Stalking: The Veiled Epidemic

July 8, 2009
Ryan S. Shugarman, MD
Volume 26, Issue 7

Through high-profile media cases and in film, the American public has had glimpses into the psychological phenomenon and criminal behavior known as stalking. But do these glimpses truly represent the types of stalking offenses that are commonly perpetrated? Academicians and public policy makers have only begun to focus attention on stalkingin the past 10 to 15 years. As is often the case, the dissemination of information relevant to treating clinicians often lags behind by many years. Thus, many mental health professionals have not been adequately trained to recognize stalking behavior and to treat those who perpetrate it.

Being Stalked--An Occupational Hazard?

Through high-profile media cases and in film, the American public has had glimpses into the psychological phenomenon and criminal behavior known as stalking. But do these glimpses truly represent the types of stalking offenses that are commonly perpetrated? Academicians and public policy makers have only begun to focus attention on stalking in the past 10 to 15 years. As is often the case, the dissemination of information relevant to treating clinicians often lags behind by many years. Thus, many mental health professionals have not been adequately trained to recognize stalking behavior and to treat those who perpetrate it.

The following review of stalking is designed to draw attention to this important societal problem and to assist clinicians in recognizing stalking behaviors and intervening in a therapeutic manner.

Definitions

While legal definitions differ somewhat from state to state, a generally accepted clinical definition of stalking is “an abnormal or long-term pattern of threat or harassment directed toward a specific individual,” and “the willful, malicious, and repeated following and harassing of another person that threatens his or her safety.”1 From a legal standpoint, the crime of stalking generally consists of 4 elements:

• Repeated, unwanted involvement with the victim

• Explicit or implicit threats made to the victim

• Reasonable fear experienced by the victim

• The intention to instill fear in the victim

This last condition, which is stipulated by many states, is not always present in the clinical setting, such as when a stalker wishes to pursue a romantic relationship with the victim and intends no harm.

 

Facts on stalking victimization

Using data from the National Violence Against Women Survey, Tjaden and Thoennes2 reported the lifetime prevalence of stalking victimization in the United States to be 12% for women and 4% for men. These researchers, whose definition of stalking required victims to feel only “somewhat frightened,” reported that women are 3 times more likely to be stalked than raped in a 1-year period.

Research indicates that no one is immune from being stalked-children, celebrities, health care professionals, women, men, straight and gay individuals, and otherwise average citizens.2,3 However, the majority of stalking victims (74% to 80%) are female.2,3 The average age of stalking victims, male or female, is 28 years old.2 Individuals from low-income households, as well as those who are divorced or separated, are at increased risk for stalking victimization.3 While whites and minorities are equally likely to be victimized, most victims are targeted by persons of their own race.3

Typical perpetrators and why they stalk

No single profile accurately captures the various etiological and motivating factors for stalking behavior. Instead, typological frameworks have been used to examine factors such as the stalker’s relationship with the victim, apparent motivation, and psychiatric diagnosis.4-7 We know that the majority of stalkers are male (68% to 87%), and most stalkers-male and female combined-are in their 30s.2-5,8 Most stalkers (80% to 85%) are unmarried at the time of the offense; roughly half have never been in an intimate relationship; half have criminal records; and approximately 40% are underemployed or unemployed.4,5,9,10 Rates of perpetration do not differ by race.2

Various studies show that 25% to 78% of stalkers have Axis I disorders; 17% to 32% have substance use disorders; and 25% have a history of suicidal ideation or self-injurious behavior.4,9-12 While most were not psychotic at the time of the offense, 17% of stalkers in one study had a history of schizophrenia, and 15% had delusional disorder.4,9,10 Axis II diagnoses (especially cluster B) were highly prevalent, particularly among nonpsychotic stalkers.9,10,12-14

Among victims of stalking, the majority know their stalkers, who are typically similar in age to them.2-5,8 In up to 30% of cases, victims are stalked by former intimate partners, and in 57% of cases the stalking behavior began before the dissolution of the relationship (Table).2,3,5,8

Why do stalkers engage in repeated bouts of unwanted contact with the victim-in spite of the risk of substantial repercussions? Stalkers are driven by conscious and unconscious motivations, as well as proximal and distal factors. Factors that underlie stalking behavior typically include the desire for (re)unification with the victim and/or for retribution/punishment.5 Stalking behavior may also presage a planned attack or may occur secondary to delusional beliefs.5

Concepts from attachment, behavioral, cognitive, and psychodynamic theories shed additional light on the cause of this maladaptive behavior. Many stalkers lack experience with successful intimate relationships, and some evidence suggests that stalkers have a relatively high prevalence of disruptions in early childhood attachments.5,9,15 Because stalkers typically have deficient coping skills, continued rejection by the victim can serve a behaviorally reinforcing function.15 Such rejection provides the stalker with acknowledgment and allows him to remain “linked” to the victim.9,15 Psychodynamic considerations involve themes of narcissistic fragility and instability of the stalker’s self-construct; ideation and devaluation of the victim; projection of negative self-attributes onto the victim; and vacillation between a desire for unification with the victim versus a yearning to seek vengeance or enact punishment.15,16

Many classification schemes for stalkers involve an examination of the stalker’s motivations. In the typological framework developed by Mullen and colleagues,5 5 stalker subtypes are recognized, which, in decreasing order of prevalence, are as follows:

• Rejected stalker: stalking begins following rejection by a known victim, with the goal of achieving reunion, exacting revenge, or a combination thereof

• Intimacy seeker: stalker desires to establish intimacy with the victim

• Incompetent suitor: stalker seeks gratification of his needs

• Resentful stalker: stalker acts out of a sense of feeling harmed and strives to frighten the victim and cause distress

• Predatory stalker: this individual engages in instrumental stalking behavior, in preparation for a planned attack such as rape

Commonly exhibited stalking behaviors

Stalkers tend to engage in multiple and varied behaviors, which can be divided into 3 main groups: communication with the victim; approach behaviors; and harming measures.17

Communication methods include making phone calls and sending letters or messages or cyberstalking-an increasingly common method of communicating with and/or harassing the victim.3 Approach behaviors involve following or spying on the victim (experienced by 34% of victims in one study), waiting at (29%), or appearing in locations where the victim is known to be present (31%).3 Harming measures include spreading rumors (36%), making threats (30% to 45%), damaging property (24% to 40%), physical assault (18% to 36%), sexual assault (2% to 9%), and murder (0.25% to 0.5%).3-5,8 While most threats are not carried out, between 25% and 50% of threats progress to assaults.5,8,18,19 Most assaults do not involve the use of a weapon or serious injury to the victim.3,4,9 Victims most likely to be harmed are former intimate partners of stalkers, and public figures are less likely to be harmed than private persons.4,18

Duration of stalking period

Data from the 2006 Supplemental Victimization Survey3 indicate that in 41% of cases, stalking lasted for 6 months or less, and in an additional 31% of cases, for less than 1 year. However, 17% of stalking cases persisted for 2 to 5 years, and 11% persisted for 5 years or longer. Other data have revealed that stalkers who targeted strangers usually did so for shorter periods (0.8 months) than those who targeted non-strangers (11.2 months),8 whereas current or former intimate partners have stalked for significantly longer periods (2.2 years) than have non-intimate partners (1.1 years).2

Assessment. risk management, and treatment

Assessment and risk management is an ongoing process, because specific risk factors and motivations for stalking often change over time.20,21 The treating clinician may wish to refer the suspected stalker to a forensic psychiatrist or another mental health professional with expertise in stalking to assist in the formulation of a risk management plan and periodic reassessment of potential risk.20,22 An evaluator may also speak with collateral sources; review available treatment and police records; and collaborate with law enforcement personnel, attorneys, and victim advocates to help establish, implement, and enforce effective strategies to minimize risk.22,23

It is important for the evaluator to use a nonjudgmental, empathic interactional style throughout the assessment and treatment process. Aside from its therapeutic value, this approach increases the likelihood of gaining insight into the stalker’s motivations, objectives, core values, and pathological defense mechanisms.22 The evaluator should investigate the nature, extent, and duration of the current (as well as any previous) stalking behavior. This includes ascertaining the types and number of stalking behaviors exhibited; level of physical approach behavior; history and nature of threats; time devoted to stalking behaviors; escalation of behavior over time; consequences experienced by the stalker; and willingness to die to accomplish his goals.23

Similarly, the evaluator should inquire about the victim’s characteristics and interactions with the stalker; harm caused to the victim; and legal measures taken against the stalker.21 Equally important is the need to review the stalker’s current support system, strengths, and protective factors; previous relationships; past reactions to limit-setting; history of menacing, violence, abuse, and criminality; and tendency to act on threats.23 In addition, the standard components involved in violence risk assessment (eg, ownership of weapons, formulation of a plan, access to the victim, prior violence, use of substances, failure to recognize or consider alternatives, and magnitude and imminence of potential harm) need to be explored.23 Identifying the stalker’s subtype and obtaining psychological testing can also help elucidate motivating factors, personality style, risk for harm to the victim, and amenability to treatment.21,23 Currently, there are no empirically validated actuarial instruments designed to assess the risk of violence among stalkers.

From a risk management standpoint, the evaluator should document all incidents of stalking, encourage a total ban on contact between stalker and victim, and ensure that the stalker is cognizant of the potential consequences of his actions.21 A specific set of intervention strategies should be developed and modifiable risk factors addressed.21,22 Heightened vigilance is required when events anger or humiliate the stalker.23 Similarly, signs of psychiatric decompensation and/or intensification of stalking behaviors need to be recognized, with consideration given to emergency hospitalization when clinically indicated.22 Likewise, the evaluator should possess sufficient knowledge of his or her state’s duty-to-protect statutes and relevant case law.

To date, there are no reliable outcome studies that address therapeutic interventions for stalkers, for whom treatment is usually court-mandated.21 Identification of the stalker’s hopes and desires may serve as a therapeutic starting point.22 Subsequently, the therapist can use one of many therapeutic options (eg, cognitive-behavioral, supportive, motivational, psychodynamic) to increase the stalker’s awareness of the counterproductive nature of his behavior and the resultant harm to both victim and stalker.21

The therapist might highlight the inordinate amount of time the stalker has devoted to his stalking behavior at the expense of other aspects of his life, the potential criminal sanctions, and the psychological distress incurred by both stalker and victim.22 For some stalkers, providing insight into underlying motivating factors driving the stalking behavior can be helpful.21 Another therapeutic tool involves redirecting the stalker’s preoccupation with the thoughts and feelings of the victim to his own thoughts and feelings (typically involving loneliness and other unpleasant emotions), which can then be explored.22

While it is essential for the treating clinician to exhibit empathy, it is critical to avoid colluding with the stalker’s minimizations, justifications, and self-deceptions.24 Techniques aimed at increasing empathy for the victim (eg, through role-playing or use of victim statements/impact reports) can be used, as can measures aimed at improving social skills.22,24 Modifiable risk factors should always be addressed, and underlying mental illness adequately treated.22,24 The exact techniques and paths of therapeutic intervention will vary based on factors such as the stalker’s subtype and level of social skills and the therapist’s experience with, and preference for, particular treatment modalities.

CASE VIGNETTE

Jonathan is a bright but fairly shy 19-year-old who met Melanie, a fellow classmate, in the sixth grade. Over the next several years, Jonathan and Melanie rarely spoke, but by the age of 17, his feelings toward her had intensified, and he professed his love for her in a poem. Melanie’s response was met with surprise, however, when she referred to him as a “stalker” and requested that he refrain from contacting her again. Though disheartened and confused by her reaction, Jonathan remained undeterred and persisted in sending her letters that simultaneously expressed his apologies and pled for her affection, despite being suspended from school for such conduct. Jonathan admitted to visiting Melanie’s home on one occasion to hand-deliver a letter but denied ever making threats or engaging in harming behavior.

With worsening depressive symptoms and eventual suicidal ideation, Jonathan was hospitalized for 10 days, where he was started on an antidepressant regimen and referred for outpatient treatment. While Jonathan realized that his all-consuming preoccupation with Melanie had contributed to his distress and adverse consequences, he nevertheless enjoyed fantasizing about her and could not accept either the inappropriateness of his actions or the possibility of not having Melanie as a part of his life. “I want to leave her alone, but there’s something inside that won’t let me,” he remarked.

According to the Mullen typology,5 Jonathan was classified as an intimacy-seeking stalker. He was deemed a significant risk for attempting to contact Melanie again but was thought to pose a low risk for committing any overt acts of violence. To target Jonathan’s depressive symptoms and possible ruminations, his antidepressant dosage was increased. Therapy goals included improving Jonathan’s insight into the distress caused to both him and to Melanie, exploring aspects of Jonathan’s life with which he was dissatisfied, identifying short- and long-term goals, and teaching him methods to tolerate distress. With treatment, Jonathan’s preoccupation with Melanie decreased considerably.

References:

References


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