Help for the Helping Professional: Risk Management Strategies

The success of psychotherapy is correlated with the attachment between client and 
therapist in the therapeutic relationship (Farber, 2015). According to Dr. Farber, 
empathy and building the bond of attachment is our stock-in-trade as mental health 
practitioners. When empathy builds the bond of attachment with someone starved for 
connection, a therapist may inadvertently set themself up to become a victim of a 
stalker (Farber, 2015).

Safety Risks Often Discounted
When a therapist embarks on training, they are imbued with ethical principles to 
guide the delivery of services. One crucial ethical principle is to take reasonable 
steps to avoid harming their clients and minimize harm where it is foreseeable and 
unavoidable. However, training programs do not adequately equip mental health 
providers to take reasonable steps to mitigate the safety risks inherent in working 
within the mental health field. Unfortunately, therapists often lack support when 
they talk about the dangers faced in their profession. Therapist safety concerns 
are often met with the sentiment that “it comes with the territory.” Therefore, 
they must deal with and manage risks or even active threats alone. People often 
have the same view when nurses, physicians, firefighters, law enforcement officers, 
and service members talk about the risk they are managing. The dismissal of the 
severity of risk that mental health providers take on reduces their access to 
resources and tools to reduce that risk successfully. An industry designed to help 
individuals who struggle with the perpetration of harm against others does not negate 
the provider’s right to be free from harm. Stalking, in particular, has become a major 
concern for therapists in this technological boom.

Stalking and Therapists
Stalking is a prevalent phenomenon with significant negative psychological, physical, 
social, and financial consequences (Sheridan, Adrian, & Scott, 2019). According to 
the U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics 
(2015), a greater percentage of females experience stalking than males. Additionally, 
2.2% of females compared to 0.8% of males experienced at least one stalking victimization 
within a 12-month period. Storey and Hart (2017) correctly documented that prevalence 
estimates are considerably higher for individuals holding certain professions. 
Mental health professionals (psychologists, psychiatrists, counselors) have higher rates 
of stalking than other professionals (Galeazzie & DeFazio, 2006; Store, 2012). 
Nearly 19.5% of psychologists report being stalked in the context of their professional 
lives (Lion & Herschler, 1998; Smoyak, 2003; Whyte et al., 2011). Additionally, 32% to 64% 
of counselors have been victims of some form of harassing behavior from a client 
(Romans, Hays, & White, 1996; Store, 2016). 

Health care workers and mental health care workers have been stalked by their clients, 
as documented in several studies from the United States (Romans, Hays, White, 1996; Gentile 
et al., 2002) and abroad (Galeazzi, Elkins, & Curci, 2005; Abrams & Robinson, 2011). In fact, 
research has demonstrated that co-workers also stalk service providers, but the percentage 
of stalking from service users is higher (Ashmore et al., 2006). This means that, 
although anyone can potentially be stalked within their professional environment, mental health 
professionals are at a higher risk of being stalked by their clients than others in other 
work environments.

Reducing the Risk
Specific risk reduction and threat management interventions are needed to ensure that
therapists have effective risk management tools and risk reduction policies at their 
disposal. Why is risk reduction necessary for professionals in mental health? According 
to Galeazzi, Elkins, & Curci (2005), mental health professionals who have been stalked 
by their clients have left the field, reported lost time from work, and moved to a 
different state to escape their stalker. They have also carried weapons to work in 
response (Pope, & Vasquez, 2011). The impact of stalking on providers is substantial. 
There is limited training currently available about how to manage stalking in one’s 
mental health career. The call is to have adequate systems in place to reduce the 
likelihood of stalking and appropriately respond when it does occur. In the age of 
technology, stalking risks are increased due to clients having multiple ways to contact
their practitioners and access their personal information online. Mental health providers
may face online stalking or be stalked by phone or email in addition to unwanted physical 
presence in the professional or personal environment. Here are six risk 
management strategies: 

#1 Implement Client Consultations
Harm reduction involves the initial assessment of risk in your professional environment. 
Therapists are trained to assess risk for client harm to self and others but often do not 
view harm to themselves as a potential area to consider. Professionals working in a private 
practice setting, group forensic setting, or within a hospital setting will have different 
risk factors to consider. For example, a provider working in an independent private practice 
may wisely implement more stringent policies to reduce risk than a provider who works within 
a health system and has access to on-site security guards and other professionals that may 
serve as a risk management team.
When possible, all new clients should participate in an initial consult to determine if this
treatment setting will offer the most effective treatment and evaluate any potential risk 
factors that the provider or system may have to manage. Clinicians are encouraged to refer 
individuals to a higher level of care and to agencies that can responsibly manage harm potential 
more effectively as needed. For example, a client with a history of stalking may need to work 
with a provider in a larger treatment agency versus a solo provider in private practice in order 
to minimize the risk of intimate attachment that may lead to stalking behavior. The risk 
assessment process can inform the policies a provider creates for the safety of everyone involved. 

#2 Provider-Client Technological Access
Therapists should use business phones and office email systems versus their personal cell 
numbers and email addresses to communicate with clients. At the beginning of treatment, 
therapists should outline communication policies, specifically what content is to be 
communicated electronically (i.e., scheduling new appointments of cancellations versus 
crisis intervention) and time parameters for communication with clients (e.g., during 
business hours only). One’s communication policy should, of course, contain a limits 
of confidentiality policy and discussion of how the professional will handle violations 
of the communication policy. A communication policy that outlines limits to professional 
responsiveness and limitations to the depth of electronic communication can minimize safety 
risk by establishing clear, professional boundaries.

#3 Maintain Communication Boundaries
Therapists should adhere to the communication policies they set forth for their clients. 
If a provider establishes that they will not communicate with clients after business hours via 
email, they must not violate their own policy. If a professional indicates that they will not 
address clinical issues via email, they must follow through on that commitment. Psychotherapists 
violating their own communication policy may condition their clients to violate the policy as well. 
Boundary violations from either party increase safety risks.

#4 Seek Support from Colleagues
Mental health providers have the privilege of helping individuals who struggle with a variety 
of emotional and behavioral concerns. Given the nature of this work, risk cannot be prevented,
but it can be reduced and managed more effectively with support. Not unlike individuals seeking 
services for distress due to being threatened, clinicians also need support as they implement 
protocols to reduce their risk or manage active threats. The inherent risk of the mental health 
profession does not negate the need for support in the face of risk management or active threat 
reduction. I encourage therapy for therapists to help them manage the distress of working within 
risky situations or addressing active threats.

#5 Individualized Action
When therapists are managing an active stalking threat, they must take care of themselves the 
same way they take care of others. They must seek support from other mental health 
professionals to determine ways to work within the boundaries of ethical mandates while 
preventing harm to themselves. They may also need to seek the assistance of law enforcement 
to manage risk and prevent harm. The individual goals and efforts of mental health providers 
to manage the risk inherent in their position can make a significant difference in the
 outcomes they experience.

#6 Systemic Action
Training therapists to implement protocols to minimize their safety risks is vitally important 
to bringing about widespread change in risk management for mental health providers. 
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 appropriate boundaries in this type of relationship 
(Galeazzi, Elkins, & Curci, 2005). Mandating risk management continuing education for 
mental health providers to learn how to minimize their own safety risk should be encouraged.
Consultation services for psychologists who are navigating managing active stalking threats 
should be more accessible. The impact of reduced safety for therapists comes at too great 
a cost to themselves and their communities. Mental health providers need systemic protection 
plans so that they can continue working hard to minimize distress and improve life 
functioning for their clients.