Karen M. Abrams, MD

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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