37-42.