American Board of Psychological Specialties

Mental-health professionals are at a significantly increased risk of being stalked by current or former clients (Galeazzi, Elkins, & Curci, 2005; Hudon-Allez, 2006; Kaplan, 2006; Lion & Herschler, 1998; McIvor & Petch, 2006; Miller, 1985; Morgan & Porter, 1999; Pathe & Mullen, 1997; Pathe, Mullen, & Purcell, 2002; Romans, Hays, & White, 1996; Sandberg, McNiel, & Binder, 2002). In addition, practitioners who are stalked are slower to recognize or accurately interpret early indicators and less likely to report victimization. Research has suggested therapist-stalking is an underrecognized problem for which most therapists are poorly prepared (McIvor & Petch). There are, however, precautions practitioners can integrate into their practices and lifestyles to reduce the likelihood of being stalked. Duty to Prevent With all clients, practitioners should establish and reinforce the reality that the therapist- client relationship is purely professional. For example, care should be taken to begin and end all sessions on time. This is especially important for clients who repeatedly try to stretch session time with the therapist, because this type of behavior may signal the beginning of more insidious and dangerous behavior. Similarly, self-disclosure (which can be an effective therapeutic intervention) should never be used unless there is an identifiable and specific therapeutic benefit to the client (beyond that of feeling trusted, etc.). Unnecessary and inappropriate self-disclosure may contribute to a client’s misperception of the therapist’s intent and feelings. Mental health practitioners should be attentive to the client’s subtle efforts to push beyond the professional relationship, such as asking personal questions or complimenting on a personal level. These potential red flags of future stalking behavior are often overlooked by therapists, as on the surface and in isolation they appear completely innocuous. Any time a client pushes or oversteps a boundary, the behavior should be carefully documented. Should crossing a boundary happen a second time, consultation with a colleague should be sought. Given the typical pattern of escalation, if the intrusive and/ or unwanted behavior continues for more than 2 weeks all efforts to re-establish appropriate boundaries should be discontinued, and the client should be transferred to another therapist (Pathe & Mullen, 2002). Though therapists have a clear responsibility to their clients, their primary responsibility is to themselves. Specific precautions can reduce the likelihood of becoming a stalking victim. In the office environment, mental health professionals should avoid leaving out magazines or mail with any address or identifying label, decorating with pictures of family and/or friends, and leaving car keys where clients might see them (as they typically reveal the make of the car). Therapists should keep their cars locked at all times, avoid leaving personal items where they can be seen through the windows, and not use personalized license plates. Similarly, as a stalker’s primary tool is his or her victim’s routine, mental health practitioners should attempt to leave for work and home at different times each day and take different routes to and from work. It is obviously safest to have an unmarked parking place or to park in different places every day. All therapists should know the exact location of the police and fire departments near their offices and homes in case they are ever pursued while driving. As a matter of course, mental health professionals should ensure the physical security of their homes (e.g., good lighting, solid doors, safety windows, intermittently changing all locks, etc.).

Therapists in Danger: Take Action to Stop Stalkers Annals spring 2007 Beyond that, to protect the security of private information, psychotherapists should consider know the steps to take: Have an unpublished/unlisted telephone number (including reverse directories). Get and use caller ID and call blocking Formally request that the DMV not release auto registration information to anyone other than law enforcement and other governmental agencies (access is required by law) and specified financial institutions (for loans, liens, insurance, etc.) Ask each utility company and bank to place a password on all accounts to restrict inquiries Use a private post office box for mail because law prohibits releasing personal information about the box owner without an original subpoena Use the post office box address on checks, credit accounts, driver’s licenses, vehicle registrations, property titles, business cards, and letterheads Put all property/assets into a trust for increased security and financial protection Use a double-cut shredder to destroy all identifying mail, labels, receipts, etc. Some of these recommendations (and those to follow) are admittedly cumbersome and restrictive. Some may be seen as excessive or may even cause the therapist to appear paranoid. Yet, when compared to the effort it takes to withstand and survive being stalked, intact and unharmed, these preventative efforts are minimal. To ensure against cyber-security threats, mental health professionals should install, frequently update and regularly use a security program on all computers (at home and work). Passwords should be changed intermittently and should never be based on personal facts (such as family names, birthdates, etc.) Perhaps the best way to protect oneself from cyberstalking is to have one computer that is only used for accessing the Internet. An alternative might be to store all files on a flash or external drive and to store no personal or professional information on the computer’s hard-drive. Using non-identifiable user IDs and email addresses for all but professional contacts can further protect a ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ therapist’s privacy, and so can using a fictitious name when participating in newsgroups, blogs, bulletin boards, and especially in Usenet groups focused on psychotherapy. It is also advisable to occasionally search one’s name on the Internet to learn what others might be able to discover. Beyond a Reasonable Doubt Mental health practitioners who suspect they are being stalked by a current or former client should immediately consult with a colleague who specializes in stalking. This expert can help the victim assess his or her own behavior, habits, and routines for any areas of vulnerability that might be perceived as invitations to the stalker. Practitioners should consult an attorney familiar with the given jurisdiction’s stalking laws (Miller, 2001). Although attorneyclient confidentiality is more absolute than that of therapist-client, care should be taken to protect the client/stalker’s confidentiality, even if the mental health professional retains the attorney. In order to establish a record and a pattern of behavior, every incident of suspected stalking should be reported to the police. If any or all of the recommended consultations are made anonymously, all experts should be told they are consulting with a mental health professional who, at least for the time being, is choosing to protect his or her client’s confidentiality. Victims rarely stop their stalkers by ignoring the harassment, which may work for other obnoxious behaviors. If the initial stalking behavior brings the offending client into contact with the therapist/victim, a clear and firm limit must be set on the client’s behavior once, and only once. Anything more becomes intermittent reinforcement— one of the most effective ways to increase a given behavior. If the initial stalking behavior does not allow the therapist/victim to set an immediate verbal limit, no contact should be initiated by the therapist to do so. If the client/stalker has a history of assault (physical or sexual) and/or when the first incidence of harassment/stalking includes threats (especially of violence), no effort to re-establish limits or boundaries should be made. Rather, if the client is mentally ill he or she should be hospitalized; if the client is not mentally ill, the therapist/victim should make a formal and non-confidential report to the police without delay. If the stalker is a current client, the therapist should consult with a chosen expert regarding how and when the client/stalker should be transferred to another therapist. This decision must be made on an individual basis and requires one to weigh several unique factors: The therapist’s level of comfort and experience working with stalkers The client/stalker’s history and diagnosis The nature of the therapeutic relationship The characteristics of the stalking behavior The decision to transfer or terminate a client on the basis of behavior toward the therapist is often emotional, and it is ethically difficult. Yet given that stalking behaviors are self-reinforcing, typically worsen, and often end in violence, this decision should actually be an easy one: The client should be transferred, because not to do so would be unethical. The only issues to consider in consultation with an expert are when, how, by whom, and to whom the transfer should be made. It should be noted that the longer a therapist waits to transfer a client/stalker, the harder it becomes to attain the transfer. Should the transfer become impossible, civil commitment should be considered. Because stalkers seldom stalk both genders, the client/stalker should be transferred to a therapist of the opposite gender of the therapist/ victim. The theoretical orientation of the new therapist should also be considered in light of the underlying motivation of the client/stalker; for example, an intimacy-seeking stalker should perhaps be transferred to a cognitive-behavioral therapist rather than a humanistic or psychodynamic practitioner. Obviously, the receiving therapist should be fully informed of the reason for the transfer and the exact nature and extent of the stalking behavior. Every consideration and decision made during this process should be carefully documented in order to demonstrate the client was appropriately and ethically terminated or transferred rather than abandoned. This is especially important in light of the frequency with which stalkers (especially, “rejected” types) file complaints with licensing boards and professional organizations against the stalked therapists who “reject” their approaches (Pathe et al., 2002). ◆ ◆ ◆ ◆ www.americanpsychotherapy.com spring 2007 Annals 31 Restraining and Constraining Stalking In all probability, ending the professional relationship will not end the stalking and may actually result in escalation—especially in those stalkers motivated by perceived rejection. As such, the therapist/victim should immediately get a new phone number (for work and/or home) but should not immediately disconnect the old. Keeping the old number connected to an answering machine and not blocking the stalker’s telephone number allows for the collection of evidence when the client/stalker continues to call. Similarly, the therapist/victim should change his or her Internet service provider and email address, but maintain the old account and not block the stalker’s emails. As with the phone, this will allow for the collection of cyber-evidence. If the client/stalker’s email address is or becomes known, do not open any correspondence as many providers have return receipts, which will alert the stalker when you open his or her email. Along with reporting every incident of stalking behavior to the police, the therapist/victim should consider applying for a restraining order, despite the fact that research suggests they are generally ineffective against stalkers (Morrison, 2001; Mullen, Pathe, Purcell, & Stuart, 2000). As with collected police reports, a restraining order may ultimately be used as evidence to demonstrate the legally required pattern of stalking behavior. In many cases, restraining orders are only granted on the basis of multiple threatening, harassing, and/or aggressive behaviors by the offender against the victim. Should criminal charges be filed against the client/stalker, the restraining order is persuasive evidence because it represents a different judge’s affirmation of a pattern of behavior. If the order is not respected, and certainly if the stalking behavior subsequently worsens, charges should be filed against the offending party. When the case goes to trial, the prosecutor will need to show that the defendant’s pattern of behavior meets the legal definition of stalking. In anticipation of this need, the therapist/victim must carefully document every incident and keep all evidence (which may include copies of store surveillance tapes and witness declarations). If the stalker is convicted and incarcerated, the therapist/ victim should make a formal request to the Department of Corrections that he or she be notified in advance of the stalker’s release. In the End Not only are mental health practitioners at increased risk of being stalked, research demonstrates that their families and supervisees/ interns are as well (Romans et al., 1996; Lion & Herschler, 1998). An average of 25% to 35% of all stalking cases include or progress to violence (Leavitt, Presskreischer, Mayhuth, & Grasso, 2006; Galeazzi et al., 2005; Purcell, Powell, & Mullen, 2005; Meloy, 1996). With this in mind, aside from any legal duty, therapists have an inherent obligation to protect themselves and those around them from victimization, as well as to protect their clients from slipping into harmful behavior. Failure to accurately identify and appropriately respond to client-stalking behavior is essentially equivalent to negligently contributing to the client’s harm to self and others. A study conducted in the United States and Canada found that, in general, stalking resulted in workplace violence 44% of the time (Feldman, Holt, & Hellard, 1997). In looking only at inpatient facilities, that rate went up to 67%. Of significance to employers is the finding that while 86% of the time the stalker’s violence is perpetrated on the target—secretaries, receptionists, and security guards are also vulnerable to assault—especially in cases where such persons attempt to prevent access to the victim (Meloy, 1996). Therefore, employers are well advised to provide all employees with in-service training regarding stalking, confidentiality (for clients and co-workers), and handling crisis situations.

References: Feldman, T. B., Holt, J., & Hellard, S. (1997). Violence in medical facilities, a review of 40 incidents. Journal of the Kentucky Medical Association, 95(5),183–189. Galeazzi, G. M., Elkins, K., & Curci, P. (2005). The stalking of mental health professionals by patients. Psychiatric Service, 56(2), 137–138. Hudon-Allez, G. (2006). The stalking of psychotherapists by current or former clients: Beware of the insecurely attached! Psychodynamic Practice, 12(3), 249–260. Kaplan, A. (2006). Being stalked—an occupational hazard? Retrieved from http://www.insightefap. com Leavitt, N., Presskreischer, H., Maykuth, P. L., & Grisso, T. (2006). Aggression toward forensic evaluators: A statewide survey. Journal of the American Academy of Psychiatry and the Law, 34(2), 1–9. Lion, J. R., & Herschler, J. A. (1998). The stalking of clinicians by their patients. In J. R. Meloy, (Ed.), The Psychology of Stalking: Clinical and Forensic Perspectives (pp. 163–173). San Diego, CA: Academic Press. McIvor, R. J., & Petch, E. (2006). Stalking of mental health professionals: An underrecognized problem. The British Journal of Psychiatry, 188, 403–404. Meloy, J. R. (1996). Stalking (obsessional following): A review of some preliminary studies. Aggression and Violent Behavior, 1(2), 147–162. Miller, N. (2001). Stalking laws and implementation practices: A national review for policymakers and practitioners. (DOJ-197066). (pp. 37–38, 47, Appendix 1). alexandria, VA: Institute for Law & Justice. Miller, R. D. (1985). The harassment of forensic psychiatrists outside of court. Bulletin American Academy of Psychiatry and the Law, 13(4), 337–343. Morgan, J. F. & Porter, S. (1999). Sexual harassment of psychiatric trainees: Experiences and attitudes. Postgraduate Medical Journal, 75(885), 410–413. Morrison, K. (2001). Predicting violent behavior in stalkers: A preliminary investigation of Canadian cases in criminal harassment. Journal of Forensic Science, 46(6), 1403–1410. Mullen, P. E., Pathe, M., Purcell, R., & Stuart, G. W. (2000). Stalkers and Their Victims. Cambridge, U.K.: Cambridge University Press. Pathe, M., & Mullen, P. E. (1997). The impact of stalkers on their victims. British Journal of Psychiatry, 170(1), 12–17. Pathe, M., Mullen, P. E., & Purcell R. (2002). Patients who stalk doctors: Their motives and management. The Medical Journal of Australia, 176(7), 335–338. Purcell, R., Powell, M. B., & Mullen, P. E. (2005). Clients who stalk psychologists: Prevalence, methods, and motives. Professional Psychology: Research and Practice, 36(5), 537–543. Romans, J. S. C., Hays, J. R., & White, T. K. (1996). Stalking and related behaviors experienced by counseling center staff members from current or former clients. Professional Psychology-Research and Practice, 27(6), 595–599. Sandberg, D. A., McNiel, D. E., & Binder, R. L. (2002). Stalking, threatening, and harassing behavior by psychiatric patients toward clinicians. Journal of the American Academy of Psychiatry and the Law, 30(2), 221–229.

About the Author Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE, DABFM, is a Diplomate of the American Psychotherapy Association (APA) and is a regular columnist for Annals of the American Psychotherapy Association. He has been a member of APA since 1999.