by Dr. Jocelyn Markowicz, PhD, Psychologist

Help for the Helping Professional: Risk Management Strategies

The success of psychotherapy is correlated with the attachment between client and therapist in the therapeutic relationship (Farber, 2015). According to Dr. Farber, empathy and building the bond of attachment is our stock-in-trade as mental health practitioners. When empathy builds the bond of attachment with someone starved for connection, a therapist may inadvertently set themself up to become a victim of a stalker (Farber, 2015).

Safety Risks Often Discounted

When a therapist embarks on training, they are imbued with ethical principles to guide the delivery of services. One crucial ethical principle is to take reasonable steps to avoid harming their clients and minimize harm where it is foreseeable and unavoidable. However, training programs do not adequately equip mental health providers to take reasonable steps to mitigate the safety risks inherent in working within the mental health field. Unfortunately, therapists often lack support when they talk about the dangers faced in their profession. Therapist safety concerns are often met with the sentiment that “it comes with the territory.” Therefore, they must deal with and manage risks or even active threats alone. People often have the same view when nurses, physicians, firefighters, law enforcement officers, and service members talk about the risk they are managing. The dismissal of the severity of risk that mental health providers take on reduces their access to resources and tools to reduce that risk successfully. An industry designed to help individuals who struggle with the perpetration of harm against others does not negate the provider’s right to be free from harm. Stalking, in particular, has become a major concern for therapists in this technological boom.

Stalking and Therapists

Stalking is a prevalent phenomenon with significant negative psychological, physical, social, and financial consequences (Sheridan, Adrian, & Scott, 2019). According to the U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (2015), a greater percentage of females experience stalking than males. Additionally, 2.2% of females compared to 0.8% of males experienced at least one stalking victimization within a 12-month period. Storey and Hart (2017) correctly documented that prevalence estimates are considerably higher for individuals holding certain professions. Mental health professionals (psychologists, psychiatrists, counselors) have higher rates of stalking than other professionals (Galeazzie & DeFazio, 2006; Store, 2012). Nearly 19.5% of psychologists report being stalked in the context of their professional lives (Lion & Herschler, 1998; Smoyak, 2003; Whyte et al., 2011). Additionally, 32% to 64% of counselors have been victims of some form of harassing behavior from a client (Romans, Hays, & White, 1996; Store, 2016). 

Health care workers and mental health care workers have been stalked by their clients, as documented in several studies from the United States (Romans, Hays, White, 1996; Gentile et al., 2002) and abroad (Galeazzi, Elkins, & Curci, 2005; Abrams & Robinson, 2011). In fact, research has demonstrated that co-workers also stalk service providers, but the percentage of stalking from service users is higher (Ashmore et al., 2006). This means that, although anyone can potentially be stalked within their professional environment, mental health professionals are at a higher risk of being stalked by their clients than others in other work environments.

Reducing the Risk

Specific risk reduction and threat management interventions are needed to ensure that therapists have effective risk management tools and risk reduction policies at their disposal. Why is risk reduction necessary for professionals in mental health? According to Galeazzi, Elkins, & Curci (2005), mental health professionals who have been stalked by their clients have left the field, reported lost time from work, and moved to a different state to escape their stalker. They have also carried weapons to work in response (Pope, & Vasquez, 2011). The impact of stalking on providers is substantial. There is limited training currently available about how to manage stalking in one’s mental health career. The call is to have adequate systems in place to reduce the likelihood of stalking and appropriately respond when it does occur. In the age of technology, stalking risks are increased due to clients having multiple ways to contact their practitioners and access their personal information online. Mental health providers may face online stalking or be stalked by phone or email in addition to unwanted physical presence in the professional or personal environment. Here are six risk management strategies: 

#1 Implement Client Consultations

Harm reduction involves the initial assessment of risk in your professional environment. Therapists are trained to assess risk for client harm to self and others but often do not view harm to themselves as a potential area to consider. Professionals working in a private practice setting, group forensic setting, or within a hospital setting will have different risk factors to consider. For example, a provider working in an independent private practice may wisely implement more stringent policies to reduce risk than a provider who works within a health system and has access to on-site security guards and other professionals that may serve as a risk management team.

When possible, all new clients should participate in an initial consult to determine if this treatment setting will offer the most effective treatment and evaluate any potential risk factors that the provider or system may have to manage. Clinicians are encouraged to refer individuals to a higher level of care and to agencies that can responsibly manage harm potential more effectively as needed. For example, a client with a history of stalking may need to work with a provider in a larger treatment agency versus a solo provider in private practice in order to minimize the risk of intimate attachment that may lead to stalking behavior. The risk assessment process can inform the policies a provider creates for the safety of everyone involved. 

#2 Provider-Client Technological Access

Therapists should use business phones and office email systems versus their personal cell numbers and email addresses to communicate with clients. At the beginning of treatment, therapists should outline communication policies, specifically what content is to be communicated electronically (i.e., scheduling new appointments of cancellations versus crisis intervention) and time parameters for communication with clients (e.g., during business hours only). One’s communication policy should, of course, contain a limits of confidentiality policy and discussion of how the professional will handle violations of the communication policy. A communication policy that outlines limits to professional responsiveness and limitations to the depth of electronic communication can minimize safety risk by establishing clear, professional boundaries.

#3 Maintain Communication Boundaries

Therapists should adhere to the communication policies they set forth for their clients. If a provider establishes that they will not communicate with clients after business hours via email, they must not violate their own policy. If a professional indicates that they will not address clinical issues via email, they must follow through on that commitment. Psychotherapists violating their own communication policy may condition their clients to violate the policy as well. Boundary violations from either party increase safety risks.

#4 Seek Support from Colleagues

Mental health providers have the privilege of helping individuals who struggle with a variety of emotional and behavioral concerns. Given the nature of this work, risk cannot be prevented, but it can be reduced and managed more effectively with support. Not unlike individuals seeking services for distress due to being threatened, clinicians also need support as they implement protocols to reduce their risk or manage active threats. The inherent risk of the mental health profession does not negate the need for support in the face of risk management or active threat reduction. I encourage therapy for therapists to help them manage the distress of working within risky situations or addressing active threats.

#5 Individualized Action

When therapists are managing an active stalking threat, they must take care of themselves the same way they take care of others. They must seek support from other mental health professionals to determine ways to work within the boundaries of ethical mandates while preventing harm to themselves. They may also need to seek the assistance of law enforcement to manage risk and prevent harm. The individual goals and efforts of mental health providers to manage the risk inherent in their position can make a significant difference in the outcomes they experience.

#6 Systemic Action

Training therapists to implement protocols to minimize their safety risks is vitally important to bringing about widespread change in risk management for mental health providers. Psychiatrists and psychologists are the professionals most likely to be stalked, possibly because aspects of the psychotherapeutic relationship can produce misunderstandings about the nature of the intimacy generated and appropriate boundaries in this type of relationship (Galeazzi, Elkins, & Curci, 2005). Mandating risk management continuing education for mental health providers to learn how to minimize their own safety risk should be encouraged. Consultation services for psychologists who are navigating managing active stalking threats should be more accessible. The impact of reduced safety for therapists comes at too great a cost to themselves and their communities. Mental health providers need systemic protection plans so that they can continue working hard to minimize distress and improve life functioning for their clients.

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References

Abrams, K. M., & Robinson, G. E. (2011). Stalking by patients: Doctors’ experiences in a Canadian urban area. Journal of Nervous and Mental Disease, 199, 738-743. 

Ashmore, R. Jones, J., Jackson, A., & Smoyak, S. (2006). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing, 13, 562-569. 

Farber, S. (2015 ) My Patient, My Stalker Empathy as a Dual-Edged Sword: A Cautionary Tale. American Journal of Psychotherapy | Vol 69, No. 3, 331-355. 

Galeazzi, G.M., Elkins, K., & Curci, P. (2005). The stalking of mental health professionals by patients. Psychiatric Services, 56, 37-138. 

Gentile, S. R. , Asamen, J. K., Harmell, P.H.,, & Weathers, R. (2002). The stalking of psychologist by their clients. Professional Psychology, Research and Practice, 33, 490-494. 

Lion, J.R., & Herschler, J.A. (1998). The stalking of clinicians by their patients. In J.R. Meloy (Ed.), The psychology of stalking: Clinical and forensic perspectives (pp. 163-173). San Diego, CA: Academic Press.

Mark M. A. Bureau of Justice Statistics, January 22, 2015, NCJ 248470.

Pope, K. S., & Vasquez, M. J. T. (2011). Ethics in psychotherapy and counseling: A practical guide (4th ed.). John Wiley & Sons Inc.

Romans, J.S. C., Hays, J.R., & White. T. K. (1996). Stalking and related behaviors experienced by counseling center staff members from current or former clients. Professional Psychology: Research and Practice, 27, 595-599. 

Sheridan, L. North, A. C. & Scott, A. J. (2019). Stalking in the Workplace. Journal of Threat Assessment and Management. Vol. 6, No. 2, 61-75.

Smoyak, S. (2003). Perspectives in mental health clinicians on stalking continue to evolve. Psychiatric Annals, 33, 641-648. 

Storey, J.E., Hart, S.D., & Lim. Y.L. (2017). Journal of Threat Assessment and Management. Vol. 4, No. 3 122-143. 

U.S. Department of Justice Office of Justice Programs. Bureau of Justice Statistics, January 2015. https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5217

Whyte, S., Penny, C., Christopherson, S., Reiss, D., & Petch, E. (2011). The stalking of psychiatrists. International Journal of Forensic Mental Health, 10, 254-26.

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