My Patient, My Stalker Empathy as a Dual-Edged Sword: A Cautionary Tale

Introduction

When the comedy film What About Bob was released in 1991, I expected to be annoyed by yet another stereotype of the remote psychoanalyst, but nonetheless was curious enough to see it. I loved it. I enjoyed seeing the arrogant psychiatrist get his comeuppance from his lovable patient who stalked him. An adolescent patient of mine also had seen it and when I was about to take a summer vacation, she joked that I should not be surprised to spot her sitting on a blanket near me on the beach. I laughed at this healthy expression of both her affection for me and anger for leaving. Eight years later after I began to be stalked, I recalled the film. There was nothing funny about it then. I felt for that psychiatrist and understood his terror.

Evolutionary theory explains how man’s body and mind evolved (Pinker 1997). Like the other creatures in the animal kingdom, we are capable of violence to others and ourselves, but are different in one crucial way. We are “quite alone in our capacity to murder in cold blood, to torture one another and to threaten our species’ very existence” (de Zulueta, 1994, p.vii). The fight-or-flight response is the most obvious example but other anxiety states have also been speculatively traced to the evolutionary experience of predation (Ehrenreich, 1997; Marks, 1987; Marks & Nesse, 1994).

I was stalked for 11 months, at a time when there was little literature on the subject and when I was in no frame of mind to consider seeking it had there been. It was a horrific experience that induced a posttraumatic stress disorder and impaired my thinking more than I knew at the time.

When it began, I knew little about stalking, equating stalkers with serial killers who hunted their prey, usually celebrities. Although not all stalkers are violent, I did not know this then. I muddled my way alone through this experience, then sought forensic advice, and years later, after reading the literature on stalking that helped me deconstruct this experience, I was convinced that it is a very real occupational hazard (Kaplan 2006) for health and mental health clinicians. I came to understand why I had become such an enticing morsel for my predator.

Several years after it stopped, when I had some emotional distance from it, I wanted to understand just how and why it happened and how and why it stopped. I reviewed my notes and collection of letters, photographs, and tapes, which jogged my memory of this time. I realized I had done some things that inadvertently served to maintain the stalking relationship. I do not blame myself for this. There was nothing in my professional training to prepare me for being stalked; there was a lot in it that prepared me to use my empathy in dealing with my stalker. I concluded that my empathy and compassion had served as a double-edged sword, allowing my stalker to reveal her history of stalking psychotherapists and providing me with other critical information. But the combination of empathy for my stalker and fear of her served to maintain the stalking behavior.

The psychodynamics that characterize most mentally disturbed, violent offenders generally involve preoedipal character pathology expressed in personality and delusional disorders (Skoler 1998).

Kaplan said that there had to be something about obsessive love that resonates deeply within our collective unconscious.

When Empathy is Our Undoing

Forensic psychologist J. Reid Meloy said that “no good deed goes unpunished. Perhaps it is the clinician’s burden to experience this firsthand . . .” (Meloy, 2002, p. 230). Empathy is our “good deed” and it can turn on us.

Empathy, the capacity to imagine and understand emotions being experienced by another, works through the activity of mirror neurons in the brain that fire when we act and when we observe another performing the same action. That is, through mirror neurons, we can respond in synchrony with the behavior of others, mirroring their behavior, facial expression, and tone of voice as if they were our own (Rizzolatti, Fogassi, & Gallese 2001).

The therapist’s capacity for empathy is related to how the attachment relationship develops in treatment. Process and outcome research has found that success in psychotherapy is correlated not with a specific technique or theoretical orientation but with a factor related to attachment (Kroll, 1993), the “fit” between patient and therapist (Farber, 2000). For psychotherapists of any orientation, empathy is our stock-in-trade, building the bond of attachment. Without it, we have nothing.

Stalkers have severe attachment disorders (Meloy, 1992), making them desperately hungry for attachment. When our empathy builds the bond of attachment in someone starved for it, we can inadvertently become the victim of a stalker. Our empathy becomes a double-edged sword. Shakespeare used the idiom “hoisted by his own petard” to refer to a double-edged sword. As you read the account of my struggle with my stalker, you will understand how my empathy became my petard.

What is Stalking?

Stalking is characterized by excessive interest in developing closeness or intimacy. It involves repeated and persistent unwanted communications and contacts that create fear in the recipient. It is characterized by focused attention, increased energy, following behaviors, and obsessive thinking about and impulsivity directed toward the victim (Meloy, 1998). Stalking often begins with harassment, then escalates to more overtly threatening behavior.

Several psychosocial factors converge to produce stalking. Those who become stalkers suffer from social incompetence, isolation and loneliness, obsessional thinking, pathological narcissism, and extreme aggression. Some research suggests that stalkers may be more intelligent than other criminals (Meloy, 1998).

Stalking as A Criminal Offense

Therapists are accustomed to thinking about patients clinically. Coping effectively with stalking requires us to seek the help of forensic mental health experts and develop an ability to think forensically, a most radical shift in how we think about patients, not at all easy to make. It is a shift from wanting to be of help to the patient to protecting oneself from him.

Stalkers are often thought to be eccentric, harmless, lonely people, so that the terrible consequences of stalking are often underestimated. Stalking affects one fifth of all women and an unknown number of men—and the end result may be violence and bloodshed. Stalking is a very old behavior but a relatively new crime (Meloy 1999), and is recognized as a crime in North America, some European countries, Australia, and New Zealand (Meloy and Fisher 2005). Stalkers are criminals, a simple truth often ignored or not understood by mental health clinicians, law enforcement agencies, and the media.

A case of stalking that resulted in murder gave rise to a court decision in 1969 that would set a national standard of care for psychotherapists. The Tarasoff decision came after a University of California psychologist treating a male student became so fearful of his patient’s potential aggressiveness that he tried, unsuccessfully, to have the patient committed involuntarily. However, the therapist, in compliance with the ethic of patient confidentiality, did not warn Tatiana Tarasoff, a fellow student and the object of his patient’s malignant attention, of his concerns. To escape the unwanted, obsessive advances of the male student, Tatiana left for vacation and was murdered by him the day she returned to school. Her parents filed a suit against the therapist and the university for contributing to her death by not advising her of the severity of the situation. A 1976 rehearing of the case called for a legal duty to protect the intended victim, even if the patient is not verbally threatening to harm another. That is, the stalking behavior itself is threatening enough. “The protective privilege ends where the public peril begins” (Walcott, Cerundolo, & Beck, 2001. p. 329).

The first anti-stalking law in the United States was enacted in California in 1990 to address behaviors that are menacing, rather than annoying, and more dangerous than simple harassment. Stalking laws vary widely from state to state. In New York, where I was stalked, the stalking statute went into effect in 1999, making stalking a criminal offense, with four degrees of stalking that ranged from a misdemeanor crime to violent felony offense. Although stalking laws clearly consider it a crime, forensic experts believe that all threatening behavior, whether subtle harassment or overtly threatening conduct, should be felonies.

The Risk for Mental Health Professionals

Psychiatric patients have severe psychopathology that makes them more likely to become stalkers. The associated loneliness, isolation, and disordered attachment patterns predispose them to very dysfunctional attempts to connect with others. Meloy and Fisher (2005) found that

Although it was found that those who work with the more severely ill psychiatric patients at inpatient treatment settings are at particular risk for becoming victims (Galeazzi et al., 2005; Kaplan, 2006; Lion, 1998; McIvor, & Petch 2006; Orion, 1997), an Italian study found 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 in private practice (Mastronardi et al. 2013).

The deranged transference¹ that develops can precipitate the development of a delusional attachment. The behavior pattern can escalate to verbal threats, usually after the therapist confronts the stalker about his behavior, to violence, such as breaking into the therapist’s home or office, or physical assaults, thus creating a true psychiatric emergency.

Pope and Vasquez (2011) reviewed research that indicated almost one in every five psychologists reported having been physically attacked by at least one client. More than 80% reported having been afraid that a client would attack him. More than one out of four had summoned the police or security personnel for protection, and about 3% reported obtaining a weapon because they were so fearful. It has been found that 16% of social workers have been stalked at some time in their career by a client (Truman & Mustaine, 2011). Galeazzi et al. (2005) studied the incidence of stalking in a more varied group (N = 361) of professionals in Italy, including psychiatric nurses, psychiatrists, psychologists, or residents in psychiatry, art therapists and educators involved in psychiatric rehabilitation. A total of 122 respondents (34%) reported having been stalked. In 90% of cases the stalker was a client under the direct care of the clinician (N = 35).

Forensic Research in Attachment, Diagnoses, and Typology of Stalking

Forensic mental health professionals work with the legal system. Most receive training first in their own discipline, then further training in forensic mental health. The data on stalking has been culled from studies of stalkers and victims, including clinicians who were actively treating the patient-stalker or had treated him or her in the past. Comparing the studies is nearly impossible because of the many inconsistencies in the literature about types of stalkers.

The research shows that there is the convergence of five psychosocial factors in stalking: social incompetence, isolation and loneliness, obsessional thinking, pathological narcissism, and extreme aggression (Meloy, 1998). Stalking may begin years, even decades, after patient and clinician had contact with each other, making it apparent that the patient had become deeply bound to the clinician, who was quite unaware of the depth of the bond.

Forensic psychologist J. Reid Meloy has used attachment and object relations theory to provide a lens through which we can understand bizarre kinds of violence such as stalking and serial killing (Meloy, 1992, 1998; Meloy & Fisher 2005; Farber 2000, 2002).

Mahler’s separation-individuation theory holds that successfully navigating separation-individuation processes establishes an individual’s sense of separateness and uniqueness from the love object (Mahler, Pine, & Bergmann 1975). Empirical research supports Meloy’s (1996) theory that obsessional following represents major childhood attachment pathology, with developmental disturbances during the differentiation and practicing subphases, while research by Dutton and Golant (1995) suggests that disturbances during the rapprochement subphase contribute to pathological attachment in stalking. Most stalkers (63%) were found to undergo a change or loss of primary caregiver in childhood (Kienlen, Birmingham, Solberg, O’Regan, & Meloy, 1997), with many reporting a history of abuse by the primary caregiver. In addition, Kienlen et al. investigated precipitating factors to stalking, and found that 89% of the stalkers had significant stresses—usually losses—within seven months of the onset of stalking behavior. The authors think that stalkers try to compensate for a recent loss through pursuit of the object or stalking victim and may stalk as a means of revenge toward the victim, whom they blamed for the loss.

Stalkers are not cut from one cloth. In addition to the predominance of severe attachment disturbances, most present with a variety of major Axis I psychiatric diagnoses, usually schizophrenia or another delusional disorder, a mood disorder, or substance abuse or dependency, and Axis II personality disorders falling within the Cluster B group, such as histrionic, narcissistic, antisocial, and borderline personality disorders (Kienlen et al., 1997; Meloy, 1996; Zona et al., 1993). Many have both an Axis I and Axis II disorder (Zona et al., 1998). Those with bipolar disorder, when in a manic phase, may have grandiose beliefs, manifesting as delusions of power and special relationships.

There are several key dilemmas for the patient with borderline disorder. There is a strong wish for closeness and an equally strong fear of being engulfed by the other, thus losing a sense of self through closeness. This dilemma is associated with mood lability and instability. Those with borderline disorder cannot tolerate a sense of ambiguity and thus, their thinking is polarized. There are no in-betweens. They tend toward splitting of objects, and when treating patients with borderline disorder, clinicians may find themselves the focus of an idealization much greater than they initially thought. If this idealization is not sufficiently explored or is inadvertently encouraged by the therapist, it will become shattered. The patient will go into a rage of disappointment in which the mental representations of the therapist plummet drastically from perfection to monstrous, and the patient will treat the therapist accordingly. Therapists who overlook the powerful intimacy evoked by therapy may find themselves cast in the role of someone who had abused or abandoned the patient.

Stalker-Victim Typology

Zona, Palearea, and Lane (1998) have identified a stalker–victim typology comprised of a simple obsessional type, a love obsessional type, and an erotomania type. In the simple obsessional type, the victim and suspect have some prior knowledge of each other. Many such cases are outgrowths of a prior intimate relationship. The stalker’s motive may be to coerce the victim back into a relationship or to seek revenge. Other simple obsessional types involve nonintimate relationships from the work environment. The largest group in the simple obsessional type is a physician-patient, psychotherapist-patient, or teacher-student relationship (Zona, Palearea, and Lane 1998). The love obsessional type of stalking is characterized by absence of an existing relationship. The victim may be a celebrity but this is not always the case. The stalker usually has schizophrenia or bipolar disorder, which manifest as thought disorders and/or delusions, or the stalker may have a Cluster B personality disorder, such as antisocial, borderline, histrionic, or narcissistic, which focuses on dramatic, emotional, or erratic features (Zona, Palearea,& Lane 1998).

The erotomanic stalker has a delusion in which he believes and pursues the notion that the object of his affection reciprocates his loving feelings and/or fantasies. Despite its name, erotomania may not be overtly sexual. It is the notion of the romantic or spiritual union with an idealized true love that is craved. Delusions are notoriously difficult to treat. The patient may understand the therapist’s empathy to mean “I know you really love me.” The patient may interpret everything the therapist does as a coded message confessing eternal love and devotion, manifesting a psychotic disconnection from reality, a deranged transference.

Characteristic of erotomaniacs is la belle indifference, which explains how they can profess to love their victims and yet remain so indifferent to

In erotomania the illness often occurs during an acute psychosis, usually in patients with schizophrenia, or in a manic phase of bipolar disorder, or in a borderline regression to a psychotic state. The stalking can last many years; the stalker may stop stalking the current victim only when another potential victim seems more alluring.

To understand this severe narcissism, it is useful to understand the notion of the narcissistic triad—narcissistic entitlement, disappointment and disillusionment at the frustration of narcissistic needs, and narcissistic rage (Murray, 1964). Narcissistic rage and jealousy, the two most prominent emotions of the stalker, serve to defend against more vulnerable feelings of narcissistic injury, which are outside his awareness. Anger, motivated by envy, feeds the pursuit to damage or destroy that which cannot be possessed. Stalkers may be jealous of those the victim loves, thus placing the victim’s loved ones at danger. A parallel process of projective identification ensues, in which the stalker induces in the victim the obsession the stalker feels. James Lasdun (2013), a teacher who was stalked by a student, said the stalker’s ultimate revenge is that he intrudes himself into his victim’s mind and takes up so much “space” there that he gets the victim to obsess about him as much as he is obsessed with the victim. “I will get you to feel tormented in the same way that I feel tormented by you. I will get you to hate me in the same way that I hate you.” It is a form of projective identification, a process of communication by which the patient dissociates and projects his own unacceptable emotions into the analyst, who could then know experientially what the patient was feeling (Bromberg 1998).

There are, however, certain limitations in understanding stalkers in terms of diagnostic categories or typologies (Zona, et al., 1998). The exclusive DSM categories do not fit many stalkers. Research has indicated that cases of stalking are best understood in terms of the specific stalker– victim dyad. The coping techniques suited to one type of stalker may backfire with another. The only common denominator to all bullying stalkers is pent-up rage at victim, whom the stalker perceives as unnecessarily frustrating and witholding. The aim of stalking is to teach the victim a lesson, to punish (Zona, et al., 1998).

Stalkers are hungry for a safe and secure attachment, but they are incapable of forming one. They find the empathy provided by psychotherapists enticing because their disordered thinking understands it to mean that they will finally have the kind of love and attachment they crave.

There is no easy answer to coping with a stalker. It is best to identify the type of stalker, if possible, something a forensic expert is able to do. The basic good forensic advice is to avoid all contact with a stalker even as the victim takes precautions. But feeling ignored only inflames the stalker’s narcissistic rage, and may increase persistence, intrusiveness, and aggression.

Forensic Research on Gender

Most reported stalkers are male (although stalking of males by females may be underreported). Male stalkers are more likely to have a history of criminal offenses and substance abuse than female stalkers and are more likely to progress from explicit threats to physical assaults on the victim (Meloy, 1998). The motivations for stalking and the choice of victims are what distinguish female from male stalkers. Most female stalkers are motivated by an intense wish to establish an intimate relationship with the victim, who often is a professional helper (physician, psychotherapist, or teacher). The female stalker tends to seek intimacy with her victim. Women often target other women, usually stalking women who are older than they are, whereas men generally stalk women younger than themselves (Purcell, Pathe, & Mullen, 2001; Meloy & Boyd, 2003).

One-quarter of female stalkers had erotomanic delusions, believing that their victims were in love with them. This delusion often occurs during psychotic states, especially in patients with schizophrenia, bipolar disorder, and borderline personality disorder. The rest of female stalkers hope that their pursuit would culminate in a relationship, usually romantic or sexual, but sometimes they might include a friendship or mother-daughter type relationship (Meloy & Boyd, 2003).

The context of stalking differed between genders but the degree of intrusiveness and harm did not. Female stalkers are more likely to target someone they have known, and rarely target strangers. They are also more inclined to phone or write than physically follow their victim. “The most common form of stalking involves simple obsessional male stalking prior sexually intimate females” (Meloy, 1998, p. 5).

The Experience of Being Stalked

As you read my account of being stalked, certain sentences are in bold print to call your attention to actions that I think unwittingly served to maintain the stalking behavior.

The Introduction

In mid-December 1998 I received a phone call from a woman seeking psychotherapy. The first question she asked, unlike the usual ones about insurance or evening or weekend hours, immediately informed me that I was about to have a most unusual experience. “Are you pregnant?” This ludicrous question struck me as funny but I refrained from laughing and told her that her question told me that it was very important for her to know if I were pregnant. “Yes,” she said. Her previous therapist, Dr. Linda, had become pregnant and terminated treatment to go on maternity leave. She wanted to be certain it did not happen again. I assured her that I was not pregnant and we made an appointment for a consultation the following week at 1 P.M. I advised her that if she arrived early, not to be concerned if I did not answer the doorbell to my office (which was in my home); I would most likely be out to lunch but would be back in time for the appointment.

When I returned to my office, a car was parked there—stenciled with a picture of Mickey Mouse, along with a musical notation, the name, Doctor Susie, and a phone number. As the car door opened, I saw that the owner appeared to be in her late forties, dressed casually, and unkempt. When she entered the office, I commented that she had quite an unusual-looking car, at which she smiled broadly. She revealed that she was “an absolutely magnificent pianist and musical genius” who gave piano lessons to children. She also played piano at a local restaurant on Saturday nights.

Susie said she was a pathological liar but would try very hard not to lie to me. I was shocked by how truthful she was. It was my empathy that enabled her to be so honest. I asked her to tell me more about her experience with Dr Linda. She went to explain their last appointment had been three weeks earlier, and since then she has called and left daily messages at Dr. Linda’s home. The previous day was Dr. Linda’s due date and Susie wanted to be sure that she and the baby were alright. Dr. Linda had not returned any calls.

Susie volunteered that she never had held a steady job, but for a while she had run a golf course, been a coin dealer, and operated a candy warehouse, her father’s business. Although Susie went to a music college, she never graduated because she gave the orchestra “a hard time.” She said she had a Ph.D. from a “university without walls,” explaining that was why she calls herself Dr. Susie. Dr. Susie and Mickey Mouse were her logos, and she used them to decorate her car, her home, and her clothing. She wanted me to call her Dr. Susie, and she called me Dr. Sharon. She seemed to be quite intelligent, and there was something quite endearing and likable about her. I continued to call her Dr. Susie. She reluctantly disclosed prior psychiatric hospitalizations, that she had been diagnosed with bipolar disorder, and was receiving psychiatric disability payments. “But I’m all right now, much better,” she added. When I inquired about medication, she said that she had been on the mood stabilizer lithium, but no longer took it because she did not need it.

Susie explained she could accept that Dr. Linda could no longer be her therapist, but could not accept that Dr. Linda would not see her socially and would not return her calls. It felt to her as if Dr. Linda had died, a terrible loss.

I asked Susie to return the following week so that I could get a better sense of what had happened and think about how I might be helpful to her. The following week Susie arrived announcing that someone from Dr. Linda’s office had called to tell her the doctor had delivered the baby and both mother and child were doing well. Susie sounded sad as she recalled how much she had really liked Dr. Linda, and then became angry, saying that “all of a sudden, she became pregnant.” I commented that she seemed angry at Dr. Linda. “Yes, I am. All that baby can do is sleep and eat, pee and shit. I am so much more interesting than that!”

The Stalking History

During this session I discovered that 17 years earlier, Susie’s then four-year-old daughter was doing poorly in nursery school and a psychotherapist associated with the school referred both Susie and her daughter to an outpatient mental health center, where they were treated for a year. Susie became quite depressed and had suicidal thoughts, and was hospitalized for a few weeks. Ms. Storm, the outpatient therapist, had become very special to Susie, and upon discharge from the hospital, she returned to treatment with her for a few years—until Ms. Storm’s supervisor insisted that she stop treatment with Susie. Susie stayed in touch with Ms. Storm until beginning three-times-a-week treatment with Dr. Barbara, a candidate at a psychoanalytic training institute.

I discovered how special Dr. Barbara had become to her. Susie recalled that she had written songs about Dr. Barbara, performed in her home office, and bought Dr. Barbara expensive gifts (which went unaccepted). Suddenly and with no explanation, Dr. Barbara cut down the frequency of appointments to once a week. And then, after five and a half years of treatment, Dr. Barbara abruptly ended therapy without prior notice. Susie responded by ordering several pizzas in Dr. Barbara’s name and having them delivered to Dr. Barbara’s home around midnight. Susie began to follow Dr. Barbara and her family by car. It was apparent to Susie that Dr. Barbara thought Susie was dangerous and would come after her. Susie explained to me “If she thought I’m a stalker, I gave her something to be afraid of!”

Susie revealed that Dr. Barbara and her husband, a lawyer, went to the police with a copy of the DSM description of delusional disorder, erotomanic type. This resulted in the police visiting Susie and warning her to stop harassing Dr. Barbara. This enraged Susie. She exclaimed “An erotomaniac? What does she think I am, a fucking bulldyke?” Susie, in turn, reported Dr. Barbara to the psychology board for sexual misconduct. Dr. Barbara filed criminal charges against Susie, who was sent away to a state psychiatric hospital. Upon discharge, Susie began seeing Dr. Linda.

By the time Susie left the appointment, I felt as if I had been run over by a Mack truck. I was stunned that she presented herself to me as a relentless stalker with no awareness of how horrified I was to hear it. She seemed to feel listened to and heard empathically, and she seemed to assume that I felt for her and all she went through at the hands of the horrid therapists. I knew I had to protect myself and could never accept her for treatment. She distorted my listening in a way that was remarkably out of touch with reality, making it clear to me how psychotic she was. Despite my fear of her, I knew that I had to stall for time to think about how I could tell her that I could not treat her. I knew that refusing to treat her, as Dr. Barbara had done, or refusing to see her socially would enrage her, and I did not want to enrage her any more than necessary. I called Susie’s insurance company and they revealed nothing of her stalking history, although I was certain they knew of it.

I decided to curb my usual candor and directness; I lied about why I could not see her for treatment so that it might not feel so much like a rejection. I told her that she deserved a more intensive treatment than my schedule allowed, and that the proper treatment required a hospital based program, where she could receive both psychotherapy and medication, including a mood stabilizer. Susie was certain that she did not need to be on a mood stabilizer. I suggested that she was not the best judge of that. She seemed stunned and left. The next day I received a managed care authorization for further treatment, with a diagnosis of Bipolar I. I also received a curt, angry letter from Susie requesting her medical records, which I sent to her.

How the Therapist Became a Therapy Pen Pal

Several weeks later, toward the end of January 1999, I received a very long phone message from Susie, saying that she was trying to channel her anger at me into something more constructive by writing a report about me. She also said she was revising the song she had written about Dr. Barbara and sang it to my answering machine. She expressed some remorse about what she had done to Dr. Barbara. I was struck by how much more lucid and reflective she seemed.

Soon after, I begin to receive numerous hang-up phone calls at my office and home phones. I tried unsuccessfully to have the calls traced. Then I sent Susie a brief letter, saying I believed she was making those calls, and insisted she stop. Days later, I received a letter from Susie in a far more thoughtful, kinder tone, with an Indian Head penny enclosed for luck. She said after reading my letter, she had thrown out all her treatment records and police reports about her interactions with Dr. Barbara. Susie said she intended to work on her therapy song album, named after a song about her treatment in Dr. Barbara’s office, and said there would be a song in the album written for and dedicated to me.

After the letter, I began to receive several long phone messages from Susie, asking me to reconsider seeing her for treatment. I did not return her calls. Numerous hang-up phone calls followed.

By now, Susie had invaded my mind; I realized that I had become the victim of a stalker. I recalled that an actress had been killed by her stalker, and when I awoke up each morning my first thoughts were: “Is this the day she’ll kill me? Is it the day she’ll kill my husband? Or my son?” I wished I did not have a home office. Each time I saw a car the same color and make as Susie’s, my heart pounded.

Then I received a phone message from Susie: she had found another therapist. I was jubilant. A few days later I sent her a letter reiterating why I could not see her and wishing her well in her treatment. I received a very angry letter on stationery emblazoned with Susie’s favorite cartoon character, Mickey Mouse.

In April, I received a summons to appear in small claims court. Susie was suing me for $200. She claimed I owed her money because she could have been giving music lessons and earning income rather than seeing me. I began to panic; I knew sending her any amount of money would not appease her, and I was afraid to confront her in court, afraid she would attack me or my husband or anyone who accompanied me.

In a moment of lucidity about this case, I remembered that a member of one of my professional organizations was not only a clinical social worker but also a forensic social worker in the New York City court system, so highly acclaimed that there had been an article about him in The New York Times (Kleinfeld, 1998)². He suggested I file a harassment complaint with the local police and request an order of protection. I did that the next day. The order of protection was denied. Because Susie never overtly threatened me, I was told that there was nothing they could do. I was so frazzled that it did not occur to me to tell the police of her stalking history, criminal charges, and resulting hospitalization, which might have expedited matters.

Weeks later, early in May, Susie called, asking to settle out of court. I refused. She asked for an apology from me for the things I said in my treatment record. About this time, I received a call from Hillel. He had spoken to someone in the district attorney’s office about getting the local police actively involved in a new case of stalking by someone with a history of the crime. Although this was somewhat reassuring, it made me even more anxious; it meant that this really was this serious.

Reconsidering my interactions with Susie and trying to appease her, I called her and apologized for my words in her record that hurt her. In a conciliatory and reflective tone, she said that she been so angry at Dr. Linda for ending treatment that she took it out on me, and she said she would drop the small claims court case.

The following day, a woman from the district attorney’s office called and offered to look up my stalker’s history, and asked for her name. I froze, fearful that I would be breaching the ethic of confidentiality by disclosing Susie’s name. The woman impatiently advised that if I did not tell her the name, she could not help me. As soon as I provided Susie’s name, the woman recognized it, and said there was a pretty thick file about Susie. The woman remembered prior cases against Susie, and advised me to call her if the stalking persisted. If it did, she promised she would get the local police to pay Susie a warning visit.

Despite Susie’s assurances that the case would be dropped, I received a letter from a local mediation center asking me to appear at a hearing. Feeling more empowered, I responded that I would not participate. A week later, I received a letter from Susie apologizing and telling me that she had dropped the small claims charges. In the letter she explained that she realized she was unwell; she was remorseful for her behavior. When she wasn’t having acute symptoms, she was lucid. Her new therapist was trying to find a psychopharmacologist to help with treatment, and “if you ever see Dr. Barbara, please tell her for me I miss her and I’m sorry.”

She also included a business card, on the back of which she had hand written a “free coupon” for dinner for two any Saturday night for “Dr. Sharon and guest” at a restaurant where she played piano.

I sent her a note reiterating that I did not have contact outside my office with people I have seen for consultation or treatment. A few days later I received a note from her saying that she has begun treatment with another therapist. I sent a letter in support. A few weeks later I received her business card with a note thanking me for my letter, asking me yet again to be her guest for dinner on a specific date in June. Also enclosed was a printed coupon, suggesting Susie had gone to the time and trouble to have it printed. Again, I sent a letter reiterating my policy of no outside contact.

Two weeks later I received a package of photographs of various items decorated with Susie’s favorite cartoon character and her Mickey Mouse logo. This included a photo of her car, a fireplace mantel with figurines, a stained glass window of the cartoon, a wall mural, her recording studio, and her boyfriend, wearing a tee shirt her distinctively embellished with the cartoon character and logo. Because I was feeling supported by the forensic contact and was no longer so fearful of her, I did not feel compelled to respond to pacify her.

There was no contact in July and August; I began to relax a bit. On vacation, I came across two books, Barbara Ehrenreich’s (1997) Blood Rites: Origins and History of the Passions of War, based on the prey-topredator paradigm, and psychiatrist Doreen Orion’s (1997) personal account, I Know You Really Love Me; A Psychiatrist’s Journal of Erotomania, Stalking, and Obsessive Love. As frightening as Dr. Orion’s story was, it helped me to realize that not all stalkers are of the same stripe; my stalker was not as violent or intrusive as Dr. Orion’s. My stalker was not a serial killer; she was a serial stalker.

Early in September I received a note from Susie, saying her father died a month and a half before, along with a very moving tape of a song she wrote for him: “Daddy, I hardly knew you.” I listened to it and cried. By this time I knew that I should not respond to her overtures but it seemed so cold and heartless not to send a condolence note. With most the most conflicted of feelings, I sent her a brief note. I received a letter from Susie telling me that the song she had written to her father would be played on a radio show. The letter continued, “Thanks for your continued empathetic support. I know we’re little more than strangers technically, but feel for myself that you are my therapy pen pal. Be in touch soon.” She signed herself, “Dr. Susie, musical genius.”

A few weeks later a message was left on my answering machine at midnight. A male voice, identifying himself as a friend of Susie, told me to tune in to a syndicated radio show at four A.M. to hear the song on national radio. I felt enraged.

I continued to receive hang-up phone calls through early November. Then I received a call from Susie, once again asking me to treat her. Immediately I told her clearly and firmly that there was no role I could play in her life. “I cannot be your friend. I cannot be your therapist. Do not call, write, send me mail, photos, anything. I do not want to hear from you or about you ever again.” I was about to ask “Do you understand?” but quickly realized that this might invite a dialogue. I conveyed clarity, forcefulness, and anger with no effort to be kind.

It was, paradoxically, the most truly empathic response to her. I had put myself in her shoes and spoke to the level of her pathology and deranged transference. It was a long overdue dose of reality testing that apparently punctured any delusion she might have had about me. It was truly an “AHA!” moment for me. I had come to understand that an empathic response is not necessarily warm nor compassionate (Hopenwasser 2008), nor must it sound kind. It must speak to the stalker’s level of ego-and self-organization. Finally, I had done that. I never heard from her again, although I still get occasional hang-up calls, which may or may not be from her.

The Stalker’s Lack of Empathy

Michael Lyvers (1999) tells us that social animals use empathy to great evolutionary advantage. Empathy helps them read each other and figure out how to act. Empathy is a visceral, inborn tendency to identify with other human beings but our tendencies toward empathy can be blocked by anger and hatred.

My stalker was grossly lacking in empathy. When she was less angry and less manic, she was capable of more humane interactions. Her lack of empathy contributed to her being branded a criminal and hospitalized involuntarily.

The manic defense plays a prominent role in the lives of those terrified of grief and sadness (Akhtar, 2001). Susie’s manic stalking of psychotherapists made her feel omnipotent and invigorated; it was a powerful defense against depression. Like many patients with bipolar disorder, Susie refused mood-stabilizing medication because she did not want to give up this manic exhilarating experience.

The Psychopathology of optimal Distance

A concept that is useful in considering the stalker’s psychopathology is that of optimal distance, which refers to a psychic position that permits intimacy without loss of autonomy and separateness without painful aloneness (Akhtar, 1992). It derives from Mahler’s view of optimal distance as “a position between mother and child that best allows the infant to develop those faculties which he needs in order to grow, that is, to individuate” (Mahler, Pine, & Bergman, 1975, p. 291). During the rapprochement subphase of separation-individuation, no distance from the mother is satisfactory. “Closeness soothes narcissistic wounds but stirs up the dread of fusion. Being apart enhances pride but leaves one lonely” (Akhtar, 1992, p. 30). During separation-individuation, a child may develop a fantasy of there being an optimal distance between himself and the mother, a fantasy formed from knowledge of childhood realities such as pets on leashes, farm animals on tethers, and pre-school children on outings holding onto a rope held by the teacher.

It would seem that each stalker has an optimal distance to his victim that should be understood on a case-by-case basis. My stalker seemed not to have a need to intrude physically into my home. She seemed to want me to be at some proximity that she could control, by face-to-face meetings, by phone, by having a meal in her presence, or by my listening to recordings of her music. She wanted me to be the optimally available mother of rapprochement that she apparently never had.

Processes that Fueled the Stalking

Presented here are a few processes that can shed further light on what happened between my stalker and me. The original concept of projective identification is understood to be an unconscious process of communication (Klein 1946), while Bromberg (1998) regarded it as a dissociated form of communication in which the patient could detach and project his own unacceptable emotions or thoughts onto the analyst, who could then know experientially what the patient was feeling. In contrast, Grinberg (1979) presented the concept of projective counteridentification in which the analyst is the passive object of the patients projections and introjections. The patient’s emotional response may be quite independent from the analyst’s own emotions, which appear largely as a reaction to the patient’s projections that are likely to be extremely intense. The intensity of this mechanism is usually related to traumatic infantile experiences, during which the patient suffered the effect of violent projective identifications.

When counteridentification occurs, normal conmmunication between the patient’s and analyst’s unconscious will be disturbed, and the unconscious material rejected by the patient will be violently projected into the analyst, who suffers its consequences.

Some very difficult patients have constitutional problems of excessive aggression and envy along with traumatic childhood histories, resulting in persecutory fantasies of an omnivorous maternal object. They may rely on manic defenses to avoid the pain of loss and the persecutory feelings of envy (Waska, 2000).

Another illuminating process is that of the analyst’s incorporation of an invasive object (Williams, 2004). Very severely disturbed patients may create a sense of the therapist’s being invaded. With some stalkers it is more than a sense of being invaded. Some stalkers literally break into the therapist’s home or office. “An object that invades in this way, it is suggested, experiences a compulsive need to expel unbearable states of mind using others as a repository” (Williams 2004, p. 1333). When the analyst has incorporated an invasive object he is likely to feel unstable, controlled, alienated, possessed, ill, or diseased.

Stalking and Addiction

There is evidence that psychoactive substance use disorders and certain behavioral addictions, such as bulimia nervosa, pathological gambling, and sexual addiction, share an underlying biopsychological process of addiction (Goodman, 2008). Meloy and Fischer (2005) illustrate the parallels between stalking and addiction. They discuss data from neuroimaging (fMRI) studies of romantic love that suggest stalking may be associated with heightened activity of subcortical dopaminergic pathways of the brain’s reward system, perhaps in combination with low activity of central serotonin. They propose that this set of neural correlates may contribute to the stalker’s focused attention, increased energy, following behaviors, obsessive thinking, and impulsivity directed toward the victim. They also discuss several biopsychological phenomena associated with romantic rejection, including the protest response, frustration attraction, abandonment rage and mate guarding. They conclude that stalking may be associated with a specific set of biological components and they offer suggestions for further research into this pathological emotional/motivational state.

In addition, stalking, romantic love, and addiction are marked by kindling phenomena. Just as a spark applied to small pieces of kindling wood will ignite a log that eventually can turn into a roaring bonfire, sensitization or kindling in the brain has far-reaching consequences for psychopathology (Kraus, 2000; Post & Weiss, 1998; Marra, 2005). The more episodes that occur, the harder it is to treat each subsequent episode (i.e. a fire that has spread is harder to put out and can readily spread further). Those who are highly emotional have had their emotionality kindled, and so they respond with much emotion to minimal stress.

The stalker’s emotionality seems to take on a life of its own. This is seen most clearly in rapid-cycling bipolar disorder, in which future episodes of depression, hypomania or hypermania seem to occur by themselves with greater frequency (Hornbacher, 2008; Farber, 2012; Ode, 2009). Writer MaryaHornbacher (1998, 2008), who suffered from bulimia, self-mutilation, and rapid cycling bipolar disorder, said “Over time, you start to lose the chemical ability to fight off episodes, so the earlier in a person’s life we can diagnose, the better their chances of avoiding future episodes” (Ode, 2009).

Individuals who are in love show the basic symptoms of addiction, including tolerance, dependency. cravings, withdrawal, and relapse. As tolerance builds, the lover feels compelled to interact with the beloved (or victim) more and more frequently. If the beloved breaks off the relationship, both the lover and the stalker show the common signs of withdrawal, including depression, crying, lethargy, anxiety, insomnia or hypersomia, loss of appetite or binge eating, irritability, and chronic loneliness. Like most addicts, rejected lovers and stalkers may go to degrading lengths to procure the beloved. I suggest that when the relationship with the stalker is decisively ended, the stalker, in a very real sense, must detoxify from an addiction to the relationship and is prone to relapse. Long after the relationship is over, the association with the “people, places, and things” that promote relapse can trigger both the lover’s and stalker’s cravings, and it initiates obesssive thinking and compulsive pursuit to achieve contact with the beloved.

Conclusions

There is only one thing more painful than learning from experience, and that is not learning from experience.

—Archibald MacLeish

I was stalked for 11 months. Had I known then what I know now, I would not have responded directly to my stalker, and it might have shortened the time of suffering. My experience demonstrates the wisdom of forensic risk-management advice, that the most effective responses to stalking are no response or to convey very clearly to your stalker that you are not interested in having any relationship with him (Proctor 2003).

I had intuitively arrived at what security expert Gavin de Becker (1999) calls the detach and watch plan. It is common for restraining orders to precede violence. In stalking cases, a dynamic of engage and enrage, detach and watch is safer. The victim makes one explicit, unconditional rejection and stops all contact.

Forensic experts emphasize the importance of a comprehensive diagnostic workup to inform attempts to cope with stalking. Such a comprehensive diagnosis does not neglect both personality and substance abuse disorders, even in the face of a florid Axis I psychosis. In addition, it is also important to classify the type of stalker-victim relationship that has been established. It was not clear what type of stalker I was dealing with. She may have been a love–obsessional or an erotomanic type. If she were the erotomanic type, then she had the delusion that I reciprocated her feelings and wanted to be with her as much as she wanted to be with me. Here Strauss’ (1991) understanding of the treatment of delusions is most informative.

Strauss (1991) discussed the nature of delusions in terms of five characteristics, which are summarized as emerging from normal thoughts and fading again, with multiple causes, evolving into other phenomena, having connections to a separate self, and having affective, perceptual, as well as cognitive aspects. That is, delusions can undergo qualitative changes into other phenomena, e.g., hallucinations, and vice versa.

In the treatment of someone with a delusion, the clinician must place himself or herself in the patient’s shoes, using the degree of interpersonal closeness to titrate the intensity of the delusions the person is having. “If the clinician becomes too distant, the delusions increase. There appears to be an optimal level of interpersonal closeness/distance in relation to delusional intensity in such patients” (Strauss, 1991, p. 58). In my continued contact as the patient’s “therapy pen-pal” I became interpersonally close, sending a welcoming message about a continued relationship. In my last contact with her, a clear rejection, I had finally reached that optimal level of interpersonal closeness/distance that radically altered the intensity of her delusion. The forensic assistance I had helped me to be no longer afraid of her.

There seem to be two possible outcomes of my final response to her. The first is that it drastically shattered her sense of self-esteem and in order to feel better, she found another victim to be delusional about and to stalk. The second one is that given that she had at times struggled, albeit unsuccessfully, against acting upon her destructive impulses, and had superior intelligence as well as some insight, she might have been able to use this as an opportunity to struggle once more against these impulses, perhaps this time more successfully than in the past. If she were to adhere to prescribed mood-stabilizing and antidepressant medications, and become involved in a psychotherapy relationship that supported this development, this might make this positive outcome possible.

Although most stalkers deny that their behavior is threatening to the victim and declare that they are motivated out of love or some similar cognitive distortion, this is not true for all stalkers; each stalker must be assessed and treated individually (MacKenzie & James, 2011; Tschan, 2005; Vergel, 2009; Mullen, Pathe, & Purcell 2008). For treatment to be successful, the patient must come to accept the reality that he is a stalker. The focus of therapy should be on factors that sustain the stalking, such as the stalker’s narcissistic sense of entitlement, and the patient must confront the self-deceptions which deny, minimize, or justify the behavior (Mullen et al 2008).

Curiosity about my experience of being stalked led me to explore this subject. I have learned a great deal the hard way from my experience, and while I would be interested to know about the outcome with my stalker, I will not allow my curiosity to get the better of me.