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Dr. A has been treating Ms. W, a graduate student, for depression. Ms. W made subtle comments expressing her interest in pursuing a romantic relationship with her psychiatrist. Dr. A gently redirected her, and she seemed to respond appropriately. However, over the past 2 weeks, Dr. A has seen Ms. W at a local park and at the grocery store. Today, Dr. A is startled to see Ms. W at her weekly yoga class. Dr. A plans to ask her supervisor for advice.
Dr. M is a child psychiatrist who spoke at his local school board meeting in support of masking requirements for students during COVID-19. During the discussion, Dr. M shared that, as a psychiatrist, he does not believe it is especially distressing for students to wear masks, and that doing so is a necessary public health measure. On leaving, other parents shouted, “We know who you are and where you live!” The next day, his integrated clinic started receiving threatening and harassing messages, including threats to kill him or his staff if they take part in vaccinating children against COVID-19.
Because of their work, mental health professionals—like other health care professionals—face an elevated risk of being harassed or stalked. Stalking often includes online harassment and may escalate to serious physical violence. Stalking is criminal behavior by a patient and should not be constructed as a “failure to manage transference.” This article explores basic strategies to reduce the risk of harassment and stalking, describes how to recognize early behaviors, and outlines basic steps health care professionals and their employers can take to respond to stalking and harassing behaviors.
Although this article is intended for psychiatrists, it is important to note that all health professionals have significant risk for experiencing stalking or harassment. This is due in part, but not exclusively, to our clinical work. Estimates of how many health professionals experience stalking vary substantially depending upon the study, and differences in methodologies limit easy comparison or extrapolation. More thorough reviews have reported ranges from 2% to 70% among physicians; psychiatrists and other mental health professionals appear to be at greater risk than those in other specialties and the general population.1-3 Physicians who are active on social media may also be at elevated risk.4 Unexpected communications from patients and their family members—especially those with threatening, harassing, or sexualized tones, or involving contact outside of a work setting—can be distressing. These behaviors represent potential harbingers of more dangerous behavior, including physical assault, sexual assault, or homicide. Despite their elevated risk, many psychiatrists are unaware of how to prevent or respond to stalking or harassment.
Recognizing harassment and stalking
Repeated and unwanted contact or communication, regardless of intent, may constitute stalking. Legal definitions vary by jurisdiction and may not align with subjective experiences or understanding of what constitutes stalking.5 At its essence, stalking is repeated harassing behaviors likely to provoke fear in the targeted person. FOUR is a helpful mnemonic when conceptualizing the attributes of stalking: Fixated, Obsessive, Unwanted, and Repetitive.6Table 1 lists examples of common stalking behaviors. Stalking and harassing behavior may be from a known source (eg, a patient, coworker, or paramour), a masked source (ie, someone known to the target but who conceals or obscures their identity), or from otherwise unknown persons. Behaviors that persist after the person engaging in the behaviors has clearly been informed that they are unwanted or inappropriate are especially concerning. Stalking may escalate to include physical or sexual assault and, in some cases, homicide.
Stalking duration can vary substantially, as can the factors that lead to the cessation of the behavior. Indicators of increased risk for physical violence include unwanted physical presence/following of the target (“approach behaviors”), having a prior violent intimate relationship, property destruction, explicit threats, and having a prior intimate relationship with the target.7
Stalking contact or communication may be unwanted because of the content (eg, sexualized or threatening tone), location (eg, at a professional’s home), or means (eg, through social media). Stalking behaviors are not appropriate in any relationship, including a clinical relationship. They should not be treated as a “failure to manage transference” or in other victim-blaming ways.
There are multiple typologies for stalking behavior. Common motivations for stalking health professionals include resentment or grievance, misjudgment of social boundaries, and delusional fixation, including erotomania.8 Associated psychopathologies vary significantly and, while some may be more amenable to psychiatric treatment than others, psychiatrists should not feel compelled to treat patients who repeatedly violate boundaries, regardless of intent or comorbidity.
Patients are not the exclusive perpetrators of stalking; a recent study found that 4% of physicians surveyed reported current or recent stalking by a current or former intimate partner.9 When a person who is a victim of intimate partner violence is also stalked as part of the abuse, homicide risk increases.10 Workplace homicides of health care professionals are most likely to be committed by a current or former partner or other personal acquaintance, not by a patient.11 Workplace harassment and stalking of health care professionals is especially concerning because this behavior can escalate and endanger coworkers or clients.
Continue to: Risk awareness: Recognize your exposure...
Risk awareness: Recognize your exposure
About 80% of stalking involves some form of technology—often telephone calls but also online or other “cyber” elements.12 One recent survey found the rate of online harassment, including threats of physical and sexual violence, was >20% among physicians who were active on social media.4 Health professionals may be at greater risk of having patients find their personal information simply because patients routinely search online for information about new clinicians. Personal information about a clinician may be readily visible among professional information in search results, or a curious patient may simply scroll further down in the results. For a potential stalker, clicking on a search result linking to a personal social media page may be far easier than finding a home address and going in person—but the action may be just as distressing or risky for the clinician.13 Additionally, items visible in a clinician’s office—or visible in the background of those providing telehealth services from their home—may inadvertently reveal personal information about the clinician, their home, or their family.
Psychiatrists are often in a special position in relation to patients and times of crises. They may be involved in involuntary commitment—or declining an admission when a patient or family wishes it. They may be present at the time of the revelation of a serious diagnosis, abuse, injury, or death. They may be a mandated reporter of child or elder abuse.2 Additionally, physicians may be engaged in discourse on politically charged public health topics.14 These factors may increase their risk of being stalked.
Conducting an online visibility self-assessment can be a useful way to learn what information others can find. Table 2 outlines the steps for completing this exercise. Searching multiple iterations of your current and former names (with and without degrees, titles, and cities) will yield differing results in various search engines. After establishing a baseline of what information is available online, it can be helpful to periodically repeat this exercise, and to set up automated alerts for your name, number(s), email(s), and address(es).
Basic mitigation strategies
In the modern era, being invisible online is impractical and likely impossible—especially for a health care professional. Instead, it may be prudent to limit your public visibility to professional portals (eg, LinkedIn or Doximity) and maximize privacy settings on other platforms. Another basic strategy is to avoid providing personal contact information (your home address, phone number, or personal email) for professional purposes, such as licensing and credentialing, conference submissions, or journal publications. Be aware that driving a visually distinct vehicle—one with vanity plates or distinct bumper stickers, or an exotic sportscar—can make it easier to be recognized and located. A personally recorded voicemail greeting (vs one recorded by, for example, an office manager) may be inappropriately reinforcing for some stalkers.
Workplaces should have an established safety policy that addresses stalking and harassment of employees. Similarly, patients and others should receive clear education on how to contact different staff, including physicians, with consideration of how and when to use electronic health information portals, office numbers, and emails. Workplaces should not disclose staff schedules. For example, a receptionist should say “I’ll have Dr. Diaz return your call when she can” instead of “Dr. Diaz is not in until tomorrow.” Avoid unnecessary location/name signals (eg, a parking spot labeled “Dr. Diaz”). Consider creating alert words or phrases for staff to use to signal they are concerned about their immediate safety—and provide education and training, including drills, to test emergency responses when the words/phrases are used. Leaders and managers should nurture a workplace culture where people are comfortable seeking support if they feel they may be the target of harassment or stalking. Many larger health care organizations have threat management programs, which can play a critical role in preventing, investigating, and responding to stalking of employees. Increasingly, threat management teams are being identified as a best practice in health care settings.15Table 3 summarizes measures to mitigate risk.
What to do when harassment or stalking occurs
Consulting with subject matter experts is essential. Approach behaviors, stalking patterns, and immediate circumstances vary highly, and so too must responses. A socially inept approach outside of the work setting by a patient may be effectively responded to with a firm explanation of why the behavior was inappropriate and a reiteration of limits. More persistent or serious threats may require taking actions for immediate safety, calling law enforcement or security (who may have the expertise to assist appropriately), or even run/hide/fight measures. Others to notify early on include human resources, supervisors, front desk staff, and coworkers. Although no single measure is always indicated and no single measure will always be effective, consultation with a specialist is always advisable.
Attempting to assess your own risk may be subject to bias and error, even for an experienced forensic psychiatrist. Risk assessment in stalking and harassment cases is complex, nuanced, and beyond the scope of this article; engagement with specialized threat programs or subject matter experts is advisable.15,16 If your medical center or area has police or security officers, engage them early. Risk management, insurers, and legal can also be helpful to consult. Attorneys specializing in harassment, stalking, and domestic violence may be helpful in extreme situations.17Table 417,18 highlights steps to take.
While effective interventions to stop or redirect stalking behavior may vary, some initial considerations include changing established routines (eg, your parking location or daily/weekly patterns such as gym, class, etc.) and letting family and others you live with know what is occurring. Consider implementing and bolstering personal, work, and home security; honing situational awareness skills; and learning advanced situational awareness and self-defense techniques.
Continue to: Clinical documentation and termination of care...
Clinical documentation and termination of care
Repeated and unwanted contact behaviors by a patient may be considered grounds for termination of care by the targeted clinician. Termination may occur through a direct conversation, followed by a mailed letter explaining that the patient’s inappropriate behaviors are the basis for termination. The letter should outline steps for establishing care with another psychiatrist and signing a release to facilitate transfer of records to the next psychiatrist. Ensure that the patient has access to a reasonable supply of medications or refills according to jurisdictional standards for transfer or termination of care.19 While these are common legal standards for termination of care in the United States, clinicians would be well served by appropriate consultation to verify the most appropriate standards for their location.
Documentation of a patient’s behavior should be factual and clear. Under the 21st Century Cures Act, patients often have access to their own electronic records.20 Therefore, clinicians should avoid documenting personal security measures or other information that is not clinically relevant. Communications with legal or risk management should not be documented unless otherwise advised, because such communications may be privileged and may not be clinically relevant.
In some circumstances, continuing to treat a patient who has stalked a member of the current treatment team may be appropriate or necessary. For example, a patient may respond appropriately to redirection after an initial approach behavior and continue to make clinical progress, or may be in a forensic specialty setting with appropriate operational support to continue with treatment.
Ethical dilemmas may arise in underserved areas where there are limited options for psychiatric care and in communicating the reasons for termination to a new clinician. Consultation may help to address these issues. However, as noted before, clinicians should be permitted to discontinue and transfer treatment and should not be compelled to continue to treat a patient who has threatened or harassed them.
Organizational and employer considerations
Victims of stalking have reported that they appreciated explicit support from their supervisor, regular meetings, and measures to reduce potential stalking or violence in the workplace; unsurprisingly, victim blaming and leaving the employee to address the situation on their own were labeled experienced as negative.2 Employers may consider implementing physical security, access controls and panic alarms, and enhancing coworkers’ situational awareness.21 Explicit policies about and attention to reducing workplace violence, including stalking, are always beneficial—and in some settings such policies may be a regulatory requirement.22 Large health care organizations may benefit from developing specialized threat management programs to assist with the evaluation and mitigation of stalking and other workplace violence risks.15,23
Self-care considerations
The impact of stalking can include psychological distress, disruption of work and personal relationships, and false allegations of impropriety. Stalking can make targets feel isolated, violated, and fearful, which makes it challenging to reach out to others for support and safety. It takes time to regain a sense of safety and to find a “new normal,” particularly while experiencing and responding to stalking behavior. Notifying close personal contacts such as family and coworkers about what is occurring (without sharing protected health information) can be helpful for recovery and important for the clinician’s safety. Reaching out for organizational and legal supports is also prudent. It is also important to allow time for, and patience with, a targeted individual’s normal responses, such as decreased work performance, sleep/appetite changes, and hypervigilance, without pathologizing these common stress reactions. Further review of appropriate resources by impacted clinicians is advisable.24-26
1. Nelsen AJ, Johnson RS, Ostermeyer B, et al. The prevalence of physicians who have been stalked: a systematic review. J Am Acad Psychiatry Law. 2015;43(2):177-182.
2. Jutasi C, McEwan TE. Stalking of professionals: a scoping review. Journal of Threat Assessment and Management. 2021;8(3):94-124.
3. Pathé MT, Meloy JR. Commentary: Stalking by patients—psychiatrists’ tales of anger, lust and ignorance. J Am Acad Psychiatry Law. 2013;41(2):200-205.
4. Pendergrast TR, Jain S, Trueger NS, et al. Prevalence of personal attacks and sexual harassment of physicians on social media. JAMA Intern Med. 2021;181(4):550-552.
5. Owens JG. Why definitions matter: stalking victimization in the United States. J Interpers Violence. 2016;31(12):2196-2226.
6. College of Policing. Stalking or harassment. May 2019. Accessed March 8, 2020. https://library.college.police.uk/docs/college-of-policing/Stalking_or_harassment_guidance_200519.pdf
7. McEwan TE, Daffern M, MacKenzie RD, et al. Risk factors for stalking violence, persistence, and recurrence. Journal of Forensic Psychiatry & Psychology. 2017;28(1):3856.
8. Pathé MT, Mullen PE, Purcell R. Patients who stalk doctors: their motives and management. Med J Australia. 2002;176(7):335-338.
9. Reibling ET, Distelberg B, Guptill M, et al. Intimate partner violence experienced by physicians. J Prim Care Community Health. 2020;11:2150132720965077.
10. Matias A, Gonçalves M, Soeiro C, et al. Intimate partner homicide: a meta-analysis of risk factors. Aggression and Violent Behavior. 2019;50:101358.
11. US Bureau of Labor Statistics. Fact sheet. Workplace violence in healthcare, 2018. April 2020. Accessed November 24, 2021. https://www.bls.gov/iif/oshwc/cfoi/workplace-violence-healthcare-2018.htm
12. Truman JL, Morgan RE. Stalking victimization, 2016. Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. Report No.: NCJ 253526. April 2021. Accessed November 24, 2021. https://bjs.ojp.gov/library/publications/stalking-victimization-2016
13. Reyns BW, Henson B, Fisher BS. Being pursued online: applying cyberlifestyle–routine activities theory to cyberstalking victimization. Criminal Justice and Behavior. 2011;38(11):1149-1169.
14. Stea JN. When promoting knowledge makes you a target. Scientific American Blog Network. March 16, 2020. Accessed November 24, 2021. https://blogs.scientificamerican.com/observations/when-promoting-knowledge-makes-you-a-target/
15. Henkel SJ. Threat assessment strategies to mitigate violence in healthcare. IAHSS Foundation. IAHSS-F RS-19-02. November 2019. Accessed November 24, 2021. https://iahssf.org/assets/IAHSS-Foundation-Threat-Assessment-Strategies-to-Mitigate-Violence-in-Healthcare.pdf
16. McEwan TE. Stalking threat and risk assessment. In: Reid Meloy J, Hoffman J (eds). International Handbook of Threat Assessment. 2nd ed. Oxford University Press; 2021:210-234.
17. Goldberg C. Nobody’s Victim: Fighting Psychos, Stalkers, Pervs, and Trolls. Plume; 2019.
18. Bazzell M. Extreme Privacy: What It Takes to Disappear. 2nd ed. Independently published; 2020.
19. Simon RI, Shuman DW. The doctor-patient relationship. Focus. 2007;5(4):423-431.
20. Department of Health and Human Services. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule (To be codified at 45 CFR 170 and 171). Federal Register. 2020;85(85):25642-25961.
21. Sheridan L, North AC, Scott AJ. Stalking in the workplace. Journal of Threat Assessment and Management. 2019;6(2):61-75.
22. The Joint Commission. Workplace Violence Prevention Standards. R3 Report: Requirement, Rationale, Reference. Issue 30. June 18, 2021. Accessed November 24, 2021. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3-30_revised_06302021.pdf
23. Terry LP. Threat assessment teams. J Healthc Prot Manage. 2015;31(2):23-35.
24. Pathé M. Surviving Stalking. Cambridge University Press; 2002.
25. Noffsinger S. What stalking victims need to restore their mental and somatic health. Current Psychiatry. 2015;14(6):43-47.
26. Mullen P, Whyte S, McIvor R; Psychiatrists’ Support Service, Royal College of Psychiatry. PSS Information Guide: Stalking. Report No. 11. 2017. Accessed November 24, 2021. https://www.rcpsych.ac.uk/docs/default-source/members/supporting-you/pss/pss-guide-11-stalking.pdf?sfvrsn=2f1c7253_2
Dr. A has been treating Ms. W, a graduate student, for depression. Ms. W made subtle comments expressing her interest in pursuing a romantic relationship with her psychiatrist. Dr. A gently redirected her, and she seemed to respond appropriately. However, over the past 2 weeks, Dr. A has seen Ms. W at a local park and at the grocery store. Today, Dr. A is startled to see Ms. W at her weekly yoga class. Dr. A plans to ask her supervisor for advice.
Dr. M is a child psychiatrist who spoke at his local school board meeting in support of masking requirements for students during COVID-19. During the discussion, Dr. M shared that, as a psychiatrist, he does not believe it is especially distressing for students to wear masks, and that doing so is a necessary public health measure. On leaving, other parents shouted, “We know who you are and where you live!” The next day, his integrated clinic started receiving threatening and harassing messages, including threats to kill him or his staff if they take part in vaccinating children against COVID-19.
Because of their work, mental health professionals—like other health care professionals—face an elevated risk of being harassed or stalked. Stalking often includes online harassment and may escalate to serious physical violence. Stalking is criminal behavior by a patient and should not be constructed as a “failure to manage transference.” This article explores basic strategies to reduce the risk of harassment and stalking, describes how to recognize early behaviors, and outlines basic steps health care professionals and their employers can take to respond to stalking and harassing behaviors.
Although this article is intended for psychiatrists, it is important to note that all health professionals have significant risk for experiencing stalking or harassment. This is due in part, but not exclusively, to our clinical work. Estimates of how many health professionals experience stalking vary substantially depending upon the study, and differences in methodologies limit easy comparison or extrapolation. More thorough reviews have reported ranges from 2% to 70% among physicians; psychiatrists and other mental health professionals appear to be at greater risk than those in other specialties and the general population.1-3 Physicians who are active on social media may also be at elevated risk.4 Unexpected communications from patients and their family members—especially those with threatening, harassing, or sexualized tones, or involving contact outside of a work setting—can be distressing. These behaviors represent potential harbingers of more dangerous behavior, including physical assault, sexual assault, or homicide. Despite their elevated risk, many psychiatrists are unaware of how to prevent or respond to stalking or harassment.
Recognizing harassment and stalking
Repeated and unwanted contact or communication, regardless of intent, may constitute stalking. Legal definitions vary by jurisdiction and may not align with subjective experiences or understanding of what constitutes stalking.5 At its essence, stalking is repeated harassing behaviors likely to provoke fear in the targeted person. FOUR is a helpful mnemonic when conceptualizing the attributes of stalking: Fixated, Obsessive, Unwanted, and Repetitive.6Table 1 lists examples of common stalking behaviors. Stalking and harassing behavior may be from a known source (eg, a patient, coworker, or paramour), a masked source (ie, someone known to the target but who conceals or obscures their identity), or from otherwise unknown persons. Behaviors that persist after the person engaging in the behaviors has clearly been informed that they are unwanted or inappropriate are especially concerning. Stalking may escalate to include physical or sexual assault and, in some cases, homicide.
Stalking duration can vary substantially, as can the factors that lead to the cessation of the behavior. Indicators of increased risk for physical violence include unwanted physical presence/following of the target (“approach behaviors”), having a prior violent intimate relationship, property destruction, explicit threats, and having a prior intimate relationship with the target.7
Stalking contact or communication may be unwanted because of the content (eg, sexualized or threatening tone), location (eg, at a professional’s home), or means (eg, through social media). Stalking behaviors are not appropriate in any relationship, including a clinical relationship. They should not be treated as a “failure to manage transference” or in other victim-blaming ways.
There are multiple typologies for stalking behavior. Common motivations for stalking health professionals include resentment or grievance, misjudgment of social boundaries, and delusional fixation, including erotomania.8 Associated psychopathologies vary significantly and, while some may be more amenable to psychiatric treatment than others, psychiatrists should not feel compelled to treat patients who repeatedly violate boundaries, regardless of intent or comorbidity.
Patients are not the exclusive perpetrators of stalking; a recent study found that 4% of physicians surveyed reported current or recent stalking by a current or former intimate partner.9 When a person who is a victim of intimate partner violence is also stalked as part of the abuse, homicide risk increases.10 Workplace homicides of health care professionals are most likely to be committed by a current or former partner or other personal acquaintance, not by a patient.11 Workplace harassment and stalking of health care professionals is especially concerning because this behavior can escalate and endanger coworkers or clients.
Continue to: Risk awareness: Recognize your exposure...
Risk awareness: Recognize your exposure
About 80% of stalking involves some form of technology—often telephone calls but also online or other “cyber” elements.12 One recent survey found the rate of online harassment, including threats of physical and sexual violence, was >20% among physicians who were active on social media.4 Health professionals may be at greater risk of having patients find their personal information simply because patients routinely search online for information about new clinicians. Personal information about a clinician may be readily visible among professional information in search results, or a curious patient may simply scroll further down in the results. For a potential stalker, clicking on a search result linking to a personal social media page may be far easier than finding a home address and going in person—but the action may be just as distressing or risky for the clinician.13 Additionally, items visible in a clinician’s office—or visible in the background of those providing telehealth services from their home—may inadvertently reveal personal information about the clinician, their home, or their family.
Psychiatrists are often in a special position in relation to patients and times of crises. They may be involved in involuntary commitment—or declining an admission when a patient or family wishes it. They may be present at the time of the revelation of a serious diagnosis, abuse, injury, or death. They may be a mandated reporter of child or elder abuse.2 Additionally, physicians may be engaged in discourse on politically charged public health topics.14 These factors may increase their risk of being stalked.
Conducting an online visibility self-assessment can be a useful way to learn what information others can find. Table 2 outlines the steps for completing this exercise. Searching multiple iterations of your current and former names (with and without degrees, titles, and cities) will yield differing results in various search engines. After establishing a baseline of what information is available online, it can be helpful to periodically repeat this exercise, and to set up automated alerts for your name, number(s), email(s), and address(es).
Basic mitigation strategies
In the modern era, being invisible online is impractical and likely impossible—especially for a health care professional. Instead, it may be prudent to limit your public visibility to professional portals (eg, LinkedIn or Doximity) and maximize privacy settings on other platforms. Another basic strategy is to avoid providing personal contact information (your home address, phone number, or personal email) for professional purposes, such as licensing and credentialing, conference submissions, or journal publications. Be aware that driving a visually distinct vehicle—one with vanity plates or distinct bumper stickers, or an exotic sportscar—can make it easier to be recognized and located. A personally recorded voicemail greeting (vs one recorded by, for example, an office manager) may be inappropriately reinforcing for some stalkers.
Workplaces should have an established safety policy that addresses stalking and harassment of employees. Similarly, patients and others should receive clear education on how to contact different staff, including physicians, with consideration of how and when to use electronic health information portals, office numbers, and emails. Workplaces should not disclose staff schedules. For example, a receptionist should say “I’ll have Dr. Diaz return your call when she can” instead of “Dr. Diaz is not in until tomorrow.” Avoid unnecessary location/name signals (eg, a parking spot labeled “Dr. Diaz”). Consider creating alert words or phrases for staff to use to signal they are concerned about their immediate safety—and provide education and training, including drills, to test emergency responses when the words/phrases are used. Leaders and managers should nurture a workplace culture where people are comfortable seeking support if they feel they may be the target of harassment or stalking. Many larger health care organizations have threat management programs, which can play a critical role in preventing, investigating, and responding to stalking of employees. Increasingly, threat management teams are being identified as a best practice in health care settings.15Table 3 summarizes measures to mitigate risk.
What to do when harassment or stalking occurs
Consulting with subject matter experts is essential. Approach behaviors, stalking patterns, and immediate circumstances vary highly, and so too must responses. A socially inept approach outside of the work setting by a patient may be effectively responded to with a firm explanation of why the behavior was inappropriate and a reiteration of limits. More persistent or serious threats may require taking actions for immediate safety, calling law enforcement or security (who may have the expertise to assist appropriately), or even run/hide/fight measures. Others to notify early on include human resources, supervisors, front desk staff, and coworkers. Although no single measure is always indicated and no single measure will always be effective, consultation with a specialist is always advisable.
Attempting to assess your own risk may be subject to bias and error, even for an experienced forensic psychiatrist. Risk assessment in stalking and harassment cases is complex, nuanced, and beyond the scope of this article; engagement with specialized threat programs or subject matter experts is advisable.15,16 If your medical center or area has police or security officers, engage them early. Risk management, insurers, and legal can also be helpful to consult. Attorneys specializing in harassment, stalking, and domestic violence may be helpful in extreme situations.17Table 417,18 highlights steps to take.
While effective interventions to stop or redirect stalking behavior may vary, some initial considerations include changing established routines (eg, your parking location or daily/weekly patterns such as gym, class, etc.) and letting family and others you live with know what is occurring. Consider implementing and bolstering personal, work, and home security; honing situational awareness skills; and learning advanced situational awareness and self-defense techniques.
Continue to: Clinical documentation and termination of care...
Clinical documentation and termination of care
Repeated and unwanted contact behaviors by a patient may be considered grounds for termination of care by the targeted clinician. Termination may occur through a direct conversation, followed by a mailed letter explaining that the patient’s inappropriate behaviors are the basis for termination. The letter should outline steps for establishing care with another psychiatrist and signing a release to facilitate transfer of records to the next psychiatrist. Ensure that the patient has access to a reasonable supply of medications or refills according to jurisdictional standards for transfer or termination of care.19 While these are common legal standards for termination of care in the United States, clinicians would be well served by appropriate consultation to verify the most appropriate standards for their location.
Documentation of a patient’s behavior should be factual and clear. Under the 21st Century Cures Act, patients often have access to their own electronic records.20 Therefore, clinicians should avoid documenting personal security measures or other information that is not clinically relevant. Communications with legal or risk management should not be documented unless otherwise advised, because such communications may be privileged and may not be clinically relevant.
In some circumstances, continuing to treat a patient who has stalked a member of the current treatment team may be appropriate or necessary. For example, a patient may respond appropriately to redirection after an initial approach behavior and continue to make clinical progress, or may be in a forensic specialty setting with appropriate operational support to continue with treatment.
Ethical dilemmas may arise in underserved areas where there are limited options for psychiatric care and in communicating the reasons for termination to a new clinician. Consultation may help to address these issues. However, as noted before, clinicians should be permitted to discontinue and transfer treatment and should not be compelled to continue to treat a patient who has threatened or harassed them.
Organizational and employer considerations
Victims of stalking have reported that they appreciated explicit support from their supervisor, regular meetings, and measures to reduce potential stalking or violence in the workplace; unsurprisingly, victim blaming and leaving the employee to address the situation on their own were labeled experienced as negative.2 Employers may consider implementing physical security, access controls and panic alarms, and enhancing coworkers’ situational awareness.21 Explicit policies about and attention to reducing workplace violence, including stalking, are always beneficial—and in some settings such policies may be a regulatory requirement.22 Large health care organizations may benefit from developing specialized threat management programs to assist with the evaluation and mitigation of stalking and other workplace violence risks.15,23
Self-care considerations
The impact of stalking can include psychological distress, disruption of work and personal relationships, and false allegations of impropriety. Stalking can make targets feel isolated, violated, and fearful, which makes it challenging to reach out to others for support and safety. It takes time to regain a sense of safety and to find a “new normal,” particularly while experiencing and responding to stalking behavior. Notifying close personal contacts such as family and coworkers about what is occurring (without sharing protected health information) can be helpful for recovery and important for the clinician’s safety. Reaching out for organizational and legal supports is also prudent. It is also important to allow time for, and patience with, a targeted individual’s normal responses, such as decreased work performance, sleep/appetite changes, and hypervigilance, without pathologizing these common stress reactions. Further review of appropriate resources by impacted clinicians is advisable.24-26
Dr. A has been treating Ms. W, a graduate student, for depression. Ms. W made subtle comments expressing her interest in pursuing a romantic relationship with her psychiatrist. Dr. A gently redirected her, and she seemed to respond appropriately. However, over the past 2 weeks, Dr. A has seen Ms. W at a local park and at the grocery store. Today, Dr. A is startled to see Ms. W at her weekly yoga class. Dr. A plans to ask her supervisor for advice.
Dr. M is a child psychiatrist who spoke at his local school board meeting in support of masking requirements for students during COVID-19. During the discussion, Dr. M shared that, as a psychiatrist, he does not believe it is especially distressing for students to wear masks, and that doing so is a necessary public health measure. On leaving, other parents shouted, “We know who you are and where you live!” The next day, his integrated clinic started receiving threatening and harassing messages, including threats to kill him or his staff if they take part in vaccinating children against COVID-19.
Because of their work, mental health professionals—like other health care professionals—face an elevated risk of being harassed or stalked. Stalking often includes online harassment and may escalate to serious physical violence. Stalking is criminal behavior by a patient and should not be constructed as a “failure to manage transference.” This article explores basic strategies to reduce the risk of harassment and stalking, describes how to recognize early behaviors, and outlines basic steps health care professionals and their employers can take to respond to stalking and harassing behaviors.
Although this article is intended for psychiatrists, it is important to note that all health professionals have significant risk for experiencing stalking or harassment. This is due in part, but not exclusively, to our clinical work. Estimates of how many health professionals experience stalking vary substantially depending upon the study, and differences in methodologies limit easy comparison or extrapolation. More thorough reviews have reported ranges from 2% to 70% among physicians; psychiatrists and other mental health professionals appear to be at greater risk than those in other specialties and the general population.1-3 Physicians who are active on social media may also be at elevated risk.4 Unexpected communications from patients and their family members—especially those with threatening, harassing, or sexualized tones, or involving contact outside of a work setting—can be distressing. These behaviors represent potential harbingers of more dangerous behavior, including physical assault, sexual assault, or homicide. Despite their elevated risk, many psychiatrists are unaware of how to prevent or respond to stalking or harassment.
Recognizing harassment and stalking
Repeated and unwanted contact or communication, regardless of intent, may constitute stalking. Legal definitions vary by jurisdiction and may not align with subjective experiences or understanding of what constitutes stalking.5 At its essence, stalking is repeated harassing behaviors likely to provoke fear in the targeted person. FOUR is a helpful mnemonic when conceptualizing the attributes of stalking: Fixated, Obsessive, Unwanted, and Repetitive.6Table 1 lists examples of common stalking behaviors. Stalking and harassing behavior may be from a known source (eg, a patient, coworker, or paramour), a masked source (ie, someone known to the target but who conceals or obscures their identity), or from otherwise unknown persons. Behaviors that persist after the person engaging in the behaviors has clearly been informed that they are unwanted or inappropriate are especially concerning. Stalking may escalate to include physical or sexual assault and, in some cases, homicide.
Stalking duration can vary substantially, as can the factors that lead to the cessation of the behavior. Indicators of increased risk for physical violence include unwanted physical presence/following of the target (“approach behaviors”), having a prior violent intimate relationship, property destruction, explicit threats, and having a prior intimate relationship with the target.7
Stalking contact or communication may be unwanted because of the content (eg, sexualized or threatening tone), location (eg, at a professional’s home), or means (eg, through social media). Stalking behaviors are not appropriate in any relationship, including a clinical relationship. They should not be treated as a “failure to manage transference” or in other victim-blaming ways.
There are multiple typologies for stalking behavior. Common motivations for stalking health professionals include resentment or grievance, misjudgment of social boundaries, and delusional fixation, including erotomania.8 Associated psychopathologies vary significantly and, while some may be more amenable to psychiatric treatment than others, psychiatrists should not feel compelled to treat patients who repeatedly violate boundaries, regardless of intent or comorbidity.
Patients are not the exclusive perpetrators of stalking; a recent study found that 4% of physicians surveyed reported current or recent stalking by a current or former intimate partner.9 When a person who is a victim of intimate partner violence is also stalked as part of the abuse, homicide risk increases.10 Workplace homicides of health care professionals are most likely to be committed by a current or former partner or other personal acquaintance, not by a patient.11 Workplace harassment and stalking of health care professionals is especially concerning because this behavior can escalate and endanger coworkers or clients.
Continue to: Risk awareness: Recognize your exposure...
Risk awareness: Recognize your exposure
About 80% of stalking involves some form of technology—often telephone calls but also online or other “cyber” elements.12 One recent survey found the rate of online harassment, including threats of physical and sexual violence, was >20% among physicians who were active on social media.4 Health professionals may be at greater risk of having patients find their personal information simply because patients routinely search online for information about new clinicians. Personal information about a clinician may be readily visible among professional information in search results, or a curious patient may simply scroll further down in the results. For a potential stalker, clicking on a search result linking to a personal social media page may be far easier than finding a home address and going in person—but the action may be just as distressing or risky for the clinician.13 Additionally, items visible in a clinician’s office—or visible in the background of those providing telehealth services from their home—may inadvertently reveal personal information about the clinician, their home, or their family.
Psychiatrists are often in a special position in relation to patients and times of crises. They may be involved in involuntary commitment—or declining an admission when a patient or family wishes it. They may be present at the time of the revelation of a serious diagnosis, abuse, injury, or death. They may be a mandated reporter of child or elder abuse.2 Additionally, physicians may be engaged in discourse on politically charged public health topics.14 These factors may increase their risk of being stalked.
Conducting an online visibility self-assessment can be a useful way to learn what information others can find. Table 2 outlines the steps for completing this exercise. Searching multiple iterations of your current and former names (with and without degrees, titles, and cities) will yield differing results in various search engines. After establishing a baseline of what information is available online, it can be helpful to periodically repeat this exercise, and to set up automated alerts for your name, number(s), email(s), and address(es).
Basic mitigation strategies
In the modern era, being invisible online is impractical and likely impossible—especially for a health care professional. Instead, it may be prudent to limit your public visibility to professional portals (eg, LinkedIn or Doximity) and maximize privacy settings on other platforms. Another basic strategy is to avoid providing personal contact information (your home address, phone number, or personal email) for professional purposes, such as licensing and credentialing, conference submissions, or journal publications. Be aware that driving a visually distinct vehicle—one with vanity plates or distinct bumper stickers, or an exotic sportscar—can make it easier to be recognized and located. A personally recorded voicemail greeting (vs one recorded by, for example, an office manager) may be inappropriately reinforcing for some stalkers.
Workplaces should have an established safety policy that addresses stalking and harassment of employees. Similarly, patients and others should receive clear education on how to contact different staff, including physicians, with consideration of how and when to use electronic health information portals, office numbers, and emails. Workplaces should not disclose staff schedules. For example, a receptionist should say “I’ll have Dr. Diaz return your call when she can” instead of “Dr. Diaz is not in until tomorrow.” Avoid unnecessary location/name signals (eg, a parking spot labeled “Dr. Diaz”). Consider creating alert words or phrases for staff to use to signal they are concerned about their immediate safety—and provide education and training, including drills, to test emergency responses when the words/phrases are used. Leaders and managers should nurture a workplace culture where people are comfortable seeking support if they feel they may be the target of harassment or stalking. Many larger health care organizations have threat management programs, which can play a critical role in preventing, investigating, and responding to stalking of employees. Increasingly, threat management teams are being identified as a best practice in health care settings.15Table 3 summarizes measures to mitigate risk.
What to do when harassment or stalking occurs
Consulting with subject matter experts is essential. Approach behaviors, stalking patterns, and immediate circumstances vary highly, and so too must responses. A socially inept approach outside of the work setting by a patient may be effectively responded to with a firm explanation of why the behavior was inappropriate and a reiteration of limits. More persistent or serious threats may require taking actions for immediate safety, calling law enforcement or security (who may have the expertise to assist appropriately), or even run/hide/fight measures. Others to notify early on include human resources, supervisors, front desk staff, and coworkers. Although no single measure is always indicated and no single measure will always be effective, consultation with a specialist is always advisable.
Attempting to assess your own risk may be subject to bias and error, even for an experienced forensic psychiatrist. Risk assessment in stalking and harassment cases is complex, nuanced, and beyond the scope of this article; engagement with specialized threat programs or subject matter experts is advisable.15,16 If your medical center or area has police or security officers, engage them early. Risk management, insurers, and legal can also be helpful to consult. Attorneys specializing in harassment, stalking, and domestic violence may be helpful in extreme situations.17Table 417,18 highlights steps to take.
While effective interventions to stop or redirect stalking behavior may vary, some initial considerations include changing established routines (eg, your parking location or daily/weekly patterns such as gym, class, etc.) and letting family and others you live with know what is occurring. Consider implementing and bolstering personal, work, and home security; honing situational awareness skills; and learning advanced situational awareness and self-defense techniques.
Continue to: Clinical documentation and termination of care...
Clinical documentation and termination of care
Repeated and unwanted contact behaviors by a patient may be considered grounds for termination of care by the targeted clinician. Termination may occur through a direct conversation, followed by a mailed letter explaining that the patient’s inappropriate behaviors are the basis for termination. The letter should outline steps for establishing care with another psychiatrist and signing a release to facilitate transfer of records to the next psychiatrist. Ensure that the patient has access to a reasonable supply of medications or refills according to jurisdictional standards for transfer or termination of care.19 While these are common legal standards for termination of care in the United States, clinicians would be well served by appropriate consultation to verify the most appropriate standards for their location.
Documentation of a patient’s behavior should be factual and clear. Under the 21st Century Cures Act, patients often have access to their own electronic records.20 Therefore, clinicians should avoid documenting personal security measures or other information that is not clinically relevant. Communications with legal or risk management should not be documented unless otherwise advised, because such communications may be privileged and may not be clinically relevant.
In some circumstances, continuing to treat a patient who has stalked a member of the current treatment team may be appropriate or necessary. For example, a patient may respond appropriately to redirection after an initial approach behavior and continue to make clinical progress, or may be in a forensic specialty setting with appropriate operational support to continue with treatment.
Ethical dilemmas may arise in underserved areas where there are limited options for psychiatric care and in communicating the reasons for termination to a new clinician. Consultation may help to address these issues. However, as noted before, clinicians should be permitted to discontinue and transfer treatment and should not be compelled to continue to treat a patient who has threatened or harassed them.
Organizational and employer considerations
Victims of stalking have reported that they appreciated explicit support from their supervisor, regular meetings, and measures to reduce potential stalking or violence in the workplace; unsurprisingly, victim blaming and leaving the employee to address the situation on their own were labeled experienced as negative.2 Employers may consider implementing physical security, access controls and panic alarms, and enhancing coworkers’ situational awareness.21 Explicit policies about and attention to reducing workplace violence, including stalking, are always beneficial—and in some settings such policies may be a regulatory requirement.22 Large health care organizations may benefit from developing specialized threat management programs to assist with the evaluation and mitigation of stalking and other workplace violence risks.15,23
Self-care considerations
The impact of stalking can include psychological distress, disruption of work and personal relationships, and false allegations of impropriety. Stalking can make targets feel isolated, violated, and fearful, which makes it challenging to reach out to others for support and safety. It takes time to regain a sense of safety and to find a “new normal,” particularly while experiencing and responding to stalking behavior. Notifying close personal contacts such as family and coworkers about what is occurring (without sharing protected health information) can be helpful for recovery and important for the clinician’s safety. Reaching out for organizational and legal supports is also prudent. It is also important to allow time for, and patience with, a targeted individual’s normal responses, such as decreased work performance, sleep/appetite changes, and hypervigilance, without pathologizing these common stress reactions. Further review of appropriate resources by impacted clinicians is advisable.24-26
1. Nelsen AJ, Johnson RS, Ostermeyer B, et al. The prevalence of physicians who have been stalked: a systematic review. J Am Acad Psychiatry Law. 2015;43(2):177-182.
2. Jutasi C, McEwan TE. Stalking of professionals: a scoping review. Journal of Threat Assessment and Management. 2021;8(3):94-124.
3. Pathé MT, Meloy JR. Commentary: Stalking by patients—psychiatrists’ tales of anger, lust and ignorance. J Am Acad Psychiatry Law. 2013;41(2):200-205.
4. Pendergrast TR, Jain S, Trueger NS, et al. Prevalence of personal attacks and sexual harassment of physicians on social media. JAMA Intern Med. 2021;181(4):550-552.
5. Owens JG. Why definitions matter: stalking victimization in the United States. J Interpers Violence. 2016;31(12):2196-2226.
6. College of Policing. Stalking or harassment. May 2019. Accessed March 8, 2020. https://library.college.police.uk/docs/college-of-policing/Stalking_or_harassment_guidance_200519.pdf
7. McEwan TE, Daffern M, MacKenzie RD, et al. Risk factors for stalking violence, persistence, and recurrence. Journal of Forensic Psychiatry & Psychology. 2017;28(1):3856.
8. Pathé MT, Mullen PE, Purcell R. Patients who stalk doctors: their motives and management. Med J Australia. 2002;176(7):335-338.
9. Reibling ET, Distelberg B, Guptill M, et al. Intimate partner violence experienced by physicians. J Prim Care Community Health. 2020;11:2150132720965077.
10. Matias A, Gonçalves M, Soeiro C, et al. Intimate partner homicide: a meta-analysis of risk factors. Aggression and Violent Behavior. 2019;50:101358.
11. US Bureau of Labor Statistics. Fact sheet. Workplace violence in healthcare, 2018. April 2020. Accessed November 24, 2021. https://www.bls.gov/iif/oshwc/cfoi/workplace-violence-healthcare-2018.htm
12. Truman JL, Morgan RE. Stalking victimization, 2016. Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. Report No.: NCJ 253526. April 2021. Accessed November 24, 2021. https://bjs.ojp.gov/library/publications/stalking-victimization-2016
13. Reyns BW, Henson B, Fisher BS. Being pursued online: applying cyberlifestyle–routine activities theory to cyberstalking victimization. Criminal Justice and Behavior. 2011;38(11):1149-1169.
14. Stea JN. When promoting knowledge makes you a target. Scientific American Blog Network. March 16, 2020. Accessed November 24, 2021. https://blogs.scientificamerican.com/observations/when-promoting-knowledge-makes-you-a-target/
15. Henkel SJ. Threat assessment strategies to mitigate violence in healthcare. IAHSS Foundation. IAHSS-F RS-19-02. November 2019. Accessed November 24, 2021. https://iahssf.org/assets/IAHSS-Foundation-Threat-Assessment-Strategies-to-Mitigate-Violence-in-Healthcare.pdf
16. McEwan TE. Stalking threat and risk assessment. In: Reid Meloy J, Hoffman J (eds). International Handbook of Threat Assessment. 2nd ed. Oxford University Press; 2021:210-234.
17. Goldberg C. Nobody’s Victim: Fighting Psychos, Stalkers, Pervs, and Trolls. Plume; 2019.
18. Bazzell M. Extreme Privacy: What It Takes to Disappear. 2nd ed. Independently published; 2020.
19. Simon RI, Shuman DW. The doctor-patient relationship. Focus. 2007;5(4):423-431.
20. Department of Health and Human Services. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule (To be codified at 45 CFR 170 and 171). Federal Register. 2020;85(85):25642-25961.
21. Sheridan L, North AC, Scott AJ. Stalking in the workplace. Journal of Threat Assessment and Management. 2019;6(2):61-75.
22. The Joint Commission. Workplace Violence Prevention Standards. R3 Report: Requirement, Rationale, Reference. Issue 30. June 18, 2021. Accessed November 24, 2021. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3-30_revised_06302021.pdf
23. Terry LP. Threat assessment teams. J Healthc Prot Manage. 2015;31(2):23-35.
24. Pathé M. Surviving Stalking. Cambridge University Press; 2002.
25. Noffsinger S. What stalking victims need to restore their mental and somatic health. Current Psychiatry. 2015;14(6):43-47.
26. Mullen P, Whyte S, McIvor R; Psychiatrists’ Support Service, Royal College of Psychiatry. PSS Information Guide: Stalking. Report No. 11. 2017. Accessed November 24, 2021. https://www.rcpsych.ac.uk/docs/default-source/members/supporting-you/pss/pss-guide-11-stalking.pdf?sfvrsn=2f1c7253_2
1. Nelsen AJ, Johnson RS, Ostermeyer B, et al. The prevalence of physicians who have been stalked: a systematic review. J Am Acad Psychiatry Law. 2015;43(2):177-182.
2. Jutasi C, McEwan TE. Stalking of professionals: a scoping review. Journal of Threat Assessment and Management. 2021;8(3):94-124.
3. Pathé MT, Meloy JR. Commentary: Stalking by patients—psychiatrists’ tales of anger, lust and ignorance. J Am Acad Psychiatry Law. 2013;41(2):200-205.
4. Pendergrast TR, Jain S, Trueger NS, et al. Prevalence of personal attacks and sexual harassment of physicians on social media. JAMA Intern Med. 2021;181(4):550-552.
5. Owens JG. Why definitions matter: stalking victimization in the United States. J Interpers Violence. 2016;31(12):2196-2226.
6. College of Policing. Stalking or harassment. May 2019. Accessed March 8, 2020. https://library.college.police.uk/docs/college-of-policing/Stalking_or_harassment_guidance_200519.pdf
7. McEwan TE, Daffern M, MacKenzie RD, et al. Risk factors for stalking violence, persistence, and recurrence. Journal of Forensic Psychiatry & Psychology. 2017;28(1):3856.
8. Pathé MT, Mullen PE, Purcell R. Patients who stalk doctors: their motives and management. Med J Australia. 2002;176(7):335-338.
9. Reibling ET, Distelberg B, Guptill M, et al. Intimate partner violence experienced by physicians. J Prim Care Community Health. 2020;11:2150132720965077.
10. Matias A, Gonçalves M, Soeiro C, et al. Intimate partner homicide: a meta-analysis of risk factors. Aggression and Violent Behavior. 2019;50:101358.
11. US Bureau of Labor Statistics. Fact sheet. Workplace violence in healthcare, 2018. April 2020. Accessed November 24, 2021. https://www.bls.gov/iif/oshwc/cfoi/workplace-violence-healthcare-2018.htm
12. Truman JL, Morgan RE. Stalking victimization, 2016. Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. Report No.: NCJ 253526. April 2021. Accessed November 24, 2021. https://bjs.ojp.gov/library/publications/stalking-victimization-2016
13. Reyns BW, Henson B, Fisher BS. Being pursued online: applying cyberlifestyle–routine activities theory to cyberstalking victimization. Criminal Justice and Behavior. 2011;38(11):1149-1169.
14. Stea JN. When promoting knowledge makes you a target. Scientific American Blog Network. March 16, 2020. Accessed November 24, 2021. https://blogs.scientificamerican.com/observations/when-promoting-knowledge-makes-you-a-target/
15. Henkel SJ. Threat assessment strategies to mitigate violence in healthcare. IAHSS Foundation. IAHSS-F RS-19-02. November 2019. Accessed November 24, 2021. https://iahssf.org/assets/IAHSS-Foundation-Threat-Assessment-Strategies-to-Mitigate-Violence-in-Healthcare.pdf
16. McEwan TE. Stalking threat and risk assessment. In: Reid Meloy J, Hoffman J (eds). International Handbook of Threat Assessment. 2nd ed. Oxford University Press; 2021:210-234.
17. Goldberg C. Nobody’s Victim: Fighting Psychos, Stalkers, Pervs, and Trolls. Plume; 2019.
18. Bazzell M. Extreme Privacy: What It Takes to Disappear. 2nd ed. Independently published; 2020.
19. Simon RI, Shuman DW. The doctor-patient relationship. Focus. 2007;5(4):423-431.
20. Department of Health and Human Services. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule (To be codified at 45 CFR 170 and 171). Federal Register. 2020;85(85):25642-25961.
21. Sheridan L, North AC, Scott AJ. Stalking in the workplace. Journal of Threat Assessment and Management. 2019;6(2):61-75.
22. The Joint Commission. Workplace Violence Prevention Standards. R3 Report: Requirement, Rationale, Reference. Issue 30. June 18, 2021. Accessed November 24, 2021. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3-30_revised_06302021.pdf
23. Terry LP. Threat assessment teams. J Healthc Prot Manage. 2015;31(2):23-35.
24. Pathé M. Surviving Stalking. Cambridge University Press; 2002.
25. Noffsinger S. What stalking victims need to restore their mental and somatic health. Current Psychiatry. 2015;14(6):43-47.
26. Mullen P, Whyte S, McIvor R; Psychiatrists’ Support Service, Royal College of Psychiatry. PSS Information Guide: Stalking. Report No. 11. 2017. Accessed November 24, 2021. https://www.rcpsych.ac.uk/docs/default-source/members/supporting-you/pss/pss-guide-11-stalking.pdf?sfvrsn=2f1c7253_2
