For months, "Lisa" had strange but seemingly benign interactions with her client "Tom." He requested a hug at his first appointment, called her a nickname and continued to bring her small gifts after she asked him to stop. But Lisa became increasingly uncomfortable when, six months into therapy, Tom turned his camera on her after asking to take photos of flowers during a therapy session in the clinic's gardens, a common practice there to promote mindfulness and openness. Later, Tom presented Lisa with a photo album with the pictures and other gifts, including an animated movie he had created of the two of them.
After consulting with her supervisor at the mental health clinic where she worked, Lisa talked with Tom about ending therapy since his clinical symptoms had improved. But that only made things worse: He sent her a poem describing his plan to kill her family and move in with her. He threatened to send a letter to authorities and the media accusing Lisa and her supervisor of malfeasance for transferring him to a male therapist.
Lisa is the subject of a stalking vignette described in the March Journal of Threat Assessment and Management. Stalking — which the U.S. Department of Justice defines as "a course of conduct directed at a specific person that would cause a reasonable person fear" — has been criminalized in every state over the past 30 years.
Among the general population, about 16 percent of women and 5 percent of men are stalked, according to a 2011 report from the Centers for Disease Control and Preventionopens in new window. The incidence is estimated to be higher among mental health professionals: At least 7 percent to 11 percent of mental health care professionals are stalked by a patient or client during their careers, though such statistics are hard to pin down since stalking cases are underreported and even unrecognized, experts say (Psychiatric Servicesopens in new window, 2005).
Psychologists tend to categorize stalkers in five categories: rejected people, or those who won't accept a "no"; intimacy seekers who aim to win the hearts of their victims; stalkers who fail to read social cues; revenge seekers; and predators, or those who physically attack their victims (American Journal of Psychiatryopens in new window, 1999).
Mental health professionals tend to be victims of intimacy seekers or resentful stalkers because of the nature of their work. A therapist's empathy, for example, may be misconstrued by a client as romantic interest. Or a psychologist's custody evaluation may anger a client, who then makes threats in revenge.
Handling such situations is frequently complicated. While people who are not health-care providers can report threatening behaviors to the police, "the real rub for psychologists comes from the fact that you have this unique relationship, institutional constraints and consequences if you break confidentiality," says Anders Goranson, PsyD, a psychologist at the U.S. Department of Veterans Affairs in Portland, Oregon, and a professor of psychiatry at Oregon Health and Science University.
What's more, few mental health care providers are trained to recognize and respond to stalker behavior among patients, and many are reluctant to admit they don't feel comfortable taking a case, Goranson says.
To help address the problem, he and other psychologists have developed guidelines cited in the Journal of Threat Assessment and Management paper for both independent practitioners and health-care institutions. (APA does not have explicit guidelines on the topic.) The article's guidelines outline how individual providers and health-care institutions can handle stalking behavior among patients and clients safely and ethically. The psychologists are also advocating for psychology training programs and professional organizations to better prepare psychologists for the possibility of stalking.
"Stalking is real and it's significant for a certain minority of mental health care providers and health-care providers in general," says psychologist David Drummond, PhD, of Oregon Health and Science University. "We owe it to them to educate them about where that boundary is" between what's clinical and what's criminal.
Here's how to recognize and respond to stalking behavior:
Be aware. University of California, San Diego, forensic psychologist Reid Meloy, PhD, describes stalking as comprising three common elements: a pattern, threats and fear. "The paradox is that if you don't know you're being stalked, there's no crime," he says.
Psychologists in particular can be blind to the crime since they aim for empathy, trust and non-maleficence toward their patients, says Drummond, who co-authored the Journal of Threat Assessment and Management paper with Goranson and Malique Carr, PhD, of Kaiser Permanente L.A. Medical Center.
"When you think about it, the phenomenon runs contrary to what most of us learn in our training: the centrality of therapeutic relationships," he says. "The stalker turns it on its head and uses it against us."
Raising awareness of the issue needs to start with training and health-care institutions, experts say. There, current and future mental health professionals can learn to identify stalking behaviors and know where to turn in cases of troubling patient behavior. Such increased knowledge can help create a culture that makes victims of stalking feel less isolated, too, the researchers say in the paper.
Jennifer E. Storey, PhD, a postdoctoral fellow at Simon Fraser University, argues that psychology training programs and professional organizations should help mental health professionals prepare for the possibility of being stalked by patients by adding discussions of stalking in curricula, disseminating fact sheets or providing continuing education seminars on the topic (Journal of Threat Assessment and Management, 2014). "Even small steps such as these may help to increase awareness and spur work related to this important issue," she writes.
Be prepared. In their paper, Drummond, Goranson and Carr recommend asking all new patients to sign an informed consent document that sets boundaries, such as no gift-giving, no meeting outside of therapy for social activities, and no contact through social networking sites. If these boundaries are violated, it's easier to point out to the patient why he or she needs to stop.
It's also important to keep a record of any potentially inappropriate contact by patients. For example, Meloy advises saving emails and phone messages from clients so that they can be used as evidence if the situation escalates.
He also says it's a mistake to try to reason with a client who is crossing boundaries, since such discussions tend to accelerate the unwanted behavior. "If you become frightened of a patient, take action, enlist a consultant and begin to actively provide for your own safety," Meloy says.
Being prepared also means protecting your personal information online, says Keely Kolmes, PhD, a private practitioner in San Francisco. In an as-yet-unpublished study of 332 psychotherapy patients who had found personal or professional information about their psychotherapists online, she and Dan Taube, JD, PhD, of Alliant University, found that 70 percent of those surveyed found personal information about their therapists online — such as family details or a birth date — and only 27 percent of that group told their therapists about the behavior.
The good news is that such behavior is rarely harmful or ill-intentioned: Only 3 percent of patients surveyed paid for access to public records, and fewer than 1 percent hacked into an account. "What we found that should be reassuring to clinicians was, for the most part, this was just benign curiosity," says Kolmes, whose social media policyopens in new window has been used as a teaching tool and cited internationally.
Nevertheless, Kolmes recommends psychologists take precautions, such as adopting a social media pseudonym or disabling location-based social media settings, to better protect personal information. She also suggests psychologists ask family members to tighten their own social media settings since patients often look at their therapists' spouses' or children's social media pages as a way to learn more about the therapist.
Kolmes says it's important for the psychologist to bring up the topic early in therapy by encouraging patients to speak up if they see anything about their therapist in the news, online or in any other public forum. "Inviting that conversation will help patients deal with any shame and embarrassment about both their curiosity and their desire for a deeper connection," she says.
Establish connections. All psychologists should have an interdisciplinary network of colleagues who can help support them during a variety of situations, including when they become uncomfortable with or fearful of a client. In the mid-1980s, Drummond realized that when he walked into a fellow clinician's office and found a highly intoxicated patient with a revolver in his hand. "That was a wake-up call," said Drummond, who was able to help resolve the situation safely. To prevent such problems in the future, he and a team developed a system — now used throughout the VA and other major health-care systems — that flags patients who are known to be violent. The system brings together health-care professionals, law enforcement officials, nurses, hospital administrators and others trained in violence risk assessment to discuss cases brought in by concerned clinicians.
That type of collaboration is more effective than "individual psychologists or psychiatrists sitting in a corner, flipping through a patient's chart and saying, ‘Oh yeah, my gut tells me this person is at high risk or low risk'" because the team considers various risk factors before setting limits with patients or flagging them, Drummond says. "We want to make sure that we have made a good-faith effort to render the best possible risk assessment we can so that the patient may continue to receive appropriate health care in an environment where everyone feels safe," he says.
So, get to know the local professionals who are trained in violence risk assessment and understand the laws in your jurisdiction, Drummond advises. "It's too late when you have a suicidal patient to realize that you don't have a relationship with a hospital in town where you can get a patient admitted. It's too late if you don't know who the law enforcement people are in town whom you can call when a patient is threatening a neighbor or wife," he says. "You need to be thinking through these unlikely unpleasant events before you go to work so that if and when something like that occurs, you have a plan."
Take action. Your plan to address any problems will depend on your role, the client's behavior and the laws in your jurisdiction. In some cases, it may simply mean enlisting a supervisor or an expert like Meloy to help confront the patient and set clearer boundaries. If the behavior continues, you may be advised to transfer the patient's care to a provider who's aware of the patient's history.
In other cases, it may mean involving area law enforcement to help monitor the behavior and intervene if necessary. That approach was effective for a psychiatrist who consulted Drummond about a patient who had stalked him for 15 years — even calling and emailing nonstop after the psychiatrist moved from the East Coast to Oregon to escape her. When the police visited her home to warn her that her behavior was criminal, it stopped.
In extreme situations, arresting the patient — while ensuring he or she continues to receive mental health care treatment — may be the safest way to go. That was the case for a woman who stalked multiple therapists over 20 years and even held two at gunpoint.
Seek support. The consequences of being stalked can be long-lasting. One study found that 5 percent of stalked mental health providers eventually left the field and 25 percent reported lost time from work (Psychiatric Servicesopens in new window, 2005). One in seven victims moves to try to escape the stalker, the U.S. Bureau of Justice Statisticsopens in new window reports. Three percent of therapists even carry a weapon to protect against a former patient, according to the 2011 book "Ethics in Psychotherapy and Counseling: A Practical Guideopens in new window."
"It has a huge impact and continues to have an impact," Goranson says.
Yet psychologists don't always get the support they need to cope with the effects, since the problem can be stigmatized and trivialized in professional circles.
For Lisa, whose client was eventually transferred to a community-based provider, the experience left her sleep deprived and hazy, even alienated from colleagues, who considered her situation more a subject of "juicy gossip" than an opportunity to provide support, the paper says.
"Mark," a stalked psychiatrist described in the same paper, also felt less connected to colleagues, receiving little support as he installed security systems at work and home, prepared for court appearances, and began a new job. His colleagues seemed to believe that the stalker's behavior would pass.
"For people who have never experienced the terror of having someone intentionally intrude on your life with the purpose of making you feel afraid, it's difficult to communicate, they tend to blow it off," Drummond says. He recommends that victims of stalking seek therapy, since the experience can trigger symptoms of post-traumatic stress disorder. Health-care institutions, too, can help support victims of stalking by linking them with legal practitioners and connecting them with other health-care providers who have been in similar situations. At Goranson's local VA, for example, they're testing a small informal model that helps make those ties. "That's one development that we think will become more formalized," he says. "Every time we talk about it, I think, ‘Wow, we have to do this.'"