Stalking by definition is repeated acts, experienced as unpleasantly intrusive, which create apprehension and can be understood by a reasonably prudent person to be grounds for becoming fearful.¹ As a consequence of stalking, an individual gets harassed. By legal definition,² a person harasses another where a) he or she, by his or her acts intentionally or recklessly, seriously interferes with the other's peace and privacy or causes alarm, distress or harm to the other, and b) his or her acts are such that a reasonable person would realize that the acts would seriously interfere with the other's peace and privacy or cause alarm, distress or harm to other. Stalking behaviour is particularly significant among psychiatric patients that put mental health professionals at a greater risk of being victimized. A study³ conducted in a large mental health organization revealed that consultants were stalked mostly by male stalkers with diagnosis of personality disorder and major mental illness. It was concluded that stalking posed an important occupational risk factor for psychiatrists. Researchers on the subject have argued about its underrecognition and laid strong emphasis on the fact that health care professionals were at a greater risk than the general population.⁴ The impact on healthcare professionals is in the form of increasing stress, fear, helplessness and disenchantment.⁵ Study⁶ on epidemiology and characteristics of stalking depicts lifetime prevalence rates of stalking victimization ranging from 12-16% among women and 4-7% among men. It has serious social, economic, social and psychiatric consequences. There is an associated risk of violence and even homicide. A report⁷ commissioned by the Royal College of Psychiatrists, UK has found that 10.7% of its members have been victims of stalking, while one in three had suffered harassment under legal and academic definitions of the term. The survey indicated that 51 psychiatrists, nearly one a week, experienced a new case of stalking every year. Another survey⁸ revealed that in 90% of cases, the stalker was a client under the direct care of the clinician, median age of stalkers was 34, predominantly single, unemployed, 45% had a psychotic disorder, 11% had a mood disorder and 37% had a personality disorder. In the same study, it was noted that the most common methods of harassment adopted by the stalkers were intrusive approaches, telephone calls, loitering near the victims, maintaining surveillance, sending letters, following the victim, violating property, spreading gossip and sending unwanted material. About 20% of victims of stalking consult doctors about mental or somatic symptoms but often fail to inform them about the stalking.⁹ Stalking is an international issue but much less frequently understood and reported from the developing countries. Pakistan is a developing country with a history of human rights violation and social injustice. The general ambience is not conducive for medical practitioners as they are often under the threat in terms of personal security. In the recent past, there was an era where 'doctor killing' was quite rampant. Physical violence towards doctors by patients has often been reported in the media but stalking by patients to the particularly vulnerable group of mental health professionals is generally not reported. However, there are anecdotal reports that confirm the existence of this problem with serious magnitude. There are no current substantial studies conducted in Pakistan on this issue, hence no guidelines are available either from the regulatory body or the psychiatric society. A number of mental health professionals thus suffer in silence with no clear directions as what to do under the circumstances. There is also a built in fear in view of stigma attached to the discipline for discrimination, allegations and social complications. Reverting back to western countries in order to gain further insight into this issue, in Canada, stalking is defined under general heading of Criminal Harassment and falls under a Criminal Code category.¹⁰ The penalty is with imprisonment for a term not exceeding five years. The law does not delineate stalking behaviour directed to health professionals per se. The British System does have defined Anti-stalking Law.¹¹

Coming back to the local scenario, anecdotal reports mentions that the type of stalking that the mental health professional face in Pakistan is by means of cyberspace, telephone, letters, cards, gifts and by seeking multiple appointments for consultations. The general characteristics of stalkers are that they are rejected, female predominance, early or late adulthood, and histrionic. Often they would have received diagnosis for some form of mental disorder, less frequently identified as psychotics and personality disorders and are largely unrecognized by the treating psychiatrists. A number of ethical issues and social complications may arise for practitioners who become the victims of harassment besides mental health morbidity and hence, this issue needs attention and guidelines.

There is a need for proper identification of this problem through health education, media reporting and empirical studies. Guidelines can be devised by the medical council or the professional bodies. There is also a dire need for anti-stalking laws in the country. If this problem is neglected, there is likely possibility that we may see another epidemic of harassment, this time by the patients towards the mental health professionals. What do you say?

1.Mullen PE, Pathe M, Purcell R. Stalkers and their victims; 2nd Edition; Cambridge: Cambridge University Press, UK 2000; p: 2-5.

2.Legal definition in Ireland (Harassment) Non-fatal Offences against the Persons Act 1997, section 10(2). (Online) (Cited May 1, 09). Available from URL: www.sheilapantry.com/fulltext/samples/osrd/ir0034.asp.

3.McIvor RJ, Potter L, Davies L. Stalking behaviour by patients towards psychiatrists in a large mental health organization. Int J Soc Psychiatry 2008; 54: 350-7.

4.Pathe M, Mullen PE, Purcell R. Patients who stalk their doctors: their motives and management. Med J Austral 2002; 176; 335-8.

5.Sandberg DA, McNeil DE, Binder RL. Stalking, threatening and harassing behaviour by psychiatric patients toward clinicians. J Am Acad Psychiat and Law 2002; 30: 221-9.

6.Dressing H, Kuehner C, Grass P. The epidemiology and characteristics of stalking, Current Opinion in Psychiatry, 2006, 19; 4: 395-9.

7.Rose D. Stalking by patients is a real menace for psychiatrists, The Times: January 25, 2008. (Online) Cited April 24, 09. Available from URL: www.timesonline.co.uk/tol/life_and_style/health/article3248156.ece. 

8.Galeazzi, GM, Elkins K, Curci P. The Stalking of Mental Health Professionals by Patients. Psychiatric Services 2005; 56: 137-8. 

9.Dressing H. Stalking-a significant problem for patients and psychiatrists. Br J Psychiat 2006; 189: 566.

10.The Canadian Criminal Code. (Online) Cited April 29, 09. Available from URL: www.wiredsafety.org/cyberstalking_harassment/canada/ca_stalkinglaw.html.

11.British Anti-stalking Law. (Online) Cited April 24, 09. Available from URL: www.lawgazette.com.sg/2002-2/Feb02-feature2.htm.