Gail Erlick Robinson, MD

[[{"type":"media","view_mode":"media_crop","fid":"39805","attributes":{"alt":"contraception and misconceptions","class":"media-image media-image-right","id":"media_crop_4070598942410","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4009","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"147","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The American Psychiatric Association is incorporating a statement into its practice guidelines advising psychiatrists to routinely inquire about pregnancy plans and discuss the risk of unplanned pregnancy and contraception.

 Although the majority of patients seen in general psychiatric practice are women, especially women of reproductive age, psychiatrists are often unlikely to inquire about and document discussions of contraception use and pregnancy planning.

In the US, 51% of pregnancies are unintended, and 40% of unintended pregnancies end in abortion.

 Most of these unintended pregnancies occur in women who were not using any form of contraception. Unintended pregnancies have a higher risk of adverse maternal and child health outcomes. In addition, these pregnancies are costly: in 2010, the total public expenditure on perinatal care for unintended pregnancies was $21 billion. Psychiatrists who treat women and adolescent girls may find it necessary to discuss with their patients reproductive planning and the role of contraception in setting comprehensive treatment goals.

Psychiatric knowledge about these issues is important for all patients; however, it is particularly important in the case of women with chronic mental illness, many of whom lack general knowledge about contraception and are less likely to use birth control, despite wishing to prevent pregnancy.

Various psychiatric disorders have their own specific risks. In bipolar disorder, unplanned pregnancy is common. In one observational study that compared women with bipolar disorder with healthy controls, the bipolar women reported more frequent unplanned pregnancies (32.8% of pregnancies were planned among the bipolar women compared with 78.1% of pregnancies among healthy controls without mental illness).

 Women with primary psychotic disorders, such as schizophrenia, are at greater risk for coerced sex, risky sexual behavior, and unplanned/unwanted pregnancy.

 Among women with borderline personality disorder, those with more severe symptoms are at greater risk for unplanned pregnancy and teen-age pregnancy than are women who have Axis 1 disorders.

Women with substance use disorders are also at higher risk for unplanned pregnancy, which increases the risk of fetal exposure to illicit substances, alcohol, and tobacco, particularly during organogenesis in early pregnancy. In a survey of women attending outpatient drug treatment programs, high rates of pregnancy were reported, and 70.5% of pregnancies were unplanned.

 In addition, women with substance use disorders are at risk for risky sexual behaviors, including prostitution.

 In a growing number of states, instead of receiving treatment, women with substance use disorders and concomitant pregnancy are at risk for criminal prosecution.

Because of these risks, good psychiatric practice should include questions about contraception, pregnancy planning, and counseling about reproductive safety of the patient’s specific drug regimen in order to prevent unintended pregnancy and plan for a healthy pregnancy when desired.

Polypharmacy should be kept to a minimum and known teratogens, such as valproic acid and carbamazepine, should be avoided if possible in women not using reliable contraception. The psychiatrist should understand the interactions between psychotropics and hormonal contraceptives. Drugs such as carbamazepine, oxcarbazepine, topiramate, and modafinil can decrease the effectiveness of hormonal contraceptives, while oral contraceptives can decrease serum levels of valproate and lamotrigine.

 The safety of psychotropic drugs during pregnancy and the risk of untreated illness should be discussed so that if a woman becomes pregnant, she will not immediately discontinue her medication.

Psychiatrists should be prepared to ask basic questions about contraceptive use and pregnancy wishes and, if necessary, refer to a reproductive psychiatric specialist or collaborate with the patient’s primary care physician or gynecologist to establish an appropriate treatment plan.

The authors are members of the Committee on Gender and Mental Health, the Group for Advancement of Psychiatry. The authors report no conflicts of interest concerning the subject matter of this article.

 Robinson GE. Contraceptive care for women with chronic, serious mental illness. American Psychiatric Association Action Paper ADMNOV1212F; 2012. For a copy of this paper, please e-mail Dr Robinson at gail.robinson@utoronto.ca.

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Unintended Pregnancy in the United States.

http://www. guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

 Miller LJ. Sexuality, reproduction, and family planning in women with schizophrenia. 

 Marengo E, Martino DJ, Igoa A, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. 

 De Genna NM, Feske U, Larkby C, et al. Pregnancies, abortions, and births among women with and without borderline personality disorder. 

 Black KI, Stephens C, Haber PS, Lintzeris N. Unplanned pregnancy and contraceptive use in women attending drug treatment services. 

 Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid-abusing women. 

 ACOG Committee on Ethics. ACOG Committee Opinion #321: Maternal decision making, ethics, and the law. 

 Joffe H. Reproductive biology and psychotropic treatments in premenopausal women with bipolar disorder. 

 Oesterheld JR, Cozza K, Sandson NB. Oral contraceptives. 

Articles

Psychiatrists who treat women and adolescent girls may find it necessary to discuss with their patients reproductive planning and the role of contraception in setting comprehensive treatment goals. Here's why.

Contraception and Misconceptions

Laws in many states now require physicians to provide false information to patients who seek abortions. The intent of these laws is to dissuade women from having abortions.

As physicians, we are committed to accurate and truthful communication and to placing the welfare and concerns of patients first. A woman ought to be able to trust that her physician is informed about scientific evidence and will utilize this knowledge to provide optimal treatment. Moreover, she should be able to count on her physician to be 

 of her wishes and values, even when these differ from those of the physician.

In stark contrast to these expectations, physicians in Arizona, Arkansas, Georgia, Indiana, Kansas, Louisiana, Minnesota, Missouri, Oklahoma, South Dakota, Texas, and Utah are required to tell women who seek an abortion that the fetus will feel pain as it is being aborted. This information is not supported by current scientific research. A large 2010 review by the Royal College of Obstetricians and Gynaecologists in Britain found that the fetus cannot experience pain before 24 weeks’ gestation because the neural connections into the cerebral cortex are not developed until then.

, the American Congress of Obstetricians and Gynecologists (the companion organization to the American College of Obstetricians and Gynecologists) came to the same conclusion after reviewing the scientific literature.

A rigorous 2005 scientific review of evidence published in the 

Journal of the American Medical Association

 (JAMA) concluded that fetal perception of pain is unlikely before the third trimester. Although ultrasound monitoring can show intrauterine fetal movement, no studies since 2005 demonstrate fetal recognition of pain.

Physicians in Arizona, Indiana, Louisiana, Mississippi, Ohio, Oklahoma, Virginia, and Wisconsin are legally required to compel women who seek abortions to pay for an ultrasound examination and to view the screen on which it is displayed. The only purpose for requiring this costly and medically unnecessary procedure is to influence women to change their minds about 

Five states (Arkansas, Kansas, Mississippi, Oklahoma, and Texas) require that physicians inform women who seek an abortion that the procedure will increase their risk of breast cancer. This is false. The National Cancer Institute has concluded that “induced abortion is 

 with an increase in breast cancer risk.”

As psychiatrists, we are particularly concerned about the laws in 8 states (Kansas, Michigan, Nebraska, North Carolina, South Dakota, Texas, Utah, and West Virginia). These laws require physicians to inform women who seek an abortion that the procedure places them at great risk for negative psychological consequences and to refer them for counseling about these issues. Scientific studies have determined that this is false. A 2011 report in the 

 reinforced previous findings that an abortion does not cause any increase in rates of depression, suicidal thoughts, or psychiatric hospitalization.

Richard Carmona, MD, US Surgeon General under President George W. Bush, warned, “There is nothing worse than ignoring science or marginalizing the voice of science for reasons driven by changing political winds.” These politically motivated laws undermine the concept that medical decision-making is based on scientific evidence. They force physicians to act as agents of the state government rather than put their patients’ interests first. They are intended to intimidate women so that they will not have abortions. They are corrosive to honesty in the physician-patient relationship, interfere with the physician’s responsibility to the patient, and violate medical ethical principles.

, the American Psychiatric Association declared that while it is appropriate for states to require disclosure of material information regarding the risks of any recommended treatment and to obtain informed consent, these statutes are not designed to assure informed decision-making; instead they represent an unprecedented effort by the government to use physician communications as an instrument for discouraging pregnant women from exercising their constitutional right to make their own reproductive choices.

Dr Robinson is Professor of Psychiatry at the University of Toronto and Director of the Women’s Mental Health Program University Health Network; Dr Nadelson is Professor of Psychiatry at Harvard Medical School in Boston and former APA President; Dr Ochiogrosso is Assistant Professor of Psychiatry at New York-Presbyterian/Weill Cornell Medical College in NY; Dr Ordorico is an Addiction Psychiatry Specialist in New Port Richey, FL; Dr Greene is Clinical Assistant Professor and Director of the Women’s Program, New York University Langone Medical Center, NYU; and Dr Schildkrout is Assistant Clinical Professor of Psychiatry at Harvard Medical School, Beth Israel Deaconess Medical Center in Boston. All are members of the Gender and Mental Health Committee of the Group for Advancement of Psychiatry. They report no conflicts of interest concerning the subject matter of this article.

 Royal College of Obstetricians & Gynaecologists. Fetal Awareness: Review of Research and Recommendations for Practice. June 2010. http://www.rcog.org.uk/fetal-awareness-review-research-and-recommendations-practice. Accessed January 17, 2014.

 American Congress of Obstetricians and Gynecologists. Position Statement: Facts Are Important: Fetal Pain. June 20, 2013. 

http://www.acog.org/About_ACOG/ACOG_Departments/~/media/Departments/Government%20Relations%20and%20Outreach/FactAreImportFetalPain.pdf

 National Cancer Institute. Summary report: early reproductive events and breast cancer workshop. 

http://www.cancer.gov/cancertopics/causes/ere/workshop-report

 Munk-Olsen T, Laursen TM, Pedersen CB, et al. Induced first-trimester abortion and risk of mental disorder.

 APA Official Actions. Position Statement on Legislative Intrusion and Reproductive Choice. 

http://www.psych.org/File%20Library/Learn/Archives/ps2013_ReproductiveChoice.pdf

Statutes in 8 states are not designed to assure informed decision-making, say these psychiatrists; instead they represent an unprecedented effort by the government to use physician communications as an instrument for discouraging pregnant women from exercising their constitutional right to make their own reproductive choices.

Can You Trust Your Physician?

Racial/ethnic and sexual orientation minorities and women historically have been relegated to social, legal, and economic disadvantage in the United States. Such disadvantage is thought to be one of the underlying factors responsible for mental health disparities.

One of the most alarming disparities is the prevalence of violent victimization (eg, black male teenagers are more than 5 times as likely to die because of guns as their white peers). Blacks in urban communities are much more likely to be murdered, assaulted, or raped than their white counterparts.

We review how culture and disadvantage interact in particular forms of violent victimization. General recommendations are given for competent intervention, because the psychiatrist often is in the best position to gain access to multisystem interventions that can prevent further violence and address the sequelae of trauma.

Men most often experience violence inflicted by other men who are strangers. Women are more likely to be assaulted, murdered, or raped by a current or ex-partner. In the United States, 21% of female victims of violent crime were assaulted by an intimate partner compared with 5% of men.

 In the case of sexual assault, 64% of women are assaulted by a current or ex-partner versus 16% of men. The World Health Organization studied 24 countries and found rates of partner abuse of women ranging from 20% to 50%. It is estimated that 1 in 4 women who seek psychiatric care has been battered. Similarly, 25% of women who attempt suicide have been victims of domestic violence. Nearly 12% of women who have been victims of domestic violence attempt to kill their abusing partner. Male partners are responsible for 50% of the homicides of battered women. Many battered women require emergency medical services. About 20% of women seen in primary care clinics report domestic abuse, and about 17% of pregnant women have been assaulted before or during pregnancy.

Many factors contribute to such high rates of abuse, including societal attitudes that devalue women and treat them like property, offenders who are emotionally dependent on their partners and have poor conflict resolution skills, and behaviors learned while growing up in a violent household. The consequences of abuse transcend physical harm and extend to psychological symptoms such as helplessness and hopelessness, low self-esteem, shame, and guilt. Victims may experience anxiety, depression, posttraumatic stress disorder, increased substance abuse, and suicidal ideation.

Identification of victims is often difficult because women may be afraid or ashamed to speak up. Routine screening is seldom done by physicians because they fear embarrassing their patients, they do not want to get involved in possible legal matters, or they do not know how to manage the problem if the patient does speak up.

Despite the importance of dealing with abused women, there are no validated studies of best-treatment approaches. However, understanding that the therapeutic alliance is a fundamental building block for healing, the therapist can begin by appreciating how hard it may be for victims to trust their therapist. The therapist must be patient as victims struggle to define better boundaries or even think of leaving their abuser. He or she must avoid approaches that blame the victim for choosing a bad partner or for provoking abuse. Women may also need specific help and advice concerning their safety. The therapist needs to be familiar with community resources that provide privacy and security.

Solutions to reduce violence against women are multifactorial. Psychiatrists can begin by advocating for societal changes. For example, young children should be taught to respect both sexes and to resolve conflict in healthy ways. Police need special skills in risk assessment and successful interventions. The court system needs to appreciate the difficulties women have in testifying against a partner. Governments should put more resources into shelters, as well as transitional and permanent housing. Governments should also support training and employment programs for women who are attempting to achieve independence.

Native Americans have the same disorders as the general population but with greater prevalence and severity. For example, Native Americans experience 6 times the rate of alcoholism and tuberculosis, 3.5 times the rate of diabetes, and 3 times the rate of accidents, poverty, and depression. They also have a 2-fold increased risk of suicide and increased violence. Despite these risks, Native Americans generally have less access to treatment than those in the general population.

Compounding the lack of access is the cultural complexity of tribal or clan organization that may be disintegrating. Multiple agencies involved in behavioral health delivery to the Native American population often compete with one another instead of cooperating to provide needed services

Nowhere is this more tragic than in the case of suicide. In the United States, more than 30,000 people die by suicide each year. Most (90%) of the people who die by suicide have a diagnosable mental illness and/or substance abuse disorder. Native Americans, and Native American youth in particular, have a 3- to 4-fold increased risk for suicide. Statistics from 2001 show that among the Native American youth aged 15 to 17 years, the death rate is 14 of every 100,000 persons, compared with 7.2 for white Americans. Clearly, suicide is a Native American crisis (

The school environment may be the first place where the warning signs of suicide are present and recognizable. Suicides and homicides at several reservations throughout the United States have highlighted the need for tribal crisis intervention teams. Cognitive therapies to teach adolescents how to cope with adversity and increase their repertoire of coping strategies have been successfully employed. Prevention programs (eg, substance use education) can significantly reduce risk factors known to increase suicide risk.

Native Americans historically have benefited from close tribal social support. While strained and at times fragmented, this can be a great source of strength and prevention. There needs to be an increased community awareness and access to hotlines or other help resources to buttress the tribal social support. Culturally sensitive approaches to prevention and treatment include talking circles, smudging, storytelling, traditional healers, the medicine person, use of herbal remedies, and traditional ceremonies (such as the sweat lodge). For example, members of the tribes of First Nations in Canada have benefited from outreach programs to Native American youth that use native-focused comic books with native heroes and legends promoting mental health and general physical health messages.

 Although the Native American population presents particular challenges, it has innate strengths that can be used to prevent the rising tide of Native American youth suicide and violence.

Domestic violence among South Asians: an example of a community response

Domestic violence is a spectrum of abuse that includes physical, psychological, economic, and sexual harm with the intent to control another person’s behavior. It is a persistent pattern of behavior that can occur at any point during the life cycle. Domestic violence is perpetrated all over the world-and 90% to 95% of the violence is committed by men against women.

In the United States, more than 3 million women are victims of physical abuse each year. No large studies have sampled the prevalence of partner abuse among Asian Americans in the United States. However, Asians made up only 17.5% of the population in Santa Clara County, California, but they accounted for 35% of women killed in domestic violence–related deaths between 1994 and 1997.

Throughout the United States, Asian Americans have responded to domestic abuse in their own communities by establishing various programs and organizations for survivors of domestic violence. Apna Ghar (Our Home), established in 1990, is the longest-running shelter for South Asian battered women in the Midwest. This shelter helps battered women become safe and self-sufficient. It also aims to increase community awareness about domestic violence by targeting social change through education and outreach. It is the first shelter and social service agency in the nation founded specifically to provide culturally appropriate services for victims of domestic violence from the South Asian countries of India, Pakistan, Bangladesh, Nepal, Bhutan, and Sri Lanka. Over the years, expertise and services have expanded to include immigrant women from regions such as the Middle East and other parts of Asia. Apna Ghar has served more than 5200 women and children in the past 17 years.

Current programs and services at Apna Ghar include a 24-hour crisis line, a shelter staffed around the clock, counseling services, legal advocacy, children’s advocacy, transitional housing, supervised child visitation, an economic empowerment program, outreach programs, and 40 hours of domestic violence training. The accomplishments are numerous, and every year a significant number of community organizations join Apna Ghar in the fight against domestic violence.

Violence against lesbian, gay, bisexual, and transgender persons

The true prevalence of lesbian, gay, bisexual, and transgender (LGBT) hate crimes is difficult to determine. The main sources of information come from the Hate Crime Statistics Reports and the National Coalition of Anti-Violence Projects (NCAVP) annual reports from the Federal Bureau of Investigation (FBI).

In 2006, there were 1415 hate crime offenses based on sexual orientation that involved 1472 victims; this category comprised 15.5% of all reported hate crimes (

 Although more than 12,000 agencies representing 85% of the population participated in this survey, hate crimes based on sexual orientation were reported by only 2000 agencies. The NCAVP report for the same year states that there were 1393 incidents of hate crime based on sexual orientation that affected 1672 victims.

These statistics were based on reporting from only 12 agencies representing 27% of the population. However, these statistics included 11 homicides, whereas there were no homicides reported by the FBI, and 15% of the crimes in the NCAVP report were against transgender individuals, a category which was not included in the FBI report.

Interestingly, a special report from the Bureau of Justice, based on bi-annual interviews of 77,600 people from 2000 through 2003 indicates that the number of LGBT hate crimes and victims was more in the range of 30,000 annually.

 This large discrepancy may be due to the reluctance of the LGBT population to report hate crimes or the reluctance of law enforcement agencies to classify these crimes as hate crimes.

Adolescents and young adults may be at particular risk for the mental health consequences of anti-gay harassment and violence. Some studies indicate that being a victim of anti-gay violence was associated with low self-esteem and a 2-fold increase in suicidal ideation. A survey in California of middle and high school students revealed that victims of sexual orientation bias–related incidents had the highest rates of negative behaviors, including lower grades and drug and alcohol use. Larger studies of the LGBT population have also shown hate crime victimization to be associated with depression, anxiety, distress, anger, less belief in the benevolence of others, greater perceived vulnerability, and lower self-mastery.

What can be done? First, for the victim, the psychiatrist must provide an environment that respects the trauma that has been inflicted and provides safety for the healing that must occur. The victim may need specific advice to help find a safe haven in the community (

Beyond the treatment of the individual patient, psychiatrists should be advocating for legislation that better protects the rights of all citizens. Neither sexual orientation nor gender identity is included in hate crime laws in 18 states. On the federal level, although the Matthew Shepard Act, which included both sexual orientation and gender identity in its definition of hate crimes, was passed by Congress in 2007, the bill was later vetoed by President Bush.

Better epidemiological studies are needed to accurately determine the prevalence of anti-LGBT violence. In addition, educational programs are needed for law enforcement personnel and mental health care providers. A better understanding of the mental health sequelae of anti-LGBT violence will allow for improved evidence-based treatment.

The disadvantaged racial/ethnic and sexual orientation minorities and women have disproportionately experienced suicide and homicide in the United States. The complex history of each group, its language, attitudes, values, and behaviors, which interact with those of the majority culture, produce unique patterns of violence. Regardless of a victim’s background, a psychiatric approach that begins with an assessment of the cultural identity of the victim gives each victim the best chance of becoming a survivor. This approach recognizes the assets available in the victim’s community of support and provides a safe haven for learning adaptive and proactive behaviors. Finally, psychiatrists are encouraged to advocate for broader social changes that will prevent future victimization and provide greater opportunities for recovery.


				1. Office of the Surgeon General. Mental Health: Culture, Race and Ethnicity. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA); 2001. 

http://mentalhealth.samhsa.gov/cre/default.asp

. Accessed October 2, 2008.
				2. The Cultural Formulation, Appendix I. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Arlington, VA: American Psychiatric Association; 2000.
				3. Oberg CN, Rinaldi M. Pediatric health disparities. Curr Probl Pediatr Adolesc Health Care. 2006;36:251-268.
				4. Alim TN, Charney DS, Mellman TA. An overview of posttraumatic stress disorder in African Americans. J Clin Psychol. 2006;62:801-813.
				5. US Department of Justice, Bureau of Justice Statistics. Criminal Victimization in the United States, Table 43a; 2006. 

http://www.ojp.gov/bjs/abstract/cvus/gender969.htm

. Accessed October 2, 2008. 
				6. Suicide Prevention Resource Center. 

http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp

. Accessed October 2, 2008.
				7. Blue Corn Comics. 

. Accessed October 2, 2008.
				8. One Sky Center, the American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. 

. Accessed October 2, 2008.
				9. US Department of Justice-Federal Bureau of Investigation. Uniform Crime Reporting Program: Hate Crime Statistics, 2006. 

. Accessed October 2, 2008.
				10. Anti-Lesbian, Gay, Bisexual, and Transgender Violence in 2007. A report of the National Coalition of Anti-Violence Programs; 2008. 

http://www.ncavp.org/ common/document_files/Reports/2007HVReportFINAL.pdf

. Accessed October 2, 2008.
				11. US Dept of Justice, Bureau of Justice Statistics. Special Report: Hate Crimes Reported by Victims and Police; 2005. 

http://www.ojp.usdoj.gov/bjs/abstract/ hcrvp.htm

Racial/ethnic and sexual orientation minorities and women historically have been relegated to social, legal, and economic disadvantage in the United States.

The Facts About Violence Against Historically Disadvantaged Persons

Stalking is defined as the “willful, malicious, and repeated following or harassing of another person.”

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 

for becoming victims of stalking because of the nature of their profession and their interaction with lonely and unhappy individuals.

Unlike most other crimes, stalking can continue for an extended period-from a few weeks to many years.

 Roughly 90% of stalkers are men, and about 80% of victims are women.

 Most men who are stalkers either want to re-establish or initiate a relationship with a woman.

  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.

 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.

Victims often have good reason to fear for their physical safety and even their lives.

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.

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.

 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.

 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.

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.

 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.

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.

 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.

 Depression, anxiety, poor concentration, and fatigue all interfere with job performance.

 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.

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.

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 (

Patients benefit from education about stalking. It helps them understand the fear and humiliation

 they often feel and to realize that stalking is, indeed, a crime.

 This labeling and education serves to validate the victim’s feelings, reduce self-doubt, and helps to mobilize him or her into taking action. Learning about the pathology of offenders may help victims realize that the stalking is not their fault. It focuses the attention on the criminal behavior of the stalker rather than the “bad choices” of the victim.

It is also helpful for victims to understand that, as ex-partners, it is common for them to feel ambivalent toward their stalker. Such ambivalence can affect their behavior and confuse others, including those in law enforcement. Helping the patient understand that ambivalent feelings and actions toward the stalker are normal may reduce self-blame and help her stay in therapy. Likewise, assisting a patient to understand that feelings of helplessness are natural reactions to the persistence of the stalker and to the frequent problems in enlisting the support of others helps dissolve feelings of ineffectiveness.

Supportive therapy can increase a victim’s self-esteem and sense of control by helping her assert herself with the stalker and the authorities, as needed. Despite any ambivalent feelings she may have, she must understand the importance of sending clear messages to the stalker. It is essential that the therapist avoid giving the message that the victim has created the problem herself or the patient may feel revictimized.

Even if a woman has a history that results in her being vulnerable to choosing or remaining with an abusive partner, she must realize that she is not to blame for the stalking and does not deserve to be abused. Therapists should focus on the current stressors: delving too quickly into a woman’s history of poor choices may merely reinforce her self-blame and sense of worthlessness. Cognitive-behavioral therapy can help victims deal with their feelings of extreme vulnerability.

 Because many victims avoid reminders of their stalking, exposure therapy with relaxation training may treat avoidance symptoms.

In addition to obtaining collateral information, involving relatives and new partners in the process should be encouraged. Family members benefit from some support, as well as from education about stalking and its impact, and a discussion about safety issues and the harm that may come from blaming the victim.

Knowledge of community resources is essential in case the victim needs a referral to supports such as groups for stalking victims, victim advocates, or shelters. These resources help victims learn coping and safety strategies while validating feelings and reducing their sense of isolation. Online sources of information and support such as the Web site 

Therapists need to help victims deal with depression, anxiety, fear, shame, and guilt. Occasional use of medication may provide some relief, improve patient functioning, and increase the benefits of individual or group therapy by relieving severe anxiety symptoms. Both SSRIs and tricyclic antidepressants have been reported to be helpful in alleviating symptoms of posttraumatic stress disorder, as well as depression and insomnia.

 Occasional use of benzodiazepines may also relieve anxiety symptoms and insomnia. Keep in mind the potential for the development of substance abuse with these agents.

Therapists who treat stalking victims need to be aware of countertransference.

 The therapist may share the victim’s feelings of helplessness and hopelessness, which may interfere with empowering the victim and helping her regain a sense of control. Therapists may hesitate to treat a stalking victim, fearing for their own safety and what might happen to their patient. Having taken on the case, anxiety and ambivalence may interfere with the therapist’s work.

If patients are physically or sexually assaulted by their stalker, therapists may experience grief, guilt, self-doubt, anger, and powerlessness. Over-identification generates feelings of anger on the part of the therapist that are overwhelming for the victim. Therapists must avoid becoming judgmental and impatient with patients who continue to try to reason with their stalker. A female therapist may also defend against anxiety stemming from her own sense of vulnerability by unconsciously blaming the female patient with whom she has identified or by focusing on early developmental issues. Male therapists may experience different feelings, including identification with perceived feelings of rejected love in the stalker, thereby unconsciously diminishing the patient’s anger and increasing her guilt.

It is important that the therapist help the victim address practical matters and issues of safety while, at the same time, discouraging the stalking behavior if at all possible. The stalker should be told once, in clear and unequivocal terms, that his behavior is unacceptable. Beyond this, advise the victim to avoid any contact with the stalker and not respond to him at all. Returning letters or replying to unwanted e-mail with a short angry response maintains some sort of relationship and therefore, only reinforces the unwanted behavior.

Rather than changing phone numbers, victims should acquire an answering machine to record messages from the stalker while getting a new unlisted number for family and friends. The answering machine captures evidence of contact and threats from the stalker on the old number without having to reinforce the behavior by answering the phone.

 Because the ringing of a telephone often becomes a trigger for anxiety symptoms, this approach may also prevent the development of phobic symptoms related to the phone.

Victims should keep all evidence such as letters, emails, answering machine recordings, and photos of destroyed property. Even when there is no concrete evidence, victims should document the details of all incidents and unwanted intrusions, recording dates, times, and what was said or threatened by the stalker. The police should be informed as soon as possible about the harassment. Early intervention by the police (ie, speaking to the stalker) may send a clear message that the behavior is not acceptable. This may stop the behavior before it becomes entrenched.

If available, a “Threat Assessment Unit” within the police department can evaluate the specific stalking situation and make recommendations. The value of a restraining order is controversial and may depend on the particular case, but many believe that they are generally ineffective and cannot be enforced.

 Patients can get information about their region’s stalking laws from resources such as legal aid and victim support organizations.

Friends, family, and neighbors should be informed so that they can warn the victim if they see the stalker. Alerting security and colleagues at the workplace can prevent unwanted contact and preclude them from inadvertently disclosing personal information to the stalker.

Victims should avoid fixed routines and keep addresses private. They can consult with a security company to evaluate the security of their homes. Victims should also consider taking self-defense classes.

Severe emotional, social, and occupational consequences are associated with the ongoing pursuit and harassment experienced by stalking victims. Therapists must provide a supportive and empathic environment, avoid revictimizing the patient, and be aware of countertransference reactions that can potentially interfere with therapy. Stalking victims need education, counseling, possible medications, and an understanding of practical safety issues.



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 http://www.xs4all.nl/~cdirks/engfat4. html

Psychiatrists may encounter patients who present with severe emotional consequences because they are victims of stalking. In addition, psychiatrists themselves are at increased risk for becoming victims of stalking because of the nature of their profession and their interaction with lonely and unhappy individuals.

Gail Erlick Robinson, MD

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