First published on: 12 February 2010

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1 This article was downloaded by: [McEwan, Troy] On: 29 July 2010 Access details: Access Details: [subscription number ] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Journal of Forensic Psychiatry & Psychology Publication details, including instructions for authors and subscription information: Suicide among stalkers Troy McEwan a ; Paul Mullen ab ; Rachel MacKenzie b a Monash University, Centre for Forensic Behavioural Science, Melbourne, Australia b Victorian Institute of Forensic Mental Health, Melbourne, Australia First published on: 12 February 2010 To cite this Article McEwan, Troy, Mullen, Paul and MacKenzie, Rachel(2010) 'Suicide among stalkers', Journal of Forensic Psychiatry & Psychology, 21: 4, , First published on: 12 February 2010 (ifirst) To link to this Article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 The Journal of Forensic Psychiatry & Psychology Vol. 21, No. 4, August 2010, RESEARCH ARTICLE Suicide among stalkers Troy McEwan a *, Paul Mullen a,b and Rachel MacKenzie b a Monash University, Centre for Forensic Behavioural Science, Melbourne, Australia; b Victorian Institute of Forensic Mental Health, Melbourne, Australia (Received 5 January 2009; final version received 26 March 2009) Although stalkers present with multiple suicide risk factors, there have been no studies of the prevalence of suicide within this at risk group. In this study, 138 stalkers were followed up over three years using national coronial records and relative risk ratios used to compare rates of completed suicide with those in the Australian general population, psychiatric patients, and community-based offenders. Stalkers committed suicide at significantly higher rates than any of the comparison groups. Clinicians working with individuals who stalk must be mindful of the risk stalkers pose to themselves, in addition to their victims, and incorporate suicide risk assessments and crisis management into treatment. Keywords: stalking; suicide; risk factors Stalking is a relatively common behaviour in Western societies, affecting hundreds of thousands of people each year (Basile, Swahn, Chen, & Saltzman, 2006; Dressing, Kuehner, & Gass, 2005; Finney, 2006; Purcell, Pathe, & Mullen, 2002). Although stalking behaviours do arise in the absence of mental illness, psychopathology is prevalent even in non-clinical samples of stalkers (Kienlen, Birmingham, Solberg, O Regan, & Meloy, 1997; Mohandie, Meloy, McGowan, & Williams, 2006). It is therefore likely that both general and forensic mental health clinicians will confronted with clients who stalk (Dressing, Scheuble, & Gass, 2006; Galeazzi, Elkins, & Curci, 2005; Purcell, Powell, & Mullen, 2005). In these situations, risk to the victim is understandably a central concern, yet anecdotal evidence suggests that stalkers themselves often suffer severe psychological, social, and legal consequences as a result of their intrusive and unwanted behaviour (Mullen, Pathe, & Purcell, 2009). With some exceptions, stalkers presenting to mental health services tend to be males aged between 20 and 40 stalking either ex-partners or other women on whom they are fixated (Mohandie et al., 2006; Mullen et al., 2009). *Corresponding author. troy.mcewan@med.monash.edu.au ISSN print/issn online Ó 2010 Taylor & Francis DOI: /

3 The Journal of Forensic Psychiatry & Psychology 515 They are generally of average to below average intelligence and suffer from a range of mental disorders; from acute psychoses and mono-delusional disorders, to affective disorders, pervasive developmental disorders, and problematic personality traits (Harmon, Rosner, & Owens, 1998; MacKenzie & Mullen, 2008; Mullen et al., 2009; Mullen, Pathé, Purcell, & Stuart, 1999). Suicide risk factors prevalent among stalkers include being predominantly male and frequently suffering from mental disorder, as well as typically experiencing conflictual relationships and/or social isolation, unemployment, and engaging in behaviours that result in repeated frustrations, failures, and demoralisation (Mullen et al., 2009). Despite these factors there has been no research examining the relationship between stalking and suicide. The aim of this study was to compare the incidence of suicide in a sample of stalkers with that in the Australian population as a whole, with psychiatric patients, and with community-based offenders. Given that stalkers present with multiple risk factors for suicide, we hypothesised that individuals who stalk would be significantly more likely to commit suicide that individuals in any of these groups. A secondary aim of the study was to examine the relationship, if any, between characteristics of stalking behaviour and subsequent suicide. Method Design Data were collected between June 2002 and June 2006 from a community forensic mental health service with a specialist stalking clinic in the state of Victoria, Australia. Referrals came from courts, general mental health services, and community corrections (probation services). All clients exhibiting stalking behaviours were asked to participate. Stalking was identified by the presence of a criminal charge or where the referrer expressed concerns about stalking behaviour. By Victorian law, stalking is a course of conduct involving a number of proscribed activities (such as following, loitering, and various forms of communication), which occur on more than one occasion and either cause fear or are conducted with malicious intent (for discussion see McEwan, Mullen, & MacKenzie, 2007). Determining the effect on the victim was often difficult in the absence of a formal charge, so where a stalker was referred from a general health service a slightly modified definition of stalking was used. In these cases stalking was defined as a course of conduct that caused the referrer sufficient concern to request a risk assessment of the stalking behaviour. Referral materials were perused and occasionally the referrer was contacted to determine if the behaviour constituted a course of conduct. Demographic, diagnostic, and stalking behaviour data were recorded and each participant was assessed by a psychiatrist and a clinical

4 516 T. McEwan et al. psychologist. Between June and August 2007, each participant s name and date of birth was entered into the National Coroners Information System (NCIS), a computer database covering the coronial records of seven of the eight Australian states and territories (excluding Western Australia). The NCIS includes all cases in which death was unexpected, unnatural, violent, resulted from accident or injury, or where the body was unidentified or cause of death unknown. When a participant was identified in the NCIS, medical examiner and police reports, and coronial decisions were scrutinised and the coroner s decision regarding cause of death recorded. Comparative data Data on suicide rates in Australia were gathered from the Australian Bureau of Statistics (ABS, 2005). Information was collected on deaths between 1995 and 2005, where suicide was determined to be the underlying cause by a medical practitioner or coroner. The ABS draws cause of death data from individual state and territory Births, Deaths, and Marriages Registers, supplemented with information from the NCIS. Raw data on rates of suicide are provided, as well as data in age standardised format, enabling comparison over years when the age structure of the Australian population varies. Information on the suicide rate among Australian psychiatric patients was taken from Ruschena et al.s work (1998). These authors followed up all individuals who had had contact with Victorian psychiatric services between 1961 and 1994 by examining the NCIS. They identified a relative risk of suicide among individuals in contact with psychiatric services 12.4 times the expected rate in the general population. Comparative data for suicide rates among community-based offenders (parolees and probationers) were taken from English and Welsh figures reported by Sattar (2003) as no Australian data were available. A standard mortality ratio of 13:1 was identified for male community-based offenders. The English/Welsh suicide rate at the time of the study, 9.2 per 100,000 (National Institute for Mental Health in England [NIMHE], 2007), is comparable to the current Australian suicide rate of 10 per 100,000 (ABS, 2005). Results Demographics One hundred and thirty-eight clients agreed to participate (123 male) and eight refused. Time to follow up ranged from 1 to 4 years, with an average of 2.75 years (SD ¼ 0.9). Forty-two (30%) were referred from court, 44 (32%) from community corrections services, 43 (31%) from general mental health services, 7 (5%) from parole boards, and 2 individuals self referred. The mean age of the sample was 36.4 (SD ¼ 11.1). Eighty-six per cent were

5 The Journal of Forensic Psychiatry & Psychology 517 diagnosed with at least one mental disorder (details of primary diagnoses in Table 1). In 38 cases, participants were diagnosed with both an Axis I and personality disorder (40.4% of all Axis I diagnosed individuals). In 36 cases (26%), the stalker was an ex-partner of the victim. A further 48 individuals (35%) were strangers to the victim, and the remainder knew the victim as an acquaintance (e.g., through work, a professional contact, a neighbour, or a casual contact). Using Mullen s motivational stalking typology (Mullen et al., 1999), 16% were Intimacy Seekers (attempting to establish an intimate relationship), 24% Incompetent Suitors (attempting to get a date), 27% Rejected (attempting reconciliation of a relationship or exacting revenge for rejection), 24% Resentful (seeking retribution for perceived injustice), and 9% Predatory (stalking as a means to achieve gratification of sexually deviant desires). Incidence of suicide Three participants committed suicide during the follow-up period; an incidence of 2.2%. The Australian suicide rate remained steady at approximately 1 suicide in 10,000 individuals per year over the time of the study, equivalent to 2.75 suicides per 10,000 over the mean follow-up period. Calculation of relative risk showed that stalkers were almost 80 times more likely than members of the general population to have committed suicide during the follow-up period (see Table 2). Table 2 also shows the relative risk of suicide among stalkers compared to Australian males between the age of 30 and 65, individuals in contact with psychiatric services, and male community-based offenders. Characteristics of stalkers who committed suicide The three deceased stalkers were males aged between 30 and 65. In one case the stalking victim was a female ex-partner and in the others the victims Table 1. Prevalence of primary DSM-IV-TR diagnoses in sample. Primary diagnosis n % of sample Affective disorders Schizophrenia and other psychotic disorders Paraphilia Substance use disorder Anxiety disorder Asperger s syndrome Personality disorder Other No diagnosis

6 518 T. McEwan et al. Table 2. Relative risk of suicide among stalkers compared to other at risk populations. Comparison group Suicide rate a Relative risk 95% CI Stalkers 220 Australian general pop Australian males aged Individuals in contact with psychiatric services Male community-based offenders a per 10,000 over 2.75 years. were female acquaintances. For all three men, stalking behaviours were driven by a desire for a relationship with their victim (two were Intimacy Seekers whose stalking arose out of delusional beliefs, and one was a Rejected stalker who was seeking reconciliation with the victim). None of the three who killed themselves had been violent towards their victims, although one had uttered threats to the victim and her family. All three had had contact with the legal system as a result of the stalking behaviour; one had been convicted of stalking (as were 60% of the sample), one of making a threat (13% of the sample), and two were subject to the conditions of a protective order obtained by the victim (as were 45% of the sample). In both cases the conditions were breached (83% of all protective orders were breached). One of the men was diagnosed with depression at the time of assessment, one with a psychotic illness, and the other was diagnosed with PD NOS (in the 2.5 years between assessment at the stalker s clinic and his death this man also received treatment for psychosis, although the aetiology is unclear). Time between assessment and suicide was 5 months in two cases, and 2.5 years in the other. One of the three was experiencing suicidal ideation at the time of the assessment (as were 10% of the sample), and two had experienced suicidal ideation in the past (29% of the sample gave such a history). All three individuals had prior contact with psychiatric services, including inpatient admissions where depressive symptoms were a primary factor. Discussion This study indicates that stalkers presenting to forensic mental health services are at significantly increased risk of suicide when compared to both the Australian population and specific at risk groups. The three men who committed suicide all suffered from some form of mental disorder and had previously received psychiatric treatment for depression. In each case, the

7 The Journal of Forensic Psychiatry & Psychology 519 stalker was motivated by the desire for a relationship with the victim rather than by anger or resentment. They had all been subject to legal sanctions and their stalking behaviours had ultimately failed to achieve their objectives. While these three cases had a number of common features, the small sample prevents any definitive conclusions about potential risk factors for suicide. Nonetheless, these data show a clear need for further research to determine what aspects of motivation, behaviour, and individual disposition place specific stalkers at heightened risk of suicide. These results do not imply a causal relationship between stalking behaviour and suicide, but they do suggest that the ongoing stressors and negative experiences peculiar to stalking situations may increase the already heightened risk of suicide among the mentally ill. This sample of stalkers was drawn from a forensic mental health clinic and it is therefore likely that the prevalence of mental illness among stalkers is overestimated. However, a psychiatric diagnosis is not a prerequisite for referral to this specialist service and the basis for requesting an assessment is frequently the failure of the courts or correctional services to comprehend why an otherwise normal person would engage in such behaviour. It would be useful to conduct similar research among stalkers recruited from community settings such as workplaces and schools to examine the unique risk that stalking in the absence of mental disorder contributes to the risk of suicide. The negative psychological and social effects of stalking on perpetrators warrants more attention from clinicians and researchers, particularly as managing psychological distress in stalkers is likely to have the positive effect of reducing risk to victims. We make no argument for equivalence of suffering in stalking situations; one party is the offender, the other offended against. The inclination of clinicians assessing stalkers is understandably to focus on risk to victims, but these results highlight the fact that stalkers pose a considerable risk to their own mental and physical wellbeing. Therefore, clinicians assessing stalkers must be attentive to the presence of past and current suicidal ideation, always assess for the presence of depression, and routinely incorporate crisis plans and other risk management strategies into treatment. References Australian Bureau of Statistics. (2005). Suicides, Australia. Canberra: Author. Basile, K.C., Swahn, M.H., Chen, J., & Saltzman, L.E. (2006). Stalking in the United States. Recent national prevalence estimates. American Journal of Preventative Medicine, 31, Dressing, H., Kuehner, C., & Gass, P. (2005). Lifetime prevalence and impact of stalking in a European population: Epidemiological data from a middle-sized German city. British Journal of Psychiatry, 187, Dressing, H., Scheuble, B., & Gass, P. (2006). Stalking - a significant problem for patients and psychiatrists. British Journal of Psychiatry, 189, 566.

8 520 T. McEwan et al. Finney, A. (2006). Domestic violence, sexual assault, and stalking: Findings from the 2004/05 British Crime Survey. London: Home Office Online Report 12/06. Galeazzi, G.M., Elkins, K., & Curci, P. (2005). The stalking of mental health professionals by patients. Psychiatric Services, 56, Harmon, R., Rosner, R., & Owens, H. (1998). Sex and violence in a forensic population of obsessional harassers. Psychology, Public Policy and Law, 4, Kienlen, K.K., Birmingham, D.L., Solberg, K.B., O Regan, J.T., & Meloy, J.R. (1997). A comparative study of psychotic and nonpsychotic stalking. Journal of the American Academy of Psychiatry and the Law, 25, McEwan, T.E., Mullen, P.E., & MacKenzie, R. (2007). Anti-stalking legislation in practice: Are we meeting community needs? Psychiatry, Psychology and Law, 14, Mackenzie, R., & Mullen, P.E. (2008). Stalkers: Are they more intelligent or just like any other criminal? Paper presented at the 8th Annual Conference of the International Association of Forensic Mental Health Services. Vienna, July Mohandie, K.K., Meloy, J.R., McGowan, M.G., & Williams, (2006). The RECON typology of stalking: Reliability and validity based upon a large sample of North American stalkers. Journal of Forensic Sciences, 51, Mullen, P.E., Pathé, M., & Purcell, R. (2009). Stalkers and their victims (2nd ed). London: Cambridge University Press. Mullen, P.E., Pathe, M., Purcell, R., & Stuart, G.W. (1999). Study of stalkers. American Journal of Psychiatry, 156, National Institute for Mental Health in England. (2007). National suicide prevention programme for England. Annual report on progress Leeds: Author. Purcell, R., Pathe, M., & Mullen, P.E. (2002). The prevalence and nature of stalking in the Australian community. Australian and New Zealand Journal of Psychiatry, 36, Purcell, R., Powell, M., & Mullen, P.E. (2005). Clients who stalk psychologists: Prevalence, methods, and motives. Professional Psychology: Research and Practice, 36, Ruschena, D., Mullen, P.E., Burgess, P., Cordner, S., Barry-Walsh, J., Drummer, O., et al. (1998). Sudden death in psychiatric patients. British Journal of Psychiatry, 172, Sattar, G. (2003). The death of offenders in England and Wales. London: Home Office Offending and Criminal Justice Group.