Stalking Psych Regs

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Stalking Psych Reg's?

Thursday, 16 December 2004

Michele Pathe is a Forensic Psychiatrist who, with Paul Mullen, has written Stalkers and Their Victimsand more recently Surviving Stalking. She runs a website, www.antistalking.net.au which outlines services offered by the Threat Management Centre and provides information on stalking.A quick straw poll of psych registrar colleagues indicates that this could be a significant and concerning occupational hazard. I talked to Michele about this how best we can deal with this issue:

How commonly do psychiatrists in training and psychiatrists become victims of stalking?That is a question that we donâ€™t have the empirical studies to answer. Our impression is that doctors are over represented in stalking victim populations. Certainly a fair proportion of victims I see are healthcare professionals of one sort or another, particularly in the counselling professions. Some of the time it can be as a result of stalking by patients and other times by a colleague or other work contacts, as in the Margaret Tobin case, or by former intimates -being stalked in that context.But certainly there is a risk of being stalked by patients. At the moment we donâ€™t have a figure to back that up. There has been a recent random survey of psychologists in Victoria that is currently being analysed. When we tried to do that with medical practitioners the response rate was so low that it was barely worth analysing.My clinical impression, and impression of talking to colleagues, is that this is a relatively common experience. It is not just female trainees either or female psychiatrists. Males experience their share of it.

What would the proportion of male to female victims be?

I don't know because the problem here, again, is that females are more likely to ask for help. A lotof male psychiatrists and male doctors in general shy away because I guess they might be concerned that they may be blamed or disbelieved.Males, I think, don't tend to present quite as readily as females. Females feel more threatened, forobvious reasons, so they're likely to have a lower threshold for seeking help.I have however had a number of male psychiatrists who have consulted me over the last couple of years. More have phoned: I receive a lot of phone enquiries and emails from doctors.

What are the most common reasons for trainees to be stalked?What are some of the ideas that new psychiatry registrars need to think about to help protect themselves?

Being able to set boundaries. There is a risk that the sympathy and attention we provide will be misconstrued by some of our more lonely and unstable patients as romantic interest. It is important to be alert to this and to make clear to patients that the relationship is a professional one and will never be otherwise.Trainees have to be aware that, regardless of how much care is taken, those boundaries will at times be pushed: Examples include patients who present increasingly frequently, ostensibly for clinical reasons, but really they are seeking greater contact with the doctor. They typically make increasing demands on the doctor. Trainees must recognize when this is occurring, confront the patient and set limits by restricting the duration and frequency of appointments and any other inappropriate behaviours. Other staff also need to be alerted to what is happening so that they donâ€™t unwittingly encourage it.Anecdotally, this is a relatively common experience, with doctors describing how they found themselves going the extra mile; giving their patient that extra appointment, say, at the end of the day when there may be no one else around. Seeing them at the weekend when they wouldnâ€™t normally consult, or allowing the patient to have their home contact details.

Is the sense of "taking responsibility for patients" that doctors often have part of a beliefsystem that can nudge them down that pathway? Is this common?

It is common. It astounds us sometimes how much doctors really are prepared to put up with. The degree of threat and disruption to their lives on the basis of â€œI am their doctor and theyâ€™re a patient and canâ€™t help itâ€ or â€œI should just have to endure this because this is my profession, this is what I am supposed to do.â€So people do allow this to happen out of a misguided belief that we are supposed to tolerate unacceptable or even criminal behaviour. A lot of times it is criminal by the time the victim comes to me and their lives have been absolutely devastated and that of their family as well!It can also impact on their staff and other people also.

Do you think denial or embarrassment play into this?

Yes for sure. They think: "They shouldn't be feeling like that" or "I haven't got a right tofeel frightened." Often they think "If I say anything about this you wouldn't believe me" or"they'll point the finger at me and judge me as incompetent". "I haven't handled thetransference adequately". I think that such reactions are encouraged by our profession.In fact, often you can say "I really think you've done nothing to encourage it" and every step ofthe way they have behaved quite appropriately under the circumstances.

From the registrar's point of view: when it happens to us in the work place - not enough stats andinformation about risk and what to do, is likely to have percolated through to our Occupational Health & Safety Policy in hospitals.So when it does happen we're dependent on the attitudes and expertise of our consultant or supervisor.Has it been addressed to your knowledge?

Certainly in NSW consideration has been given to introducing this issue into the undergraduate medical curriculum but I am not aware of any other formal training at this level.

We are taught that there are different risks for different diagnostic groups how much should this guide us in managing the problem?

It really depends on the nature of the stalking motivation rather than the actual diagnosis.For instance, the intimacy seeker, who is seeking a relationship and who often feel the person already loves them, as in erotomania, has a lower incidence of violence. They are after that perfect relationship, theyâ€™re not usually aggressive unless they are rejected persistently and the real risk here is persistence, and psychological and social damage to the victim. Legal sanctions alone seldom work, they need treatment of their delusions. For resentful stalkers, who are seeking retribution and are motivated by a desire to frighten and distress the victim, there is a high risk of threats and persistence but a low risk of violence. Legal sanctions, even prosecution under anti-stalking statutes, may be required. For the date seeking incompetent would-be suitors, the risk of violence and of persistence is low and they can usually be managed with consistent limit setting.

Do you find there are significant long-term consequences for doctors who have been victims of stalking?

Again I don't have any real empirical basis for this but I've seen quite a few affected doctors overthe years and they typically become very weary, very disenchanted with the profession. A couple of them dropped out all together â€“ so all those years of training and they just couldnâ€™t carry on â€“ some even lost their partners and families in the process.It really does impact quite significantly on medical lives. The other thing is that stalkers are starting to realize that a great way to get back at their doctor is to make spurious complaints to the medical board or other health complaints bodies. We seem to be seeing an increasing number of false allegations and the impact of this whole process, which may progress as far as a formal hearing, is traumatic in itself. It is much harder, especially for males wrongly accused of sexual impropriety, to carry on practising in a climate of suspicion- â€œwhere thereâ€™s smoke thereâ€™s fireâ€.

Usually prevention is better than cure, are there any early intervention tips that you recommend?

The best preventative tip, I think, for everybody entering this profession is never to disclose personal details to patients or leave these where patients can access them, and to remove as far as possible his or her personal records from the public domain.I think every medical practitioner needs to be very wary about what details of their private life appear in the public domain. They should remove their phone number from the phone book and preferably rent a post office box rather than having mail sent to the home address. Silent enrolment (removing their name and address from the publicly listed electoral roll) is well worth considering â€“psychiatrists can certainly make a very good case for not being on the electoral roll.Professional registration bodies such as the College, AMA and Medical Board, should not be trusted with your private address; just donâ€™t give it to them, and ensure all your subscriptions and memberships are sent to a post office address.I think that is the first step because once people have a problem with a patient it's often too lateand they can track you to your home.Be conscious of security at home and work. It's unwise to practice alone, especially from home.When patients are pushing boundaries, set limits and ensure the patient is only seen when others are nearby. Carefully document the patientâ€™s intrusions.If unwanted intrusions continue discontinue the patientâ€™s care and transfer them to another practitioner.However, bear in mind that a patient who has already stalked a doctor is not a popular case to take on. I see a lot of stalkers and Iâ€™m not particularly perturbed about seeing them but there are some stalkers that I will not see:If a person has stalked previous female doctors, then I generally won't tempt fate by taking that caseon, it's just too risky. I would recommend an older, male doctor or someone in a public health settingwhere there may be more supports in place.There are certain things you can avoid with some patients, but most don't come with a flashing sign ontheir forehead. They may be the after hours consultation that you see relatively briefly. Thereâ€™s a book written by a female psychiatrist, Doreen Orion, called â€œI know you really love me: a psychiatristâ€™s journal of erotomania, stalking, and obsessive loveâ€It's a story of a female erotomanic patient Dr Orion saw once briefly after hours, but the womanstalked her for the next 8 years. It's an amazing and disturbing- account, but also a realeye-opener to just how tenacious these patients can be.Prevention, and if that doesnâ€™t work, early intervention, -identifying it, not denying it, and seeking advice as soon as possible, is important.

Do you think gut instinct is important in guiding a doctor to alert them to possible cases?I guess intellectually we often try to over ride that?Gut instinct is important and doctors particularly may try to override that.We should, particularly in psychiatry, be able to listen to that because it is a very useful tool.When someone is starting to sound overfamiliar, when they're starting to want more of you, that shouldset off alarm bells. People starting to make threats, certainly warrants concern. If the behaviour is continuing you really shouldnâ€™t be directly involved in that patientâ€™s care and you should be seeking advice.

Often, when we seek advice, the first port of call is our Supervisor. Sometimes, however, registrars have reported that they donâ€™t want to deal with work, training and harassment issues all with the same individual. The relationship or system feels too burdened or close or not confidential. What would be a good external service to approach for help in these instances?

I think seeking the advice of a Forensic Psychiatrist, someone with expertise in assessing offenders and risk, preferably someone who is familiar with stalking.They're not going to minimize or trivialize this sort of behaviour, and they're going to know whenone should be concerned and how to access the sorts of legal remedies that are available.Importantly, stalking by patients, especially when it is escalating or involves overt hostility, should never by ignored or â€œworked throughâ€ in therapy.

Some registrars in this situation have faced the dilemma of seeking a restraining order, which effectively states donâ€™t come where I am ( and this is where I am) or trying to use a 3rd party to warn them off?

Restraining orders are not a panacea. They are not a universal solution to stalking cases and very often the types of stalkers that pursue us professionally are the kind of individuals that arenâ€™t going to respond to intervention or restraining orders. You need to be aware that the police, in most instances, will advise an intervention order, but itâ€™s something that needs to be assessed on its merits.If you have an erotomanic individual, intervention orders are generally useless, you can go to all that trouble of pitting yourself against the individual in court with the risk of disclosing your whereabouts and then it doesnâ€™t actually stop the behaviour, because they are deluded. They often just reinterpret an order in a positive light, or see it as a challenge to be overcome on the path to true love, that sort of thing.There are other cases, like the rejected boyfriend, or in our case, the patient who behaves like a rejected stalker after the termination of a long term therapeutic relationship. Here again we would be very careful about using a restraining order because they have the potential to inflame the situation by deepening the narcissistic wound, as it were.The other group that bothers doctors, the Incompetent Suitors, those socially unskilled people who get attached and get this misguided expectation that they can have a relationship with you, are usually so easily discouraged you donâ€™t have to go to the trouble of an intervention order. But if it gets to that point itâ€™s often a sufficient sanction to make them disengage, or move on to another doctor at least.

How did you get into this area?

I've been in Forensic Psychiatry for a long time, I've always had an interest in the criminal sideof psychiatry and back in the early 90s Paul Mullen and I developed an interest in erotomania, having seen a series of cases in the forensic system. There wasnâ€™t a lot of information about this group. It became clear that quite a number of them had actually stalked their victims, although the stalking label had barely been coined back then.What became even more apparent was the detrimental effects of this behaviour on victims, though ithadn't really been described. From studying the impact of stalking, we began to collect information on cohorts of stalkers and started to formulate a typology of stalkers, based on motivation, that might enable us to predict the course of stalking, associated risks and management in any given case.

Do you mainly see stalkers and their victims?

Yes my practice is predominantly for stalking victims or victims of related behaviours like threats, harassment and bullying. I also do other related medicolegal work. In addition I work at Forensicare, in particular assessing and treating Sex Offenders. There is a bit of overlap of course with Sex offenders and Stalkers. Many sex offenders share the sorts of social deficits we encounter in stalkers, and many engage in stalking behaviours. Most stalkers, though, are not sexually motivated.At the end of the day I am dealing with psychological trauma, not just victims of isolated crimes but people who have been subjected to protracted and severe stress. I treat predominantly depressive and anxiety disorders and complex PTSD. Itâ€™s an amazing area!

What would you like to find out about the registrar population?

Well, it would be fascinating to get some kind of idea of the extent of thisIf there is any difference in terms of gender or types of training or years of training.I'd be particularly interested to know the extent of the problem and the nature of the problem that weare dealing predominantly with:I guess there are a lot of resentful patterns of stalking in the medical profession but I suspect that psychiatry sees less of that and they probably gravitate more towards the Surgical specialities where you attract disgruntled patients.I don't think in psychiatry we see as much of that. Generally we have people who get attached to us,the morbidly infatuated including erotomanics and the incompetent suitors, or people who react badly to termination of long term psychotherapy.I'd also be very interested to know what kind of help they got?I was recently talking to a GP who had an erotomanic patient. She consulted a psychiatrist who said â€clearly this woman is very attached to you so what you need to do is give her a handkerchief with your favorite perfume on it so that she has something of you, like a transitional object [laughs]So I'd be interested to see whether they have sought help, what advice they received and whether itwas effective, what sort of things have worked for themIt's just not something that we are taught and I think we need to be taught very early on, right froman undergraduate level.

ANZAPT would like to thank Michele for her thought and care in providing this information, and will be running a Responder survey on stalking at work in the new year.

Deeta Kimber ing the advice of a Forensic Psychiatrist, someone with expertise in assessing offenders and risk, preferably someone who is familiar with stalking.They're not going to minimize or trivialize this sort of behaviour, and they're going to know whenone should be concerned and how to access the sorts of legal remedies that are available.Importantly, stalking by patients, especially when it is escalating or involves overt hostility, should never by ignored or â€œworked throughâ€ in therapy.

How did you get into this area?

I've been in Forensic Psychiatry for a long time, I've always had an interest in the criminal sideof psychiatry and back in the early 90s Paul Mullen and I developed an interest in erotomania, having seen a series of cases in the forensic system. There wasnâ€™t a lot of information about this group. It became clear that quite a number of them had actually stalked their victims, although the stalking label had barely been coined back then.What became even more apparent was the detrimental effects of this behaviour on victims, though it hadnâ€™t really been described. From studying the impact of stalking, we began to collect information on cohorts of stalkers and started to formulate a typology of stalkers, based on motivation, that might enable us to predict the course of stalking, associated risks and management in any given case.

Do you mainly see stalkers and their victims?

What would you like to find out about the registrar population?

ANZAPT would like to thank Michele for her thought and care in providing this information, and will be running a Responder survey on stalking at work in the new year.

Deeta Kimber