Stalking is defined as the “willful, malicious, and repeated following or harassing of another person.”1 This harassing behavior is alarming and distressing to the victim and serves no legitimate purpose. Actions of the offender include following and loitering near the victim’s home or workplace, repeated phone calls or emails, letters and unwanted gifts, harassment of family members and partners, break-ins and destruction of property, and constant surveillance. Victims are terrorized, intimidated, and controlled by such behaviors. Over time, the harassment often escalates and becomes more threatening and violent in nature.
Psychiatrists may encounter patients who present with severe emotional consequences because they are victims of stalking. In addition, psychiatrists themselves are at increased risk 
Epidemiology
Unlike most other crimes, stalking can continue for an extended period—from a few weeks to many years.2,3 Roughly 90% of stalkers are men, and about 80% of victims are women.2,4 Most men who are stalkers either want to re-establish or initiate a relationship with a woman.4 The US Department of Justice National Violence Against Women (NVAW) Survey collected data from 8000 women and 8000 men. Roughly 8% of women and 2% of men had been stalked at some point in their lives.2 In the only community-based epidemiological study of stalking undertaken in Europe, Dressing and colleagues5 found that the lifetime prevalence of being stalked was 17.3% in women and 3.7% in men. Ninety-four percent of female victims reported being stalked by a man, whereas men were equally likely to be stalked by a man as by a woman. Data show that most women who are stalked are between the ages of 26 and 46, but victims can be from any age group.4
Victims often have good reason to fear for their physical safety and even their lives.6 In an Australian study of 100 stalking victims, more than half had been overtly threatened either directly or through family and friends, and almost half were eventually physically or sexually assaulted.7
Emotional and social consequences
Persistent harassment can take its toll on a victim’s mental health. Chronic threats, constant surveillance, and unwanted intrusion into one’s life may lead to long-term damaging psychological effects.5,8-10 The clinical consequences include depression, diminished interest in activities, guilt, anxiety, humiliation, shame, helplessness, hopelessness, and an enhanced sense of vulnerability that can continue long after the stalking has ended.8,9 Family and friends may negatively affect the situation by implying that the victim is somehow responsible for encouraging the stalker or, in the case of vic-tims stalked by ex-partners, causing guilt and low self-esteem by suggesting poor judgment in relationship choices.
Case Vignette
Annie, a 24-year-old secretary broke up with X, a man she had dated for a year, after he became increasingly controlling and possessive. He began to call 10 to 12 times a day, initially professing his love but becoming threatening if she did not return to him. He would wait outside her house or report on her activities to make her aware he had been following her. She met with him several times to try to explain that the relationship was over, to no avail. When she spoke to friends about it, they either minimized his behavior saying he was still in love or criticized her for her choice of partner. She felt initially sympathetic toward him and guilty for hurting him. She became frustrated and then frightened.
As the stalking continued, X became more destructive: he took her mail and splashed paint on her steps. The stalking began to interfere with her work. She was late on several occasions because her tires were flat. X called her work frequently, causing her boss to become impatient. Her performance deteriorated as she became anxious, depressed, and unable to sleep. Finally, she was fired.
By the time she came for therapy, she felt helpless and hopeless, was easily startled, had isolated herself from friends and family, rarely went out, and believed the stalking would never stop. She did not really think that therapy would help.
Pathé and Mullen7 surveyed 100 stalking victims and found that 83% reported heightened anxiety, including panic attacks and hypervigilance. Most women also reported sleep disturbances, intrusive recollections or flashbacks, and other posttraumatic symptoms. Many victims have reported appetite disturbance, suicidal thoughts, worsening of medical conditions, personality changes, paranoia, and substance abuse.4,7,10
Stalking victims may become quite isolated, not only because they choose to stay in to avoid their stalker but because employers and friends withdraw after also being subjected to harassment or as victims back away in humiliation.4,7,8 Victims frequently need to quit their jobs, move, change home and cell phone numbers, and buy expensive security equipment in an attempt to regain privacy. Unfortunately, these methods often fail because determined stalkers usually find the new numbers and addresses quickly.
Several studies have confirmed the enormous impact on a victim’s employment in the form of reduced productivity and/or lost time from work.2,7,11,12 Depression, anxiety, poor concentration, and fatigue all interfere with job performance.11 Absence from work occurs for various reasons including the emotional consequences of the stalking, time needed to deal with the criminal justice system or mental health professionals, and a wish to avoid contact with the stalker.
Goals of treatment
Victims of stalking may present to mental health care professionals and to general practitioners to seek relief from their symptoms and also for assistance with the problem. Despite the large number of persons who have been stalked, very little has been written about treatment.
Spence-Diehl’s Project Impact, an intensive case management approach for victims of stalking, focuses on practical issues such as crisis intervention, advocacy, and multiagency service coordination but does not address issues of psychotherapy.13 Pathé and colleagues14 advocate a therapeutic approach that combines education, combating the stalking, and cognitive-behavioral therapy.
However, neither of these approaches addresses issues of therapist countertransference. Our approach includes education, supportive psycho-therapy, and discussion of practical measures (Table).
