Commentary: The Importance of Professional Judgment in Evaluation of Stalking and Threatening Situations
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* Renée L. Binder

## Abstract

When a person is stalked, a common reaction is to consult an expert for the answers to several key questions: Is the stalker dangerous? How can I get the stalker to stop the behavior? What should I do to protect myself? Although certain risk factors are associated with an increased likelihood of violence, care must be taken in using risk factors to predict violence, because there are many exceptions to and subtleties in such analyses. Risks in stalking situations depend on interactions of potentially fluctuating and interrelated factors, and risk assessments need to be updated as more information becomes available. The consultant must consider a variety of strategies to stop the stalking behavior and to protect the victim. When one strategy does not work, the consultant should recommend shifting to another strategy. Until we have long‐term follow‐up studies about the impact of each intervention on each type of stalking situation, assessments of stalking situations will require the use of professional judgment and flexibility in conjunction with knowledge of the available literature.

Mullen *et al.*1 have written a comprehensive article about managing stalking situations. Their organizational structure of management strategies for stalkers and victims is a valuable contribution to the literature on stalking. When a person is stalked, a common reaction is to seek consultation from an expert.2 The experts are usually asked several key questions: Is the stalker dangerous? How can I get the stalker to stop the behavior? What should I do to protect myself? The article by Mullen and colleagues will be helpful in these assessments. Their tables listing options for interventions in different risk contexts are especially useful.

These authors point out that risk assessment in stalking situations is limited by a lack of prospective studies of such situations.1 Most of the available studies are based on forensic samples of stalkers or on surveys of populations and self‐reports of victims of stalking.3–7 Although these studies are valuable, they represent only a subsample of stalking situations. For example, the stalkers who are arrested may differ from those who are typically seen by mental health clinicians as patients. Also, there have not been adequate studies of whether effective management strategies are the same or different for stalkers, harassers, and perpetrators who make threats, although there is probably an overlap.2,7

When consultants are asked about the risk of dangerousness, they can refer to Mullen *et al*.1 for a summary of risk factors that increase the likelihood of violence: being an ex‐intimate, being under age 30, having less than a high school education, having prior criminal convictions, and being a substance abuser. In addition, making prior threats to the victim is a risk factor,8 and the most significant risk factor for future violence is a history of violence.9

Mullen *et al.*1 point out that care must be taken in using risk factors to predict violence, because there are many exceptions to and subtleties in such analyses. An example is the research showing that psychotic illness in the stalker decreases the risk of violence8,10–13 and that nonpsychotic stalkers are more likely to commit assaults.8,11 Although this finding may be valid in many stalking situations, it may not be valid in others, and alternative explanations are possible for the results observed in these studies. For example, it may be that the comparison group in some of these studies had an even higher risk of violence. Thus, stalkers with psychotic illness may have a lower risk of violence than do personality‐disordered individuals, but the group with psychosis may still present a greater risk of violence relative to the general population. Another explanation may be that the risk of violence is affected by the type of psychotic process. That is, the risk of violence may be decreased when the stalker has disorganized thought processes, but it may not be decreased when the stalker has organized delusional thinking, especially when the victim is blamed for alleged wrongdoing. In addition, a person with chronic undifferentiated schizophrenia may present a low risk of violence,14 but a stalker who is acutely psychotic and paranoid may have a higher risk.15,16 For example, a psychiatrist was murdered by a former patient with paranoid schizophrenia who felt that the psychiatrist had used a brain‐stimulating machine on him. It is unclear from the available records of the deceased psychiatrist to what extent stalking behavior was involved in this case. It is known from interviews of the perpetrator after he murdered the psychiatrist that he was focused on the psychiatrist and decided to kill him because of the pain he believed the psychiatrist had caused him.17

Mullen and colleagues1 report that stalkers in the category of “intimacy seekers”—that is, those who target strangers, professional contacts, and acquaintances—rarely assault their victims. I recently reviewed a case that demonstrates the exception to which they refer. In this stalking situation, a graduate student in one department of a university started to stalk a senior professor in a second department. The graduate student wrote letters and e‐mails to and left multiple phone messages for the professor over a period of months. The contacts expressed love and affection for the professor. After the graduate student went to the professor's home, a restraining order was obtained. A few months later, the graduate student approached the professor in the parking lot as he was entering his car and attacked him. The police were called, and the graduate student was arrested. Although the restraining order had not been effective in ending the stalking behavior, once the arrest occurred, the student no longer stalked the professor.

This vignette demonstrates that intimacy‐seeking stalkers, while at lower risk of violence, may still assault their victims. In addition, it shows how a restraining order, by itself, may not act as a deterrent to future contact. It may, however, be useful because it gives the police leverage to take the stalker into custody. Also, the experience of being arrested may stop future stalking in certain persons.

Mullen *et al*.1 talk about the risks of contacting the stalker. Others have described occasional exceptions to this advice. For example, in the report of the APA Task Force on Clinician Safety,3 guidance is given to clinicians for dealing with threatening patients who have incorporated the physician into their delusional system and vow retaliation or vengeance at some future date for perceived wrongs. The task force advises that the clinician should actively confront the patient and disavow any alleged culpability. The task force opined that to not respond to such a threat can support its continued existence and that delusions should be confronted as erroneous perceptions.3

Mullen *et al.*1 describe possible motivations for stalkers including seeking reconciliation, seeking revenge, and seeking a relationship. They also state that direct interventions by the victim that clarify and ameliorate the stalker's misperceptions usually are ineffective and ill advised, but there can be exceptions. An example of an exception has been reported.2 A patient with paranoid schizophrenia kept leaving voice‐mail messages for a young social worker who had been involved in his inpatient treatment. The messages said he wanted to date her. The social worker ignored the calls, but they continued. Finally, the social worker answered the phone when the patient called. The patient asked her for a date, and she replied that she was sorry but she had a boyfriend and, in fact, was engaged to be married. The patient apologized and said he had not known she was “already taken.” He never called her again.2

Similarly, in a recent stalking situation about which I was consulted, a patient with a borderline personality disorder developed an erotic transference to a psychiatrist who was treating her in psychotherapy. Despite much limit‐setting, the patient continued to insist that the psychiatrist was in love with her and that they would be a wonderful couple. The psychiatrist terminated treatment, and the patient continued stalking him for many months. She made phone calls to him, sent him letters and greeting cards, and told him that she had been watching his movements and stated that they were meant to be together. Police officers tried to set limits with the patient, including explaining criminal sanctions for stalking. The patient discontinued her stalking behavior temporarily, but then resumed contacting the psychiatrist. After consultation, the local police set up another meeting with the perpetrator. During the course of the meeting, the police officer mentioned that the psychiatrist was engaged to be married and was not available to have a relationship with anyone besides his fiancée. The police officer reported that the stalker's affect completely changed. She said that she was angry because she had not known that the psychiatrist was unavailable. After that intervention, the stalking stopped.

Mullen *et al.*1 succinctly describe the different typologies of stalkers. The potential value of such categorization is that they may lead to different effective interventions for each type of stalker. However, as they point out, research on the impact of each intervention remains limited. For example, there is certainly anecdotal evidence and clinical experience about when to use restraining orders and the value of anti‐stalking legislation. There is limited research, however, on the long‐term effectiveness of such interventions with stalkers.18

An additional strategy that may help with the evaluation of some stalking situations was not specifically mentioned by Mullen *et al.*1—the value of working as a team. Because stalking situations pose such a high potential risk to victims, it may be beneficial to have more than one consultant look at the data before making recommendations to the victim about management strategies. Law enforcement consultants can be especially helpful because they may have seen hundreds of cases of stalking and have actuarial knowledge that can be complementary to the knowledge gleaned from the experience of clinicians.

In summary, the article by Mullen *et al*.1 is an excellent overview of available knowledge about stalking situations and their management. It introduces a structure that can assist professional judgment by prompting consideration of issues that research has shown to be important in assessing stalking situations. The structure includes knowledge of the literature and collecting relevant information before making specific recommendations. The authors caution that risks in stalking situations depend on interactions of potentially fluctuating and interrelated factors and that risk assessments should be updated as more information becomes available. This cautionary advice is well worth adhering to when acting as a consultant on stalking situations. As described by Mullen *et al.,* clinicians can make a risk assessment based on available information about the stalker and the victim. However, it is important to recognize that scientific knowledge about management of stalking situations continues to be limited. The consultant must consider a variety of strategies. When one does not work, he or she should shift to another strategy. Sometimes new information that contradicts previously received information is obtained and must be integrated into the evaluation of risk. Until we have long‐term follow‐up studies about the impact of each intervention on each type of stalking situation, assessments of stalking situations will require the use of professional judgment and flexibility in conjunction with knowledge of the available literature.

*   American Academy of Psychiatry and the Law

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