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Therapists' Resources for Threats, Stalking, or Assaults by Patients
Ken Pope, Ph.D., ABPP
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I've gathered the following 59 citations of articles and books and included a brief excerpt from each to help therapists and therapists-in-training to address patient stalking, threats, or violence.
The possibility of being stalked, threatened, or assaulted by a patient is a concern for many therapists and an occupational risk for all. For example, in Ethics in Psychotherapy and Counseling: A Practical Guide, Fourth Edition, Melba Vasquez and I reviewed research indicating that:
Almost one in every 5 psychologists reported having been physically attacked by at least one client.
Over 80% of the psychologists reported having been afraid that a client would attack them.
Over half reported having had fantasies that a client would attack.
Over one out of 4 had summoned the police or security personnel for protection from a client.
About 3% reported obtaining a weapon to protect themselves against a client.
The resources I gathered below present research findings, incidence & prevalence stats, characteristics of high-risk patients, precipitating events, methods & motives, forms of attack including those that are fatal, issues in recognizing and responding to risks, PTSD & other common effects, dangers to therapists' families, issues in prosecuting patients, training recommendations, and prevention strategies.
- Kivisto, A. J., Berman, A., Watson, M., Gruber, D., & Paul, H. (2015). North American Psychologists' Experiences of Stalking, Threatening, and Harassing Behavior: A Survey of ABPP Diplomates. Professional Psychology: Research and Practice. Advance online publication.
Excerpt: "The present study has several implications for practicing psychologists. First, these findings highlight the need for more readily available clinical risk management training for practicing psychologists. Although previous research has documented the general feeling of unpreparedness among clinicians for dealing with clients' STHB, this study was the first to show that even a majority of highly trained psychologists deemed to possess a specialized level of clinical knowledge and skill endorsed feeling similarly unprepared. The pervasiveness of the problem— evident in the fact that nearly three in four psychologists in this sample were harassed at some point in their career, over one in five threatened, and about one in seven stalked—further highlights the need for improved clinical risk management training opportunities for practicing psychologists."
- Gadit, A. A. M., Mugford, G., Callanan, T., & Aslanov, R. (2014). Reported Experiences of Stalking Behavior from Patients towards Psychiatrists from the Atlantic Provinces of Canada. British Journal of Medicine and Medical Research, 4(22), 3990-4003.
Excerpt: "25% reported being the victim of stalking.... The majority of mental health professionals are unaware of any laws against stalking in Canada. There a need for education, support services and redress of this problem."
- Simon, R. I. (2011). Patient Violence Against Health Care Professionals: Safety Assessment and Management. Psychiatric Times, 28, 2.
Excerpt: "The patient who wants to stalk and harm the clinician no longer needs to leave home. He or she can do it via the Internet. Cybersnooping is facilitated by Web sites such as search engines, online forums, bulletin and discussion boards, and chat rooms. Social networking sites, such as MySpace, Facebook, Twitter, and LinkedIn, are sources of personal information. Placing personal information on Internet sites exposes the clinician to a variety of psychological and physical harms (Table 4). For example, one angry patient ordered over-the-Internet pornographic magazines and sex toys in the name of the clinician and sent it to his mother-in-law."
- Mastronardi, V. M., Pomilla, A., Ricci, S., & D'Argenio, A. (2013). Stalking of Psychiatrists: Psychopathological Characteristics and Gender Differences in an Italian Sample. International Journal of Offender Therapy & Comparative Criminology, 57(5): 526-543.
Excerpt: "Research has indicated that medical doctors and paramedics are at higher risk of being stalked than the general population. In particular, mental health care professionals alone represent one third of the victims of harassment.... We found that the rate of stalking in private mental health settings is higher than that in public settings and that the perpetrators of stalking are mainly women who mostly target mental health professionals working in private practice. Implications of the findings are noted and discussed.
- Carr, M. L., et al. (2013). "Stalking of the Mental Health Professional: Reducing Risk and Managing Stalking Behavior by Patients." Journal of Threat Assessment and Management.
Excerpt: "Among mental health professionals, 6%–11% of providers will be stalked by a patient during their career.... Ethical guidelines across multiple health care disciplines emphasize avoiding harm and maintaining patient confidentiality. Although state licensing boards allow exceptions to confidentiality as mandated or permitted by law, these state laws may offer little protection to the mental health professional being stalked by his or her patient. Failing to address stalking behaviors could be detrimental to both current and future providers as well as preventing the stalker from receiving modification of problematic behavior.... The authors propose a dual pathway, 3-tiered model of stalking management that adopts a public health approach to guide interventions both on the individual provider and systemic level"
- Tripp, A. (2009). After an attack: How to deal? Academic Psychiatry, 33, 345-346.
Excerpt: "Recently, two of the 15 residents in my cohort second postgraduate year class, including myself, were attacked by patients. Out of curiosity, I did a literature search for coping skills, educational initiatives, or other ideas to address some of my questions. A number of articles addressed the prevalence of assault during training and in one's career as a psychiatrist. I found literature addressing training recommendations for improved prevention of violence and assault. I also found out how some psychiatrists felt after being assaulted. I found no literature addressing how to cope or the unique issues of transference and emotion as both victim and health care professional. I found this astounding, given that the approximate prevalence of physical assault during psychiatric training is 30% to 40%. In summary, in addition to psychotherapy or psychopharmacology when appropriate, I think more thought and creative solutions could be found to help address the unique challenges as a trainee in working with a patient, particularly on inpatient units, after being assaulted by said patient. At the very least, this would bring discussion of this common trauma into the light of day to be examined, and shared, to better treat ourselves and our patients."
- Maclean, L., et al. (2013). Psychiatrists' experiences of being stalked: A qualitative analysis. Journal of the American Academy of Psychiatry and the Law, 41(2), 193-199.
Excerpt: ""Of the free-text responses of 2,585 psychiatrists in the United Kingdom (approximately 25% of all U.K. psychiatrists), almost 11 percent...described being stalked according to a strict research definition, and 21 percent...perceived themselves as having been stalked.... Threat minimization, negative psychological impact, awareness of vulnerability, and difficulty obtaining help were major themes in how psychiatrists viewed their experiences of being stalked."
- Cho, H., et al. (2012). "An ecological understanding of the risk factors associated with stalking behavior: Implications for social work practice." Affilia: Journal of Women & Social Work 27(4): 381-390.
In this article, we review the literature on the risk factors that are associated with stalking victimization and perpetration using Bronfenbrenner's ecological systems theory. More specifically, we identified individual-level (sociodemographic), interpersonal-level (the relationship between the perpetrators and victims), societal-level (policies), and cultural-level (gender role socialization and social norms) factors that are associated with stalking behavior. We then draw implications from our review for assessment, prevention, and intervention strategies for social workers who are working with victims and perpetrators of stalking.
- Nelsen, A. J., Johnson, R. S., Ostermeyer, B., Sikes, K. A., & Coverdale, J. H. (2015). The prevalence of physicians who have been stalked: a systematic review. Journal of the American Academy of Psychiatry and the Law, 43(2), 177-182.
Excerpt: "Prevalence rates ranged from 2 to 25 percent, although one study found a prevalence rate of 68.5 percent. Information on the physical and psychological consequences of having been stalked was also limited."
- Galeazzi, Gian Maria; & De Fazio, Laura. (2006). “A review on the stalking of mental health professionals by patients, prevention and management issues.” Primary Care & Community Psychiatry, vol. 11, #2, pp. 57-66.
Excerpt: “Research on this topic is still scarce and different operational definitions used hinder comparisons across studies. Despite these methodological problems, eight published surveys confirm that there is a high rate of professional victimization -- more than 10% across different roles in mental health -- which may be higher for younger professionals.... Results highlight the need for information, training, and clear intervention guidelines on stalking by patients. Low threshold for intervention, firm limit setting, early involvement of and discussion with colleagues, institutional responses for increasing the safety of workers, referral to police, and legal action are advised in addressing risk of stalking by patients.”
- Antonius, D., Fuchs, L., Herbert, F., Kwon, J., Fried, J. L., Burton, P. R. S., Straka, T., Levin, Z., Caligor, E. & Malaspina, D. (2010). Psychiatric assessment of aggressive patients. The American Journal of Psychiatry, 167(3), 253-259.
Excerpt: "Among clinicians, violence toward psychiatrists is common and is an important issue (10–12); more than a third of psychiatrists have been assaulted by a patient at least once (10, 13). The risk of violent victimization is greater in clinicians with less experience (11). Reports estimate that 72% to 96% of psychiatric residents have been verbally threatened (12, 14–16), and 36% to 56% have experienced physical assaults (12, 14–18).... Clinicians are often reluctant to diagnose and treat aggressive and assaultive features in adolescents and young adults with psychiatric problems, instead focusing treatment on other axis I mental disorders in the hope that this will also reduce aggressive behavior. Interventions and treatment of violent psychiatric patients may be further hampered by the assumption that violent psychiatric patients belong to a homogeneous group, whereas there are actually several subgroups of violence-prone patients whose behavior is rooted in dissimilar underlying mechanisms. This oversight is unfortunate given that proper risk assessment of violence characteristics can guide differential treatment and management considerations and help in the prevention of assaultive behavior in patients determined to be potentially violent. Another concern is that unclear or nonexistent reporting policies or feelings of self-reproach may prevent residents and clinicians from reporting assaultive behavior. This limits our understanding of the prevalence of violence by psychiatric patients and prevents us from providing the resources necessary to address the problem.
- Baer, M., (2011). Better training needed to cope with violent patients." The National Psychologist, 20(1), p. 13.
Excerpt: "On Dec. 1, 2008, at 4 p.m., I saw for the first time a family consisting of a father, a mother and two sons ages 12 and 11.... Before long, the 12-year-old attacked me physically four times. At the end of the session the parents and the psychotic 12-yeaer-old went to the police station and reported that I had struck him. I was arrested...and jailed for 28 hours. Sadly months went by before the truth was revealed at their deposition. Felony charges were reduced by the D.A. and the judge to no contest, no conviction and no punishment."
- Abrams, K. M., & Robinson, G. E. (2011). Stalking by patients: Doctors' experiences in a Canadian urban area. Journal of Nervous and Mental Disease, 199(10), 738-743.
Excerpt: "Of the 1190 physicians who responded, 14.9% reported having been stalked. Although both male and female patients were stalkers, their motives and stalking behaviors were dissimilar. Psychiatrists, surgeons, and OB/GYNs reported the highest rates of being stalked. Both male and female physicians are at an increased risk of being stalked by patients who may feel loving feelings or anger and resentment."
- Abrams, K. M., & Robinson, G. E. (2013). Stalking by Patients: Doctors' Experiences in a Canadian Urban Area (Part II)—Physician Responses. Journal of Nervous and Mental Disease, 201(7), 560-566.
Excerpt: "Approximately 15% (14.9%) of the 1190 physicians who responded reported having been stalked. The physicians reported feeling angry, frustrated, anxious, frightened, lacking control, and helpless. The physicians coped in a number of ways including terminating the physician-patient relationship, but many just ignored the problem. Most had no previous knowledge about stalking. Physicians experience a range of emotions as a result of being a victim of stalking. In view of the prevalence and the impact, physicians may benefit from education to help prepare them for the possibility of being stalked."
- Kavanagh, A., & Watters, L. (2010). Consultant psychiatrists' experience of workplace violence—A national survey. Irish Journal of Psychological Medicine, 27(2), 77-81.
Excerpt: "Ninety per cent of respondents had been the victim of verbal aggression/intimidation/threatening behaviour while 55% had been physically assaulted. The majority of incidents involved male patients aged between 21-40 years with a diagnosis of paranoid schizophrenia. Nearly 66% of incidents of physical violence occurred during a relapse of illness. The perpetrator had a history of violence in approximately half of all reported incidents. Physical assaults tended to occur more commonly in inpatient settings (63.7%). Incident reporting occurred more often in physical assaults with 66% reported informally to colleagues and 20% reported to An Garda Siochana (police force of Ireland). Eighty-nine (56%) consultants described feeling 'safe' at work. Less than 50% reported the provision of standard safety equipment in the workplace and nearly half of respondents had not attended any safety training courses since their appointment. Longer experience working as a consultant psychiatrist did not appear to have an impact on reducing the rate of assaults. In addition, those who attended safety training courses did not report a reduced rate of physical assaults."
- Seeman, M. V. (2008). Duty of care versus safety of a colleague. Journal of Ethics in Mental Health, 3, 1-4.
Excerpt: "This case describes a psychiatric patient who stalked and harassed her former psychiatrist. Balancing the safety risk to her physician against the duty to continue to treat this vulnerable patient, what should the current psychiatrist and the treating institution do?"
- Whyte, S., Penny, C., Christopherson, S., Reiss, D., & Petch, E. (2011). The stalking of psychiatrists. The International Journal of Forensic Mental Health, 10(3), 254-260.
Excerpt: "Of the 2,585 psychiatrists who submitted valid responses, 21% thought they had been stalked; the experiences of 33% met current legal criteria and 10% met strict research criteria. Three percent of respondents were currently being stalked; 2% reported that their stalking had begun in the past year. Of those who had been stalked, 64% were stalked by patients. The most commonly reported motives were intimacy seeking and resentment. Stalking persisted for over a year for 52% of victims. The stalking was intrusive, disruptive, and had significant impact."
- Dinkelmeyer, Amanda; & Johnson, Matthew B. (2002). “Stalking and harassment of psychotherapists.” American Journal of Forensic Psychology, vol. 20, #4, pp. 5-20.
Excerpt: “[M]ental health professionals are at increased risk for stalking victimization.... The majority of psychotherapists have received little or no training on how to handle potentially violent and harassing patients and are often ill prepared to deal with the situation.... [T]here are a number of clinical, civil and legal options available to clinicians. Among these are limit setting, confrontation, civil orders of protection and prosecution of stalking and stalking related offenses.”
- Catanesi, R., Carabellese, F., Candelli, C., Valerio, A., & Martinelli, D. (2010). Violent patients: What Italian psychiatrists feel and how this could change their patient care. International Journal of Offender Therapy and Comparative Criminology, 54(3), 441-44.
Excerpt: "Almost all psychiatrists (90.9%) have experienced verbal aggression; 72% have been threatened with dangerous objects and 64.58% have suffered physical aggression. Physical aggression experiences result in a 50% increase in the probability of modifying one’s therapeutic behaviour.... Psychiatrists state that they do not consider themselves to be adequately prepared to deal with the violence of patients, and almost all psychiatrists felt the need for specific training in how to manage such violence."
- Flannery, R. B. Jr. (2005). "Precipitants to psychiatric patient assaults on staff: review of empirical findings, 1990-2003, and risk management implications." Psychiatric Quarterly, vol. 76, #4, pp. 317-326.
Excerpt: "Over thirty years of empirical research have documented the characteristics of both patient assailants and staff victims. Notably absent from this literature have been similar empirical studies on the nature of patient precipitants to these assaults.... Common precipitants included staff restrictions on patient behaviors, denial of services, excessive sensory overload, and provocation by others."
- De Becker, Gavin. (1999). The Gift of Fear. Dell Publishers.
NOTE: This is the only more general resource for dealing with stalking, threats, or attacks -- all the others on this web page focus specifically on therapists coping with stalking, threats, or attacks from patients. I’m including it because it has been most consistently praised as the most helpful, informed, and practical guide to responding to stalking, threats, and attacks by colleagues and other to whom I’ve recommended it. Here is the publisher’s information about the author: "Gavin de Becker is widely considered America's leading expert on predicting and managing violent behavior. He advises such clients as the C.I.A. and the United States Supreme Court, and his 70-member firm has protected clients from terrorism in Israel, Southern Africa, Europe, and South America. This 3-time presidential appointee designed the assessment systems used to screen threats to all federal judges and the governors of eleven states, and his work has changed the way the U.S. government protects its highest officials. Mr. de Becker is a Senior Fellow at UCLA's School of Public Policy and Social Research."
- Nwachukwu, I., Agyapong, V., Quinlivan, L., Tobin, J., & Malone, K. (2012). Psychiatrists' experiences of stalking in Ireland: Prevalence and characteristics. The Psychiatrist, 36(3), 89-93.
Excerpt: "25.1% of psychiatrists in Ireland had been the subject of stalking behaviour at some point in their career. At the time of the survey, 5.5% of respondents were actively being stalked.... Most of the victims were unaware of guidelines or other supportive mechanisms in their workplace. Of those who reported their experiences to authorities, almost half were not satisfied with the support they received."
- Sullivan, Michele G. (2006, October). “Assisting patients, staying safe: a delicate balance.” Clinical Psychiatry News, vol. 34, #10.
Excerpt: “Study after study has found the same risk factors: Younger males with a history of substance abuse and past psychosis...are particularly prone to violent outbursts.... It's important to watch for signs of emergent violence. Signs that the patient might become violent include agitated behavior like pacing, explicit or implicit threats, darting eye movement, and invasion of the clinician's personal space. Violence also begets violence in these patients, Dr. Bell [Dr. Carl C. Bell, director of public and community psychiatry at the University of Illinois, Chicago] said... ‘Talking is usually the only way to deescalate this situation,’ he said. ‘But I don't mean just saying, 'Hey, calm down.' Remember that behind anger is fear or hurt, so use your skills to try and find out what the underlying issue is.’ Offering food, drink, or even a stick of gum may help dispel the violent energy. But physical contact is likely to accelerate it, so don't touch the patient, even with the intention of offering empathetic support.... But when the clinician sees signs of emergent violence, the time for talk is over. 'At this point you have to do something to defend yourself. This is where people will get into difficulty if they are in do-no-harm mode. If you get stuck here, you will end up hurt, or maybe even dead. You have to be able to shift gears from that into self-preservation.... Push the panic button, call for staff, and use any means at hand for defense,’ he said.... ‘If the attacker doesn't have a weapon, a counterintuitive but effective way to minimize injury is to simply hang on to him. Get as close as possible, clench the patient, and hang your full body weight on him until help comes."
- Savoja, V., Sani, G., Kotzalidis, G. D., De Rossi, P., Stefani, S., Pancheri, L., & Girardi, P. (2011). Bipolar disorder presenting as stalking--a case report. Psychiatria Danubina, 23(1): 69-72.
Excerpt: "A 22-year-old adoptive woman perpetrated stalking towards her gynaecologist, who took legal action to protect herself. She was admitted to a general hospital psychiatric department and diagnosed with bipolar disorder-I, manic phase, and personality disorder, not otherwise specified. She was prescribed lithium and valproate combination and followed-up as an outpatient. She underwent cognitive-behavioural therapy incorporating Bowlby's concepts. Stalking behaviour did not reemerge.... Exacerbations of psychiatric episodes may trigger stalking behaviour. Drug treatment may prevent its clinical expression, but underlying ideation and affect may need long-term psychotherapy focusing on attachment."
- McIvor, Ronan J.; & Petch, Edward. (2006). “Stalking of mental health professionals: An underrecognised problem.” British Journal of Psychiatry, vol. 188, #5, pp. 403-404.
Excerpt: “Despite causing significant psychological distress, stalking remains underrecognised and poorly managed. Healthcare organisations should ensure appropriate policies are in place to aid awareness and minimise risk, including the provision of formal educational programmes.”
- McIvor, Ronan J.; Potter, Laurence; & Davies, Lisa. (2008). “Stalking behaviour by patients towards psychiatrists in a large mental health organization.” International Journal of Social Psychiatry. vol 54, #4, pp. 350-357.
Excerpt: “Mental health professionals are at greater risk than the general population of being stalked, particularly by patients.... Duration of stalking ranged from several weeks to 16 years, and most commonly occurred at work..... Stalking by patients towards psychiatrists is common and represents an important occupational risk. Formal training programmes and policy development within healthcare organizations may help manage risk.”
- Sandberg, D.A., McNiel, D.E., & Binder, R. L. (2002). "Stalking, threatening, and harassing behavior by psychiatric patients toward clinicians." Journal of the American Academy of Psychiatry and the Law, vol. 30, pp. 221–229.
Excerpt: “Our data suggest that there is no panacea for management of STHB [stalking, threatening, or harassing behavior] by patients. Any interventions may or may not be effective in the individual case. In approaching the management of STHB toward clinicians by patients, our findings suggest the value of having a repertoire of responses. This permits flexibility in responding, so that if one intervention fails, other plausible strategies may be implemented. The most common response made by staff members in our study was to tell coworkers or supervisors about the situation.... Although the strategy was rarely implemented by staff members in our study group, some study participants' responses suggest the potential utility of involving the legal system.”
- Flannery, R. B., Hansen, M. A., Penk, W. E., & Flannery, G. J. (1994). “Violence against women: Psychiatric patient assaults on female staff.” Professional Psychology: Research and Practice, vol. 25, #2, pp. 182–184.
Excerpt: “The finding of significantly more different-gender assaults on female staff in the community raises an important question for future study. Community-based female staff tend to be younger than the male patients... These factors may contribute to increased risk of different-gender assaults. This finding may portend a new domain of occupational hazard as public and private forms of managed care increase degrees of outpatient treatment for clients with psychiatric disorders. Trends in national health care reform suggest a similar pattern that may also result in increased proportions of women as treating staff. Although the underreporting of violence (e.g., Lion, Snyder, & Merrill, 1981) is a continuing problem, extending the definition of violence in this study to include severe verbal abuse in addition to physical injury appears to have been helpful in assessing the frequency and impact of violence. In this study, there were frequent occurrences of male and female staff experiencing intense fright in the absence of serious injury, and several cases where verbal abuse and noninjurious assault resulted in intrusive memories of past incidences of abuse not related to work. The finding that male and female staff have about a 10% incidence of psychological symptoms associated with the aftermath of trauma is consistent with previous findings (Caldwell, 1992) and suggests the importance of using the more inclusive definition of violence in such studies.”
- Caldwell, Michael F. (1992). “Incidence of PTSD among staff victims of patient violence.” Hospital and Community Psychiatry, vol. 43, #8, pp. 838–839.
Excerpt: “Although traumatic events occurred fairly often, organizational support for traumatized staff at the two sites was minimal or nonexistent.... The clinical staff reported a very high rate of PTSD-related symptoms.... If one in ten employees in an industry was expected to develop a job related psychiatric disorder, the industry would likely face intense pressure to address the issue. This study shows that quite the opposite is the case in mental health facilities. Should these findings prove typical, it may be, ironically, that one of the most hazardous work settings for employee mental health is the local mental health facility.”
- Arthur, Gary L.; Brende, Joel O.; & Quiroz, Stacy E. (2003). “Violence: Incidence and frequency of physical and psychological assaults affecting mental heath providers in Georgia.” Journal of General Psychology, vol. 130, #1, pp. 22-45.
Excerpt: “The results also showed that 61% of the respondents had been victimized in violent acts of a psychological or physical nature and that 29% had feared for their lives at least once during their professional careers. These data are consistent with other research that indicates that 6 out of 10 professionals will be assaulted during their professional careers.”
- Bernstein, Howard A. (1981) “Survey of threats and assaults directed toward psychotherapists.” American Journal of Psychotherapy, vol. 35, #4, pp. 542-549.
Excerpt: “Of the 422 psychotherapists sampled, 60 indicated that they had been assaulted and 150 indicated that they had been threatened by patients. Female Ss were assaulted proportionately less than males. Prediction of such incidents was extremely poor. Of patients who had attacked or threatened therapists, 75% had a history of violent behavior, and 35% of those who had threatened therapists had a history of suicide threats or attempts. Inexperienced Ss were assaulted more often than those with experience of more than 11 yrs. After assaults, 23% of the Ss transferred their patients to another therapist. External objects were seldom used in assaults. Ss felt that their best defense was to handle the situation intuitively.”
- Danto, Bruce L. (1982/1983). “Patients who murder their psychiatrists.” American Journal of Forensic Psychiatry, vol. 3, #3, pp, 120-134.
Abstract: “Reviews literature on violent behavior directed toward psychiatrists by their patients and notes the possibility that the treatment setting, psychiatrist denial of potential danger, and psychotic transference are factors that can contribute to patient violence. The present author describes the experience of defusing a potentially violent 28-yr-old female through communication, supportive statements, encouragement to maintain control, and reward for appropriate behavior. Two case examples of psychiatrists who could not defuse their patients and were subsequently murdered by them are presented.”
- Galeazzi, Gian Maria, Elkins, K., & Curci, P. (2005). “The stalking of mental health professionals by patients.” Psychiatric Services, vol. 56, pp. 137-138.
Excerpt: “The global cumulative incidence of stalking of 11 percent among mental health workers confirms previous hypotheses that these professions are at risk of this form of victimization (7).... 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 about appropriate boundaries in this type of relationship.... As to the motivation for the stalking in this population, a majority of victims ... reported patient's desire for more intimacy as the perceived motivation. In only five cases did the victim believe that the stalking campaign was initiated as revenge for a perceived wrong—for example, refusal to certify disability to enable the patient to obtain a pension. In three cases the stalking campaign was initiated after termination of the therapeutic relationship by the mental health professional.... Instances of overt threats and physical violence were low compared with those reported in forensic settings, where violent acts are experienced by 30 to 40 percent of victims (8). It is advisable that mental health professionals maintain high levels of attention to the maintenance of boundaries in working with patients; avoid confusion between personal and professional involvement; take seriously prodromal features that possibly herald the initiation of stalking, such as requests for personal details by patients; and report stalking incidents in team meetings or in supervision (for professionals working in private practice).”
- Gentile, Steven R.; Asamen, Joy K.; Harmell, Pamela H.; & Weathers, Robert . (2002). “The stalking of psychologists by their clients.” Professional Psychology: Research and Practice., vol. 33, #5, pp. 490-494.
Excerpt: “More concrete methods of protection may be more valuable. For example, the long-term action most frequently reported by the psychologists who had been stalked in this study was an unlisted home address. This easily implemented course of action may be enough to deter the attempts of a client who is beginning to exhibit stalking behaviors. An unlisted home phone number could be an effective measure in deterring unwanted phone calls and harassing messages from a client with stalking tendencies (or from a client with poor boundaries whose actions might never escalate to a more serious level). A home-based alarm system can protect practitioners and their family members, and an office-based alarm system can protect practitioners who are working after closing hours as well. Creating obstacles that make it difficult for clients to intrude into the personal space of the practitioner and his or her family is encouraged. Having a home-based office may be convenient and economical, but it also makes stalking easier. Psychologists who practice in urban areas may be afforded a higher degree of anonymity than those practicing in more rural areas. A psychologist practicing in a small town may benefit from locating his or her home in another community to avoid coming into unwanted contact with clients outside of the office. Academic institutions that instruct future psychologists and clinical settings that train these individuals are encouraged to include formal training concerning safety issues for psychologists if they are not already doing so. Psychologists who are currently faced with a client who is exhibiting stalking behaviors may benefit from contacting their local police departments (or antistalking task forces in more urban areas) for protection for themselves and their family members. By instituting a safety plan, psychologists and their families improve their chance of not having to face such an experience.”
- Guy, James B., Brown, Katherine, & Poelstra, Paul. (1990). "Who gets attacked? A national survey of patient violence directed at psychologists in clinical practice." Professional Psychology: Research and Practice, 21, #6, 493–495.
Excerpt: “It appears that a significant number of psychologists in clinical practice have been physically attacked by a patient at some point in their career. It is unsettling to find no clear profile represented among the victims. Factors such as sex, age, theoretical orientation, and amount of training regarding the management of patient violence were apparently unrelated to being a victim of patient attack. Although it is not surprising that we found that those working in inpatient settings were most likely to be attacked, it is important to note that we also discovered that it can happen to anyone, in any work setting. It appears that all practitioners should be aware of this risk when meeting with patients. To date, most clinicians have received no training regarding the management of patient threats and violence, and they may be relatively unprepared to deal with patient attacks. Perhaps greater awareness of the pervasiveness of this danger will provide added motivation for practitioners to obtain the skills necessary to protect their safety.”
- Harris, G. T., & Rice, M. E. (1986). "Staff injuries sustained during altercations with psychiatric patients." Journal of Interpersonal Violence, vol. 1, pp. 193-211.
Excerpt: “In the 500-bed psychiatric institution that was studied, there were 123 such incidents over a 7.5-yr period. Compared to incidents that resulted in no time being lost from work, lost-time incidents more often resulted from staff members restraining patients than from patients assaulting staff. In general, the injuries sustained during patient assaults tended to be relatively minor; the injuries sustained in restraints, such as falls, sprains, or strains, tended to be much more serious in terms of time lost from work.”
- Hoge, Steven K. & Gutheil, Thomas G. (1987). “The prosecution of psychiatric patients for assaults on staff: A preliminary empirical study.” Hospital & Community Psychiatry, vol. 38, #1, pp. 44-49.
Excerpt: “An assault is a crisis point for patient and staff. Inpatient wards have available a wide variety of appropriate clinical interventions that can be directed toward the causes of the violence: seclusion and restraint, medication, transfer to secure facilities, and involuntary discharge as well as the use with the staff of exploration or debriefing, which should be an invariable response to any acting out. These measures should be the first line of intervention for assault. Assaults may also signal systems issues such as problems in staffing, morale, treatment team unity, or resources. If the core problem lies in these areas, then prosecution merely scapegoats the patient. Preferable approaches would be attempts to remedy the underlying problem. A further policy concern is related to the legal issues that impinge on the treatment alliance (6).... [W]e also recommend that when prosecution is being considered, consultation be obtained from a psychiatrist who has no direct cmical responsibility for the patient involved. Because prosecution may result in the termination of treatment, it is imperative that as part of the consultation, consideration be given to the actual ends that treaters seek, and the likelihood that they can be achieved. Such consultation will also provide an opportunity to explore alternatives, and to challenge motives that may be contaminated by countertransference issues.”
- Hudson-Allez, Glyn. (2002). “The prevalence of stalking of psychological therapists working in primary care by current or former clients.” Counselling & Psychotherapy Research. vol 2, #2, pp. 139-146.
Excerpt: “The prevalence of being a victim of harassment or stalking among the general population of the UK is held to be 11.8 per cent.... [This study showed] a prevalence rate [of the stalking of psychological therapists] of more than twice the national average at 24 per cent. The stalkers, who were equally male or female, fell into three broad categories: those clients who were needy and made early attachments to their therapists; those experiencing erotic transference; and those with personality disorders.”
- Hudson-Allez, Glyn. (2006). “The stalking of psychotherapists by current or former clients: Beware of the insecurely attached!” Psychodynamic Practice: Individuals, Groups and Organisations, vol. 21, #3, pp. 249-260.
Excerpt: “Psychotherapists who are aware of the dynamics within the therapeutic relationship can take preventative steps to inhibit the automatic fear response of a client who is insecurely attached and which may lead to stalking behaviour.”
- Hughes F. A. , Thom K., & Dixon R. (2007). “Nature & prevalence of stalking among New Zealand mental health clinicians.” Journal of Psychosocial Nursing & Mental Health Services, vol. 45, #4, pp. 32-39.
Excerpt: “An anonymous questionnaire asking respondents to describe their experiences with 12 stalking behaviors was distributed to 895 clinicians. Results indicated that regardless of discipline, women were more likely than men to have experienced one or more stalking behaviors, including receiving unwanted telephone calls, letters, and approaches; receiving personal threats: and being followed, spied on, or subject to surveillance. Women also reported higher levels of fearfulness as a consequence of stalking behaviors. Nearly half of the stalkers were clients; the remaining were former partners, colleagues, or acquaintances. In client-related cases, the majority of respondents told their colleagues and supervisors first, and the majority found them to be the most helpful resource.”
- Kaplan, Arline. (2008). "Violent Attacks by Patients: Prevention and Self-Protection." Psychiatric Times, vol. 25, #7.
Excerpt: “During their training, up to 65% of psychiatry residents are physically assaulted by patients.... In a 2003 survey of employees of the University of Rochester Medical Center's inpatient and outpatient services, 40% of responding physicians, 3% of psychologists, and 57% of registered nurses said patients had assaulted them..... In outpatient settings, a survey found that 32 of 92 psychiatrists (35%) reported serious assaults by patients (knife or gun used) and 59 respondents (64%) reported less serious assaults..... Additional guidelines offered by Appelbaum [Paul Appelbaum, MD, professor of psychiatry and director of the Division of Psychiatry, Law, and Ethics at Columbia University] include ensuring that you have a means of egress from the office if a patient gets out of control and removing from your office heavy objects that could be thrown or used as weapons.... Many clinicians have been injured because they thought that they could deal with an uncomfortable or dangerous situation without help from security staff or without consulting about the patient with a more experienced colleague. Do not try to ‘talk down’ an agitated patient without adequate physical safety precautions, Reid [William H. Reid, MD, MPH, clinical professor of psychiatry at the University of Texas Health Science Center, San Antonio] warned, adding that psychiatrists and psychologists make poor negotiators with agitated, threatening, or intoxicated people. He also cautioned men not to rely on their size and strength, ‘since even big, strong, young males can be severely injured or killed by psychotic or intoxicated patients, by patients who attack suddenly or from hiding, or by patients who wield weapons.’”
- Sandberg, D. A., McNiel, D. E., & Binder, R. L. (1998) “Characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge.” American Journal of Psychiatry, vol.155, #8, pp. 1102-1105.
Excerpt: “One of the concerns of mental health clinicians is that they may be the target of violence. According to APA's Task Force on Clinician Safety (1), approximately 40% of psychiatrists, and an even higher percentage of psychiatric nurses, have been assaulted by patients..... The association that was found between a history of aggressive behavior and stalking, threatening, or harassing staff is consistent with prior research showing that the best predictor of future aggression is a history of past aggression (6, 11). Similarly, the association between substance abuse or dependence and this type of behavior is consistent with research demonstrating that substance-related disorders are linked to aggressive behavior by mentally ill persons in the community (12, 13).”
- Lion, John R., & Herschler, Jeremy A. (1998). “The stalking of clinicians by their patients.” Chapter in Meloy, J. Reid (Ed). The psychology of stalking: Clinical and forensic perspectives (pp. 163-173). San Diego, CA: Academic Press.
Excerpt: “The following points are considered important for the recognition and management of stalking: (1) the clinician should be attuned to early inappropriate behaviors that reflect a deranged transference; (2) the clinician who encounters boundary violations should at least ponder the possibility of such violations escalating to the point of physical danger; and (3) legal and forensic consultation should be sought early which should include a clear confrontation and statement of consequences.”
- Madden, D.J., Lion, J.R.& Penna, M.W. (1976). “Assaults on psychiatrists by patients.” American Journal of Psychiatry, vol. 133, pp. 422-425.
Excerpt: “The finding that 429k of the clinicians surveyed reported having been assaulted by a patient was interesting and surprising to us.... It is our belief that denial plays a heavy role in both the ways clinicians deal with patients who might be assaultive and their recollection of assaults. One clinician who had been threatened many times by a patient and had tape recorded these threats on his life was still hesitant to take any action to prevent a potential assault. The alarming nature of patient assault on clinicians is brought home by reports of two psychiatrists who were killed by patients within the last two years. One psychiatrist on the staff of a state hospital in the Boston area was killed while attempting to disarm a patient, and another psychiatrist in New Haven was killed by a patient he had seen on only one occasion. According to several questionnaire respondents who mentioned the incident, this patient apparently incorporated the psychiatrist into a well-developed paranoid delusional system and then shot him.”
- Meloy, J. Reid. (2002). “Stalking, threatening, and harassing behavior by patients--the risk management response.” Journal of the American Academy of Psychiatry & Law, vol. 30, pp. 230-231.
Excerpt: “I suggest that a common thread among such patients is a pathological narcissism that increases the risk of humiliation in response to the more confrontational aspects of treatment, especially inpatient care. This ventral underbelly of shame sensitivity can stoke a fury that makes no distinction between the professional and private life of the clinician. 10 The study underscores the importance of a comprehensive diagnostic workup that does not neglect both personality and substance abuse disorders, even in the face of a florid Axis I psychosis.”
- Nelson, Bryce. (1983, June 14). “Acts Of Violence Against Therapists Pose Lurking Threat." New York Times.
Excerpt: “Scholars who agree that psychotherapists have reason to be fearful point to the these events: *Although precise numbers are unobtainable, it appears that a few psychiatrists are murdered by patients each year. In a six-week period in the summer of 1981, four psychiatrists, one each in Massachusetts, Florida, California and Michigan, were murdered by patients. * These murders occur both in private offices and in hospitals.... *The families of therapists are not immune from threats and assault. Psychiatrists in New York still talk about the murder of Paule Passavant LaVerne, the wife of Dr. Albert LaVerne, a psychiatrist, in the lobby of their Fifth Avenue apartment house in 1961 by a former patient of her husband. *Strange things have happened to psychiatrists who have been threatened by patients. For instance, Dr. Alan Holden, a psychiatrist who was co-chief of the prison ward at Bellevue Medical Center, disappeared in 1967 from his Park Avenue office-apartment and has never been found...”
- Pope, K. S., & Tabachnick, B. G. (1993). “Therapists' anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training.” Professional Psychology: Research & Practice, vol. 24, #2, pp. 142-145.
Excerpt: “Over 18% reported having been physically attacked by at least one client.... About one fourth of the participants reported having fantasies that a female client will attack them; one half reported such fantasies about a male client. About one tenth reported summoning police or security personnel for protection from a female client; about one fourth reported making such calls for protection from a male client. Less than 4% reported obtaining a weapon for protection against a client, and none reported using a weapon for protection.”
- Purcell, Rosemary; Powell, Martine B.; & Mullen, Paul E. (2005). “Clients Who Stalk Psychologists: Prevalence, Methods, and Motives.” Professional Psychology: Research and Practice, vol. 36, #5, pp. 537-543.
Excerpt: “The experience of being stalked by a client is disruptive both personally and professionally, as evidenced by psychologists in this sample often bolstering both their home and their workplace security. It is notable that a significant proportion of stalked psychologists considered leaving the profession as a direct result of their experience. Although the number of psychologists who have ultimately abandoned their career as a result of client stalking cannot be discerned here (because the sample consisted of current board-registered practitioners), several respondents indicated that they had transferred to nonclinical work practices in light of their stalking experiences.... Certainly the overwhelming majority of stalked psychologists in this sample indicated that nothing in their training and education adequately prepared them for client stalking. Incorporating information regarding the risks of stalking into psychology training curricula would assist psychologists in recognizing high-risk situations, determining what action to take if stalking by a client occurs, and providing specific safety precautions that can be adopted if they or a colleague find themselves subjected to such pursuit.”
- Richter, Dirk, & Berger, Klaus. (2006, April). “Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study.” BMC Psychiatry, vol. 6, #15.
Excerpt: “In the baseline assessment following an assault by a patient,...17% met the criteria for PTSD.... The management of posttraumatic stress in health care institutions requires firstly a strategy to recognize and report possible psychological sequelae. In the light of the above reported and other research findings, this seems to be a difficult task because of the avoiding behaviour of affected staff. Secondly, post-incident management support has to be provided by the organization. Recent PTSD-management strategies from US-forces and UK-military stress the importance of peer support [17,18]. Similar strategies have also been suggested for nursing staff . A crucial point in this regard is to provide support without applying debriefing techniques which seem to worsen the course of the acute stress of traumatized subjects ."
- Romans, John. S. C., Hays, Joni R., & White, Tamiko K. (1996). “Stalking and related behaviors experienced by counseling center staff members from current or former clients.” Professional Psychology: Research and Practice, vol. 27, #6, pp. 595–599.
Excerpt: “Whereas a stalking incidence level of 5.6% may be seen by some as relatively low, or perhaps not unexpected, the impact of being a target of a stalker mitigates against treating such issues as extremely rare. Another important finding to consider is the potential risk that is placed on family members of counseling center professionals. Given that nearly 8% of our sample had experienced a family member being stalked, serious consideration needs to be paid to reducing the incidence of these events.... Risk management measures such as being familiar with applicable campus policies and local-level state laws regarding stalking behaviors, and taking precautions to guard against access to personal information such as social security numbers, phone numbers, and electronic mail addresses could be easily implemented. Agency policies that train individuals who have front line contact with clients to manage and control stalking and harassment behaviors, and that encourage ongoing staff development in dealing with potentially dangerous clients are essential. We suggest that a particularly critical skill in minimizing the occurrence of these stalking and harrassing behaviors is setting effective limits with clients.”
- Rosack, Jim. (2006). “Patient Charged With Murder Of Schizophrenia Expert.” Psychiatric News, vol. 41, #19, p. 1.
Excerpt: “APA President Pedro Ruiz, M.D., observed, ‘We should not overreact and think that most patients with mental illness are more dangerous than the population at large. To do so would negate the work of Dr. Fenton. To build stereotypes would undoubtedly lead to stigma, thus increasing barriers to providing patients with the highest quality of care possible. Having said that, it is absolutely appropriate and necessary for psychiatrists to be cautious and fully alert in detecting signs of aggression and dangerousness when working with severely ill patients.’ Indeed, psychiatrists and mental health professionals are subject to a significantly higher risk of violent crime than most other categories of professionals. The U.S. Occupational Safety and Health Administration, the Bureau of Labor Statistics (BLS), and the Department of Justice (DoJ) agree that health care workers face some of the highest levels of job-related violence. BLS statistics show that there were 69 homicides of health care personnel from 1996 through 2000. According to the DoJ's National Crime Victimization Survey for 1993 to 1999, the annual rate for nonfatal violent crime for all occupations was 12.6 per 1,000 workers. For physicians, the rate was 16.2, and for nurses it was 21.9. But for psychiatrists and mental health professionals, the rate was 68.2, and for mental health custodial workers, 69.”
- Ryan, Eileen P.; Aaron, Jeffrey; Burnette, Mandi L.; Warren, Janet; Burket, Roger; & Aaron, Theresa. (2008). "Emotional Responses of Staff to Assault in a Pediatric State Hospital." Journal of American Academy of Psychiatry & Law, vol. 36, #3, pp. 360-368.
Excerpt: "The results of this study indicate that more than half (63%) of the subjects had reported being assaulted by patients in a pediatric psychiatric hospital in the previous six months.... The finding that assaulted staff (in comparison to non-assaulted staff) reported a higher level of generalized impairment at work and considered terminating employment is particularly interesting in light of the fact that there was no significant difference between the two groups in overall job satisfaction. This may reflect a level of altruism that attracts staff to work with individuals with severe mental illness, particularly children, and the sense that despite the risks to themselves, they are performing a vital service. It may also reflect some denial of the impact of assault and the risk of future assault. Several researchers have noted that nurses working in psychiatric hospitals (performing many of the same duties as direct care staff in this study) have a tendency to minimize and deny the effects of assault.9,27.... The Assaulted Staff Action Program, a voluntary peer-help, system-wide crisis intervention program to assist assaulted staff cope with the aftermath, has some empirical support for decreasing assaults by adults on staff facility-wide, but has not enjoyed widespread application and requires further study.35,36 Flannery36 postulates that a mechanism for decreasing assaults is that staff feel more supported by administration in facilities that have implemented the program, and that when staff feel supported, they feel less anxious, and that in turn is communicated to the patients who also become less anxious; thus, assaults decrease."
- Schwartz, Thomas L., & Park, Tricia L. (1999). "Assaults by Patients on Psychiatric Residents: A Survey and Training Recommendations." Psychiatric Services, vol. 50, pp. 381-383.
Excerpt: "Together these studies suggest that from 40 to 50 percent of psychiatric residents will be attacked physically during a typical four-year training program (15).... Surveys have revealed that psychiatric residents feel their training in violence management is inadequate, with residents reporting an average of only three hours of such training (14,15,16). Hatti and associates (6) emphasized interpersonal dynamics in such training and suggested that clinicians may best be served when trainers direct their attention to the anxiety and fears aroused when confronting a violent patient. This approach would allow for more efficient use of verbal skills and would help diffuse the violent situation.... We believe that the ten hours of training outlined in this paper should be given in the first training year, followed by two-hour simulation seminars during each following year of residency.... This minimal amount of dedicated time by residents and faculty may prove to be very helpful in reducing the frequency and severity of assaults by patients not only during residency but also in practice after residency."
- Whitman, R. M., Armao, B., & Dent, O. B. (1976). "Assault on the therapist." American Journal of Psychiatry, 133: 426-429.
Excerpt: “The overall data indicate that in one calendar year 1 of every 11 patients (615 of 6,720) seen in a variety of psychotherapy settings presented an assaultive threat to others in their environment, 126 were physically threatening to the psychotherapist. and 42 actually engaged in assaultive behavior toward the therapist. The 42 patients who assaulted the therapist were distributed among a variety of mental health professionals to the extent that 24% of 101 therapists were attacked during one year by at least I patient. Thus attack on the therapist is an infrequent but also inevitable phenomenon that may occur at some time to every therapist. Since one onslaught can end a therapist’s career, every therapist should have a working knowledge of a wide variety of techniques to manage assaultive patients that he can put into effect with little delay or deliberation.... The research team pooled the knowledge that the responding therapists had gained over the years in dealing with violent patients. The eight coping techniques listed above represent this collective experience. Another way of organizing the eight coping categories is the following: I) biological-physical and chemical methods of control by others or the self, 2 psychological-verbal methods of control such as firmness, honesty, and humor; and 3) social--use of family influence, pressure from social institutions--and peer influence. We have observed that therapists tend to use only one type of technique in coping with assaultive patients. Verbally oriented therapists use verbal techniques, even when physical techniques are clearly indicated, and therapists familiar with physical techniques inappropriately put these into effect when an empathic response would serve better. Our data indicate that responses to the threat of patient attack are stereotyped and instantaneous; only occasionally are they highly creative. It therefore seems useful for therapists to engage in extensive discussion, rehearsal. and other forms of training...”
- Penny, C., & Whyte, S. (2009). Trust services for psychiatrists victimised by stalkers. Psychiatric Bulletin, 33, 155-156.
Excerpt: "The Royal College of Psychiatrists has since established the Psychiatrists' Support Service. It can provide members who are victims of stalking with telephone psychological support, practical advice and legal guidance, provided by other psychiatrists with appropriate training and experience."
- Jacob, J. D., & Holmes, D. (2011). Working under threat: Fear and nurse–patient interactions in a forensic psychiatric setting. Journal of Forensic Nursing, 7(2), 68-77.
Excerpt: "the results from this research indicate, as other researchers have demonstrated, that within this highly regimented context, nurses are socialized to incorporate representations of the patients as being potentially dangerous, and, as a result, distance themselves from idealistic conceptions of care. Moreover, the research results emphasize the implication of fear in nurse–patient interactions and particularly how fear reinforces nurses' need to create a safe environment in order to practice. A constant negotiation between space, "at risk" bodies and security takes place where nurses are forced to scrutinize their actions in order to avoid becoming victims of violence. In parallel, participants also described how being able to self-identify with patients enabled therapeutic interventions to take place. However, exposure to the patient's criminal history fostered negative reactions on the nurses' part, which impede nursing work."
- Gordon, John, & Kirtchuk, Gabriel (Eds.) (2008). Psychic assaults and frightened clinicians: Countertransference in forensic settings. Forensic psychotherapy monograph series. London, England: Karnac Books.
Excerpt: "Working with disturbed and disturbing individuals in secure settings produces strong feelings, and working with those feelings is undoubtedly an essential part of providing care effectively. This book is likely to challenge readers' understandings of their own actions and reactions. It presents psychodynamically informed action research and the contribution this can offer, drawing on the intelligence afforded by emotional experience, to the restoring of both meaning and agency."
- Maclean, L., et al. (2013). "Psychiatrists' experiences of being stalked: A qualitative analysis." Journal of the American Academy of Psychiatry and the Law 41(2): 193-199.
Excerpt: "This study is a qualitative thematic analysis of the free-text responses of 2,585 psychiatrists in the United Kingdom (approximately 25% of all U.K. psychiatrists), almost 11 percent of whom described being stalked according to a strict research definition, and 21 percent of whom perceived themselves as having been stalked. It demonstrates that threat minimization, negative psychological impact, awareness of vulnerability, and difficulty obtaining help were major themes in how psychiatrists viewed their experiences of being stalked. It shows how some psychiatrists coped better than others and makes suggestions for appropriate professional support."
- Palermo, M. T. (2013). "Under siege?: Psychiatrists and stalking." International Journal of Offender Therapy and Comparative Criminology 57(5): 523-525.
"Stalking is a crime. It is a crime of control and power. Despite the growing concern and the increasing awareness of the problem, notable difference may indeed be related to the abominable nature of the behavior, it is possible that it may be attributed to the relative ease with which the condition may be categorized and diagnosed. As so often happens in the imperfect language of psychiatry, or in the age-old problem of lumping and splitting in the arena of behavior problems, the stalking phenomenon is not as straightforward as is the case of a clearly abnormal paraphilic behavior. Stalking leaves those victimized emotionally scarred. It may persist for weeks, months, or even years. The impact on the victims may be highly destructive, with feelings of guilt, frustration, and embarrassment. Some professionals ask for police protection or even leave their profession entirely. However, most of them refrain from the former because of possible societal and professional misinterpretation connected with it. Posttraumatic stress disorder is not infrequent in stalking victims. The obsessional need for attention of a dependent person may be quite different from that of a narcissistically wounded individual and, depending on the person involved, each may require a different approach. As is the case at times in other mental health situations, the professional may need to decide whether to address the issue by thinking clinically or thinking legally."