Patient Characteristics Should Determine Response to Threatening Behavior

The most effective responses to stalking, threatening, or harassing behavior (STHB) directed toward mental health professionals depend on the patient’s motivation and personality organization, suggests a study published in the American Journal of Psychotherapy.

In the study, researchers at the University of Indianapolis School of Psychological Sciences analyzed data from a questionnaire completed by 112 board-certified psychologists who had experienced at least one episode of STHB. The questionnaire covered the types of STHB the psychologists had experienced, the risk management strategies they used, and whether they felt those strategies had been effective in addressing the behavior.

“Our participants defined ‘effective’ based on their subjective sense that their response had improved the situation. This could mean a complete cessation of the STHB, but not necessarily,” lead author Aaron J. Kivisto, Ph.D., H.S.P.P., co-director of doctoral programs in psychology and an associate professor of clinical psychology told Psychiatric News. “One could imagine, for example, a situation where a patient continued to engage in harassing behavior, although the clinician felt the situation had improved as a result of improving her office security.”

The questionnaire also covered the primary psychiatric diagnoses of the patients who engaged in the STHB, what their motivations were (resentment or infatuation), and whether the patients had higher- or lower-level personality organization. Patients who had internalizing personality disorders, neurotic personality disorders only, or no personality diagnosis were coded as having higher-level personality organization. Those who had externalizing, borderline, or dysregulated personality disorders were coded as having lower-level personality organization.

Upon reviewing the data, the researchers found that the most common strategy, seeking assistance from colleagues or supervisors, was also deemed most effective by the respondents regardless of patient characteristics. However, the effectiveness of the second most common response, confronting the patient directly, was deemed effective by only about half of respondents, and in many cases it backfired.

“For patients motivated by resentment, direct confrontation made the situation worse in nearly two-thirds of cases,” Kivisto said. “By contrast, direct confrontation with [patients] with higher-level personality organization was perceived as improving the situation in about two-third of cases.”

In the paper, the researchers offer possible reasons why.

“The perceived effectiveness of these strategies may reflect these higher-functioning clients’ ego strength, which allowed them to tolerate direct conversations about the psychologist-client relationship and modify their behavior in response to minimally intrusive limit setting,” they wrote.

Conversely, when addressing STHB by patients with lower-level personality organization, protective strategies like increasing workplace security and seeking assistance from an attorney were seen as especially effective.

The bottom line is that risk management is not one-size-fits-all.

“Our study suggests that risk management responses should take into account patients’ motivations for engaging in STHB and level of personality pathology. There’s no single response likely to work for all patients all of the time, but the likelihood of responding productively might be increased when clinicians are sensitive to these contextual factors,” Kivisto said.

Prior research by Kivisto and others suggests that most mental health professionals, including psychiatrists, will be subjected to STHB at some point in their careers.

“Where the differences [among mental health professionals] likely emerge is in the variation in risk management resources available … in different settings. It’s one thing … to experience STHB in a secure inpatient setting, and another thing altogether in a home office,” Kivisto said.

To that end, Kivisto encourages all mental health professionals to be proactive in reducing risk.

“This includes seeking out training on managing potentially dangerous patients; developing a network for consultation that includes clinical, legal, and law enforcement professionals; and developing clinic policies that facilitate clear limit setting to protect clinicians confronted with patients engaging in STHB,” he said.

This study was funded by the University of Indianapolis. ■