Managing Stalking and Harassment in Clinical Practice

There is a conversation that happens in hushed tones at conferences, over coffee between colleagues, rarely in supervision, and almost never in formal training.

A clinician mentions that a former patient has been calling repeatedly. That someone has been appearing outside their office. That the emails haven’t stopped despite clear limits. That they’ve started varying their route home.

And the response from colleagues — even experienced ones — is often some version of discomfort, reassurance, and a change of subject.

We are excellent at teaching clinicians to manage the inner world of the patient. We are remarkably poor at preparing them for what to do when that inner world turns outward — toward us.

This post is an attempt to close that gap.

How Common Is This?

More common than we acknowledge. Studies estimate that 5–10% of mental health professionals experience patient stalking at some point in their careers. Female clinicians and those in solo private practice face the highest risk. Yet it remains one of the least-discussed topics in psychiatric and psychotherapy education.

Part of the silence is shame — a clinician being stalked may wonder what they did wrong, what they missed, whether the therapeutic relationship itself was a failure. Part of it is uncertainty about whether this is a clinical problem or a legal one, a personal problem or a professional one.

It is all of these things simultaneously. And it requires a response on all of these levels.

The Painful Paradox

The therapeutic relationship is built on exactly the qualities that can, in certain patients, activate dangerous attachment: consistent availability, warmth, emotional attunement, non-judgment, sustained focus on the patient’s inner life. We create a relational environment that is, for many patients, unlike anything they have experienced.

For most patients, this is transformative. For a small subset — particularly those with certain characterological organizations — this same relational intimacy can activate the very pathology we are trying to treat.

This is not a failure of the therapeutic relationship. It is a clinical reality that we must be trained to recognize and manage.

Recognizing the Spectrum Early

Stalking and harassment do not typically begin with a threatening letter or an appearance outside your home. They begin with behavior that is easy to minimize or rationalize.

The Early Warning Zone

Calls or texts between sessions that escalate in frequency

Emails that require extensive responses and arrive at odd hours

“Accidental” encounters near the office or your car

Gifts — sometimes thoughtful, sometimes excessive

Expressions of idealization that feel qualitatively different from ordinary positive transference

Requests for personal information, social connection, or contact outside the clinical frame

The clinical instinct — particularly for those of us trained in the relational traditions — is to explore the meaning of this behavior, to respond empathically, to hold the frame while remaining warm. This instinct is correct. But it must be paired with clarity.

The moment you notice a pattern, name it — in the room, therapeutically, without delay.

The Diagnostic Picture

Stalking behavior occurs across diagnostic presentations, but certain patterns appear with greater frequency:

Erotomania

Deserves special mention because it is the most clinically surprising. The patient — without any basis in reality — develops the conviction that the clinician is in love with them. This can emerge with little prior relational intensity and may be part of a delusional disorder or psychotic spectrum presentation. The delusional quality means that ordinary limit-setting and reality-testing interventions will be insufficient.

Borderline Personality Disorder

Presents a more familiar clinical picture: intense attachment, abandonment sensitivity, and splitting. Stalking behavior in BPD is most likely to emerge around termination — planned or threatened — or after significant limit-setting is experienced as rejection. The therapeutic relationship has become, for this patient, a lifeline. Their response to its loss mirrors earlier abandonment experiences, with all the desperation and rage those entail.

Narcissistic Personality Disorder

Generates a different clinical pattern: pursuit that is retaliatory rather than attachment driven. The clinician who has set a limit, delivered an unwelcome interpretation, or moves toward termination may be experienced as having delivered a profound narcissistic injury. The resulting behavior is not about longing — it is about grievance.

Dependent Personality Disorder

Produces panic-driven pursuit — frantic contact attempts that arise from terror of abandonment rather than hostility, but which can nonetheless become overwhelming and require clear management.

Paranoid Features

Can generate harassment through a different mechanism: the patient who misreads clinical actions as hostile, and whose resulting retaliatory behavior targets the clinician, their colleagues, or their licensing board.

Clinical Management: Five Principles

1. Intervene Early — Before You Are Certain

The costliest mistake is waiting until the behavior is unambiguous. By then, patterns are entrenched, documentation is thin, and options are narrower. The moment you notice concerning behavior, bring it into the therapeutic frame, consult a colleague, and begin a contemporaneous log.

2. Name It Therapeutically

The behavior must be addressed directly in the room. Not punishingly, not anxiously, but clearly:

In the Room

“I’ve noticed you’ve been calling between sessions more frequently over the past few weeks. I think it’s important that we understand together what’s happening for you during those times.”

This converts acting out into material. It invites the patient into the therapeutic work rather than simply constraining them. It also establishes — clearly and on record — that limits were communicated and the behavior was addressed.

3. Be Absolutely Consistent with Limits

Inconsistency in limit enforcement — even a single exception — resets the behavioral baseline. This is especially critical with BPD patients, where intermittent reinforcement powerfully amplifies pursuit behavior. If you have said you will not respond to after-hours calls except in emergencies, you cannot respond to an after-hours call that is not an emergency, no matter how compelling the framing.

This is not coldness. It is one of the most clinically important things you can do.

4. Document Everything, From the Beginning

Keep a dedicated log. Date and time every concerning contact. Save voicemails, emails, and texts. Note “accidental” encounters and their circumstances. This documentation serves multiple functions: it tracks the pattern over time, it protects you legally, and it creates a contemporaneous record that you acted thoughtfully and promptly.

Begin the log before you are sure you need it. You can always stop keeping it. You cannot reconstruct it retroactively.

5. Consult — Formally and Early

Consult a trusted colleague or supervisor early, both for clinical guidance and to create a legal record of your process. If the behavior has escalated significantly, a forensic psychiatry consultation is appropriate and often invaluable. Your malpractice carrier should also be notified — most have legal resources available and can advise on documentation and risk management.

The Question of Continued Treatment

This is both a clinical and an ethical question, and it deserves serious consideration rather than the assumption that continuing treatment is always the therapeutic ideal.

Is this treatment relationship still therapeutic for this patient — or is it now reinforcing the very pathology I am trying to treat?

In many cases, continuing treatment while clearly addressing the behavior remains the right course. In others — particularly when a patient’s pursuit has crossed into stalking, or when the therapeutic frame has been fundamentally and irreparably altered — termination with appropriate referral is both clinically and legally defensible.

Termination in these circumstances should include:

• Adequate advance notice

• A clear clinical rationale — not punitive, but honest

• Provision for medication continuity if applicable

• A formal referral to another provider

• Thorough documentation of the entire process

Protecting Yourself: The Dimension We Rarely Discuss

We train clinicians to protect their patients. We do not train them to protect themselves. This is an oversight we need to correct.

Physical Safety

• Ensure someone always knows your schedule when you are seeing high-risk patients

• Vary your route to and from the office periodically if you believe you are being followed

• Review what your office setting communicates — ground floor, visible parking, and predictable entry and exit patterns all increase vulnerability

• Have an exit plan for every session with a patient who presents elevated risk

Information Security

• Use a business address on all professional materials — never your home address

• Use a dedicated professional phone line separate from your personal number

• Audit your digital footprint annually: professional directories, LinkedIn, social media, and public records often contain more personal information than clinicians realize

• Many states allow address suppression for healthcare workers on voter rolls and court records — worth investigating

Legal Options

• A cease-and-desist letter from an attorney is frequently an effective early deterrent

• Restraining orders and protective orders are available to mental health professionals exactly as they are to any other citizen — and are appropriate when behavior constitutes stalking or harassment under state law

• File police report early, even if you are uncertain, it will lead anywhere — this creates a legal record of the pattern over time, which is essential if escalation occurs

What We Owe Each Other

There is a culture shift required here. We need to talk about this — openly, in supervision, in training programs, in peer consultation groups, and in professional associations.

The clinician experiencing patient harassment or stalking should not have to manage it alone, in shame, uncertain whether what they are experiencing is “really” a problem or a reflection of some clinical failure on their part.

It is not a clinical failure. It is an occupational hazard of a profession that asks us to be emotionally present, relationally available, and deeply human with people who are sometimes in profound psychological pain — and who sometimes, because of that pain, direct that pain toward us.

We can hold compassion for our patients and safety for ourselves simultaneously. These are not competing values.

The clinician who takes their own safety seriously is not less therapeutic. They are more therapeutic.

After forty years in this field, I have come to believe that the clinician who thinks ahead, names concerning behavior clearly and early, and asks for help without shame — is modeling exactly what we ask of our patients: honest self-awareness, appropriate self-protection, and the courage to name what is real.

— Robert E. Feinstein, MD

A note to readers

If this resonated with you, I’d welcome your thoughts in the comments below.

If you are currently navigating a situation like this, please reach out to a trusted colleague, supervisor, or your malpractice carrier. You should not be managing it alone.

Resources

• OSHA Workplace Violence Prevention Guidelines: osha.gov/workplace-violence

• Crisis Prevention Institute (de-escalation training): crisisprevention.com

• Threat Assessment Consultation: Contact your nearest forensic psychiatry department

• Your state psychiatric association for state-specific legal protections for healthcare workers

Robert E. Feinstein, MD

Psychiatrist, psychoanalyst, and Professor of Clinical Psychiatry at Northwell/Zucker/Hofstra School of Medicine. Founder of Empathian, a mental health education company. Teacher of the Year at six medical schools. Author of three Oxford University Press textbooks. This post is part of his ongoing series on clinical practice, training, and the human dimensions of psychiatric care.

empathian.com | Substack: Thinking About Personality Disorders