Stalking of mental health professionals: an underrecognised problem

Doctors and mental healthcare professionals are at greater riskof being stalked than the general population, particularlyby their patients. Despite causing significant psychologicaldistress, stalking remains underrecognised and poorly managed.Healthcare organisations should ensure appropriate policiesare in place to aid awareness and minimise risk, including the provision of formal educational programmes.

INTRODUCTION

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INTRODUCTION

Stalking has been defined as a constellation of behaviours involving repeated and persistent attempts to impose on another personunwanted contact and/or communication (Mullen et al, 1999).Contact can occur by loitering, following, surveillance andmaking approaches, and communication can be made by either conventionalor electronic means (Pathé & Mullen, 1997). Stalkingcan escalate and lead to intimidation, threats or violence.Anyone can be the victim of stalking, including previous orpresent partners, casual acquaintances and friends, professionalcontacts, workplace colleagues, strangers, or those in themedia spotlight. Stalking appears common: in a large US telephonesurvey, 8% of women and 2% of men said they had been stalkedat some point in their life (Tjaden & Thoenness, 1997).One widely used classification of stalkers is based on motivation:the rejected, the intimacy seeker, the resentful, the incompetent suitor and the predatory (Mullen et al, 1999). The importanceof this classification is that it helps predict risk and behaviourpatterns, and informs management approaches.

RISK TO HEALTHCARE STAFF

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RISK TO HEALTHCARE STAFF

Doctors and healthcare professionals are at greater risk thanthe general population of being stalked, particularly by theirpatients (Pathé et al, 2002; Purcell et al, 2005b).Pathé & Mullen (1997) found that healthcare professionals,particularly medical staff, were overrepresented in a sampleof self-referred victims to a stalking clinic. However, incidenceand prevalence rates in this population remain largely unknown (Lion & Herschler, 1998), owing to international differencesin definition and legal status. Threats and violence that occurin clinical practice need to be distinguished from the repetitiveand persistent behaviour typical of stalking.

All clinical staff are at risk. Romans et al (1996) reportedthat 5% of counselling centre staff had been stalked by clients,but 64% had experienced some sort of harassing behaviour. Psychiatristsand those working in related sub-specialties, such as forensicpsychiatry, may be at higher risk. In one study, cliniciansattending a US state psychiatric conference were surveyed usinga fairly strict definition of harassment. Nearly a third hadbeen subjected to stalking and a further 41% reported otherforms of distressing intrusions, including damage to property (Lion & Herschler, 1998). Psychologists also appear tobe at higher risk, according to results from two large randomsurveys. Gentile et al (2002) found that 10% of a sample ofAmerican psychologists had experienced serious stalking events during their careers, and in an Australian sample Purcell etal (2005b) found that nearly 20% had experienced stalking,nearly half of which had occurred in the previous year.

Several studies have surveyed mental health staff working withindefined settings. Sandberg et al (2002) surveyed all clinical staff employed in an American in-patient psychiatric unit.Over half the respondents had experienced some type of stalking,threatening or harassing behaviour during their career, includingthreats, telephone calls and unwanted approaches. Followingand violence were rare. Perpetrators usually targeted staffmembers who had previously treated them. Staff found the behaviour upsetting and disruptive, particularly if it continued formore than 3 weeks. Staff commonly confronted the patients abouttheir behaviour, but did not find this strategy particularlyhelpful.

Patients who stalked staff were significantly more likely thana comparison group to have a diagnosis of personality disorderand/or paranoid disorder. In addition they were more likelyto have never been married, to misuse drugs and alcohol, andto have a history of assaultative, fear-inducing and self-harming behaviour, and multiple hospitalisations (Sandberg et al, 1998).

In a recent Italian survey (Galeazzi et al, 2005), mental healthprofessionals working in public and private practice withina defined geographical area were screened for harassment bypatients. With a high response rate, a third of staff were foundto have been harassed in one of nine defined ways, and 11% werefound to have been stalked, using a strict operational definition.Clinicians were occasionally threatened, but physical attackswere rare. Most of the victims were nurses, but psychiatristsand psychologists experienced extended periods of stalking.As with the American study, the stalkers – most of whomhad a diagnosis of psychosis or personality disorder –tended to target staff who were directly involved in theircare.

Both genders can stalk staff: Sandberg et al (1998) and Purcellet al (2005b) suggested that patients who stalked staff weremore likely to be male, but Purcell et al (2001) found thatit was female stalkers who were more likely to target professional contacts. Regarding victims of stalking, there is growing evidenceto show that male mental health workers are at greater risk (Gentile et al, 2002; Galeazzi et al, 2005).

IMPACT OF STALKING

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IMPACT OF STALKING

Stalking can have a significant impact upon psychological, occupationaland social functioning for the person stalked (Pathé & Mullen, 1997;Purcell et al, 2005a). For healthcare professionals this canlead to increasing stress, fear, helplessness and disenchantment (Sandberg et al, 2002). More overt psychiatric illness maydevelop, which can have an impact on the functioning of thehealthcare service. Behavioural and security changes may beemployed to reduce risk (Galeazzi et al, 2005).

WHY ARE HEALTHCARE STAFF AT INCREASED RISK?

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WHY ARE HEALTHCARE STAFF...

As a rule of thumb stalkers do not tend to have normal psychologicalor personality profiles, and by definition those who targetmental health professionals are more likely to suffer fromsignificant psychological difficulties. Stalkers tend to havedifficulties in forming and maintaining interpersonal relationshipsand those who target clinicians may harbour unrealistic ormisplaced expectations of intimacy arising from the normal therapeuticrelationship. This is particularly so for intimacy seekers or incompetent suitors. For example, in the Italian survey themajority of mental health professionals reported the patient’sdesire for more intimacy as the perceived motivation (Galeazzi et al, 2005).In addition, through the ending of a therapeutic relationship,rejected stalking may emerge.

Patients may be overtly psychotic, their delusional system drivingstalking behaviour (Sandberg et al, 1998, 2002). This maybe complicated by substance misuse. Interestingly, pure erotomania– the delusional belief of being loved by a target ofhigher social or professional status – is comparativelyrare (Kienlen et al, 1997).

Not surprisingly, patients with nonpsychotic stalking, particularlythose suffering from personality disorder, display differentmotivations for their behaviour. In a sample of stalkers targetingindividuals in the general population, the non-delusional cohortwas influenced by factors such as anger and hostility, projectionof blame, obsessional behaviour, dependency, minimisation anddenial, and jealousy (Kienlen et al, 1997). These factorsmay be at work within the clinical setting, particularly with patients who have long-standing interpersonal attachment difficulties.It has been suggested that the common thread in such patientsis a narcissistic drive that defends against humiliation inresponse to the more confrontational aspects of treatment,especially in-patient or coercive care (Meloy, 1999).

Projection of blame can be a potent motivation for stalking,particularly within the ‘resentful stalker’ typology.Patients may develop a grudge for some perceived wrongdoingor dereliction of duty on the part of the doctor or healthcareworker. This can extend beyond the individual, with complaintsbeing made to hospital authorities and professional regulators.

Victim factors may play a part in the persistence of stalkingbehaviour. Doctors and other healthcare professionals may developa degree of tolerance to antisocial or threatening behaviour,because of its prevalence in their everyday practice. As aresult they may minimise persistent harassment, in the hopethat it will resolve spontaneously or be managed within thetherapeutic relationship. This perception may be reinforcedby feelings of guilt or inadequacy concerning clinical practiceor expertise, or concern at what colleagues might think. Unfortunately,supervisors or healthcare providers may reinforce such perceptions,either covertly or blatantly. Because of the patient’smental illness, there may be a reluctance to involve the policeor criminal justice system in managing the problem.

INCREASING AWARENESS

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INCREASING AWARENESS

Stalking of healthcare professionals is a common occupationalhazard, yet it remains underresearched and underreported, andcan lead to significant distress and psychiatric morbidity.Clinicians receive little training in the concept of stalkingor its management, even though their profession renders themmore likely to become victims. Despite increasing emphasis onrisk assessment in relation to suicide, violence and homicide,explicit awareness of stalking remains limited. Healthcareorganisations should consider adopting formal educational programmescovering recognition of stalking behaviour and risk managementstrategies, particularly for staff in the early stages of theircareer. Appropriate policies should be in place for dealingwith stalking, and staff should be advised and supported throughoutthe process.

ACKNOWLEDGMENTS

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ACKNOWLEDGMENTS

We thank Professor Paul Mullen for helpful comments on an earlierdraft of this manuscript.

REFERENCES

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