What to do if you are stalked by a patient?

What to do if you are stalked by
a patient?
Silvana Galderisi
University of Naples SUN
[email protected]
What is Stalking?
A pattern of behaviour directed at a person used to convey an
implicit or explicit threat and perceived by the target as
unwanted and intrusive
Stalking is a problem behavior involving unwanted
communications or approaches that cause fear or significant
distress, and that are repeated over more than 2 weeks
Series of actions that are not on their own criminal actions (e.g.,
sending flowers, writing love messages, waiting outside the
place of work), but when coupled with an intent to instill fear or
injury they constitute an illegal behavior
Case report - FM
A 39 years-old woman attended the outpatient unit of our University
Department of Mental Health from 2009 to 2011.
She was affected by:
Major Depressive Disorder with recurrent episodes
Borderline Personality Disorder (emotional instability,
aggressive behaviours and impulsiveness)
Transient psychotic symptoms (persecutory and erotomanic
delusions, ideas of reference)
1999: first depressive episode
2004: first psychiatric contact due to sudden change in her lifestyle and
psychopathology (social withdrawal, high levels of anxiety, physical
complaints, inner tension and depression)
2007-2008: admission to a forensic psychiatric hospital and later to a
rehabilitation unit due to stalking behaviours and physical aggression
toward her psychiatrists
Case report - FM
2009 She started attending our outpatient unit and was
prescribed treatment with quetiapine (600 mg/day) and
started CBT
2010 Due to persistent feelings of anger and irritability,
carbamazepine (400 mg/day) was added to the therapy
She regularly attended scheduled appointments, but
was not compliant with this prescription and
arbitrarily stopped quetiapine
Case report FM
The patient developed erotomanic delusions toward her
In January 2011, her psychiatrist refused to see her one day
earlier than scheduled; patient started to
• Call her phone repeatedly
• Follow her (home and to other places)
• Wait for her outside her workplace
• Send harassing emails
• Threaten her with physical aggression and death
• Vandalize her house
Relatives of the victim, the Head of Psychiatric Emergency Unit
and her family were also stalked.
What did the victim/psychiatrist do?
Altough the victim tried to rebuild the therapeutical
relationship at first, the stalking behaviours never
stopped and forced her to take increasing safety
At last, the patient was sued, arrested and convicted,
but it was difficult and time consuming for the victims
Prevalence of Stalking
Being stalked is a common
17- 30% of women and 4-12% of
men in Western nations report
being stalked at some time in
their lives
The estimates vary according to
the methodology and definitions
Purcell et al. Aust N Z J Psychiatry 36:114 –20, 2002; 2. Stieger et al, Eur J Psychiatry
22:235– 41, 2008
Prevalence of
Highest victimization rates in the mental health
professions, especially among psychologists and
psychiatrists involved in direct patient care
Prevalence in the surgical specialties approaches that
of psychiatrists
Pathé & Meloy, J Am Acad Psychiatry Law 41:200–5, 2013
Predominant motives for stalking
• Anger
• Resentment
• Infatuation
Purcell et al, Prof Psychol Res Pract 36:537– 43, 2005; Abrams & Robinson, J Nerv Ment Dis 199:738–
43, 2011; Pathé & Meloy, J Am Acad Psychiatry Law 41:200–5, 2013,
Mullen stalker
1. Rejected
2. Intimacy-seeking
3. Incompetent
4. Resentful
5. Predatory
(1) Mullen PE, Pathé M, Purcell R, Stuart GW: Study of stalkers. Am J Psychiatry 1999;156:1244–1249.
Main forms of harassment
Repeated telephone calls
Unwanted approaches
Correspondence and email
• Property damage
• Unsolicited gifts
Purcell et al, Prof Psychol Res Pract 36:537– 43, 2005; Galeazzi et al, Psychiatr Serv 56:
137–8, 2005; Abrams & Robinson, J Nerv Ment Dis 199:738–43, 2011; Pathé & Meloy, J Am Acad
Psychiatry Law 41:200–5, 2013
Main forms of harassment
SMS; on line chat rooms; whatsapp
Hacking into victim’s computer
Superimposing victim’s images on pornographic
images and web-broadcasting them
Sending e–mails with pornographic staff
Steeling victim’s identity
Writing to relatives and friends of the victim from
their email address
Accusing the victim of pedophilia or other criminal
Purcell et al, Prof Psychol Res Pract, 2005; Galeazzi et al, Psychiatr Serv, 2005; Abrams & Robinson, J
Nerv Ment Dis, 2011; Pathé & Meloy, J Am Acad Psychiatry Law, 2013
Stalking may persist for years!
Duration of stalking may vary from
two weeks to more than 10 years
The stalking of mental health
professionals by their patients tends
to be characterized by protracted
periods of intrusive behavior lasting
months or years
The most extended episodes are
associated with patients who are
deluded and female
Purcell et al, Prof Psychol Res Pract 36:537– 43, 2005; Abrams & Robinson, J Nerv Ment Dis 199:738–
43, 2011; Pathé & Meloy, J Am Acad Psychiatry Law 41:200–5, 2013,
Stalking Mental Health Professionals
Mental health professionals are
more vulnerable than others to
stalking behaviors due to the
attachments of
patients and the distress and
disturbance this causes
Male and female health
professionals share a similar
risk of victimization by patients
Is there a profile of the stalker?
• Single
• Unemployed
• With psychosis or
personality disorder
Warnings of possible stalking
Approaches outside the workplace
Repeated inappropriate
Expressions of inappropriate
Repeated loitering near the
professional or their home, office,
or car
Consequences of stalking
Disillusionment with the
Substance abuse
Purcell et al, Prof Psychol Res Pract 36:537– 43, 2005; Whyte et al, Int J Forensic
Ment Health 10:254–60, 2011
Consequences of stalking
Lifestyle changes (moving home,
bolstering security)
Practice changes (altering one’s
treatment style, referral restrictions,
security upgrades, and practice
relocation), including abandonment
of professions, especially when
malicious complaints to professional
registration boards occur
Pathé & Mullen, Br J Psychiatry 170:12–17, 1997; Purcell et al, Prof Psychol Res
Pract 36:537– 43, 2005
Options for dealing with stalkers
Workplace policies
Police action
Criminal prosecution
Civil legal action
Medical intervention
Workplace policies
Training in spotting the early signs of stalking and
managing it appropriately should be available
Mechanism for the reporting of stalking or possible
stalking to an appropriate manager at an early stage
The victim should be supported and should not be
blamed for the stalking
Maintain confidentiality for the victim and the patient
(stalker) so far as is possible with the safe management of
the situation
Counselling should be provided where necessary
Workplace safety plans should be devised in the event of
serious or particularly harmful stalking
Workplace policies
When needed, access to legal advice and assistance in
liaison with the police or in obtaining a nonmolestation order or other injunction should be
Effective policies on confidentiality of staff (and other)
information, should be in place to minimize the
chances of information being obtained and used by a
Staff identity and security should be protected to
minimize the chances of stalkers gaining access to
private areas of the workplace
What should the psychiatrist do
Be aware of the risks
inherent in therapeutic
activities (especially those
exclusive relationship)
Understand and maintain
boundaries at all times
Make patients aware of
those boundaries and set
realistic expectations
What should the psychiatrist do
See patients at risk for stalking in well-staffed
facilities with suitable security arrangements
Consider the use of a chaperone
Act according to the employer’s policy covering
Inform staff, including secretaries and receptionists,
of the stalking, to avoid inadvertent disclosure of
information to the stalker
Transfer stalker’s care to another professional
immediately, making a careful record of the transfer
and the reasons for it
What should the psychiatrist do
Do not minimize!
Clarify with the stalker, in the presence of a colleague
and then in writing that his/her communications and
approaches are unwanted and cause fear and
Explain the consequences if the stalking continues
What should the psychiatrist do
Keep a careful record of all relevant events, including
a detailed record of all stalking behaviors
experienced, all discussions that have taken place
about the issue, and what actions have been taken
Keep letters and messages, and a record of
approaches and intrusions (including the time and
place) from the stalker
Cease all contacts with the stalker
If the stalking continues, approach the police,
accompanied by a senior colleague or manager, and
insist on criminal prosecution
Options for dealing with stalkers
Advances in anti-stalking legislation over
the last two decades improved the
protection available to victims.
However, determining the point at which
patterns of behavior cross the legal
threshold and become a criminal offence is
not always easy
McKenzie & James, Behav. Sci. Law 29: 220–239 (2011)
Options for dealing with stalkers
Even evidence of repeated explicit threats or
overt acts of aggression may be insufficient for
the police to act
Repeated intrusive behaviors may be
dismissed as innocuous gestures of affection
The legal system can often be used or abused
as a means of stalking, e. g. legal process used
to facilitate the stalker’s access to the victim
Pathé et al, Journal of Law and Medicine, 12(1), 103–111 (2004); McKenzie & James,
Behav. Sci. Law 29: 220–239 (2011)
Options for dealing with stalkers
Legal sanctions alone may be effective but often
fail because the fundamental problems driving
the stalking behavior remain unresolved
When possible, underlying psychological or
psychiatric factors that led to the intrusive
behavior should be addressed
Same or other victims will be at risk of harm in
the future
Unwell stalkers may receive inappropriate
sentences and fail to receive treatment
McKenzie & James, Behav. Sci. Law 29: 220–239 (2011)
Options for dealing with stalkers
Few stalkers receive a treatment whilst in
custody or in the community either
uncharged or awaiting the court hearing
Mental health evaluation and treatment
provisions should be included in all antistalking legislation
Mullen et al, New York: Cambridge University Press. McKenzie & James, Behav. Sci.
Law 29: 220–239 (2011)