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Deciding to see a therapist is a big step – and staying in therapy requires a commitment to effect real change.

It is not surprising that many hesitate before starting therapy.

Some may be wondering how talking to a stranger can change their lives for the better.

They may not know which therapist they ought to approach – and what they should be looking for in a therapist.

Others may hesitate because they are anxiously thinking ahead: “what happens if I don’t like the therapist?”; “what if the therapist doesn’t understand my struggle?”; “what if I don’t think that enough progress is being made?”.

They may also be wondering if they can change their therapist and if they can have more than one therapist.

If you are struggling with these questions, thankfully, there may be some answers that put your mind at rest and give you the confidence to seek a therapist and engage in the healing process.

Choosing the Therapist – The Qualifications

Most clients can articulate why they wish to seek therapy – and have clear ideas about what is causing them distress or difficulty.

Clients with clinically diagnosable mental illnesses may have already sought help from a family member, friend, doctor, psychiatrist or religious leader. They may have even “Googled” their symptoms.

If specialist help is needed, choosing a therapist with the relevant qualifications and experience will be the first step.

In addition, you may wish to choose a therapist you are more likely to be comfortable with based on the therapist’s language ability, gender, culture and so on.

What should I look for in a Therapist?

Research has shown that the positive connection a client makes with their therapist accounts for 36%-50% of the changes clients experience as a result of treatment. (1)(2)

Sometimes called the “therapeutic alliance”, this is experienced by clients as liking and trusting their therapist.

Some will bond strongly with therapists if they demonstrate empathy, warmth, unconditional regard and respect. They would like their therapist to be open, non-judgmental and curious about the clients’ struggles – to have a strong desire to “walk in the clients’ shoes”.

Such clients make good progress in therapy when they feel understood and heard – as well as valued.

Others may seek therapists who are good communicators and are well informed about the issues the clients are facing. They tend to bond with therapists who are able to impart and discuss information; offer practical suggestions; articulate action plans, goals and timelines; and support the clients in their motivation to take action to effect positive change.

Many also seek insights into themselves, their emotions, the ways they react to people or situations; and their perspectives and intrusive thought patterns.

By being more present with what arises in themselves, they seek to take more control over their own lives – to respond to people and situations instead of habitually reacting to them – and to accept and let go what they cannot control.

These clients appreciate therapists who can assist in self-discovery. Therapists who are able to help articulate their “inner worlds,” and to reframe them. Therapists who empower them to navigate this “world” with more ease and confidence by playing to their strengths, rather than dwelling on what they perceive as their weaknesses.

Interestingly, studies have repeatedly shown that the type of therapy used for individual therapy (such as cognitive behavioral therapy, psychoanalytic or psychodynamic therapy, dialectical behavioral therapy, person centered therapy and so on) has only a marginal effect on the outcomes of therapy (3)(4)(5).

So, the key to choosing a therapist involves articulating what you expect from therapy and your therapist, and what kind of person you think will best meet your emotional and other needs.

It would be helpful to articulate what you want the therapist to do (and not do); and what your end goal or “vision” for therapy is. You can do this by first asking yourself the question: “what changes am I seeking that will make a real positive difference in my life?”.

Many benefit from putting all this in writing and bringing it to the first therapy session to discuss it with the therapist.

Beginning Therapy – And then Changing the Therapist 

On the first meeting with a therapist, some clients – though this may be rare – simply do not like or trust the therapist, or that they do not have the experience or knowledge to assist them.

It also sometimes happens that a client feels that the therapist is not present or really hearing the client’s narrative.

Worst still, they may see the therapist jumping to conclusions – or solutions. They may feel disrespected and “unheard” – and that they are being left behind, while the therapist is “racing” ahead of them.

Other clients may feel that the therapist is judging them or telling them what to do, think or feel – and not to do, think or feel. The clients may feel anxious, disempowered, dismissed, angry or offended.

If this happens to you, let your therapist know. If you don’t see any change in their approach, rest assured that changing therapists is likely to be helpful.

Changing Therapists Along the Way 

One situation that you may wish to avoid though, is changing therapists regularly. This is because continuity in therapy is one of the keys to progress.

Therapy is very much a journey.

Whether the goal is self-discovery, empowerment, executing action plans to change behaviour, building confidence, or managing anxiety or depression. The journey has stages, and keeping the same guide on this journey is likely to facilitate progress.

If you are in the middle of your therapeutic journey, and you wish to change therapists, it would be helpful to articulate clearly why you want to do this.

Is the therapeutic bond broken – and cannot be fixed? Is there little or no progress in your clearly articulated goals? Have you changed the goals and discussed them with your therapist – and it is clear that the therapist will not be able to assist?

Some clients simply feel that therapy has become “stale”; or they feel as though they are attending therapy to “tick the box” and to show others that they are willing and able to change.

Whatever the reasons, write them down. Discussing them openly and honestly with your therapist is likely to help.

If you wish to make a change, ask the therapist for a referral to another therapist, and give permission to the current therapist to brief the new therapist. You may wish to join in this discussion.

This is more likely to ensure that your therapeutic journey continues without disruption.

One situation you may wish to be conscious of, is changing therapists solely because the therapeutic work has become difficult. “Jumping ship” may not be the answer.

There is no doubt that therapy can be very challenging – perhaps the most challenging thing you have ever done.

The challenge could arise because the insights are uncomfortable (or even painful); the changes in behaviour require a lot of motivation to sustain; a change in perspective seems counterintuitive; or because the anxiety, intrusive rumination or low mood seem relentless.

Changing therapists may not be the answer – and may simply delay or disrupt the difficult therapeutic work ahead of you.

It is likely to be more helpful to articulate these challenges, write them down and discuss them with your therapist.

Having more than one therapist

Some clients may need more than one therapist.

A client may have an individual therapist who assists the client on their own personal journey.

They may also have a couples’ therapist to address their relationship with their partner. In that event, the therapist treats the couplehood as “the client” – and provides equal support to both parties and works towards their joint goals.

Other clients may also have a family therapist to address the relationships within the family. Again, the therapist will see the family as “the client” and assist with the family goals.

Couples and family therapists tend to provide specific modes of therapy, which have proved effective for couples and families.

In the case of individual, couple and family therapy, in most cases, it is generally considered unethical and a conflict of interest for one therapist to play all three roles.

The therapist cannot best serve the client’s, couples’, and family’s interests while wearing all three “hats”.

Once a therapist tries to do this, they may (for example) feel obliged to keep secrets from one person in the couplehood or others in the family. This may reinforce the unhealthy dynamics of secrets and deceit that brought the clients to therapy in the first place.

Conflicts of interest create confusion, anxiety, anger and disappointment for clients.

Keeping to ethical boundaries is more likely to ensure that the therapeutic journey is not sabotaged.

Unethical conflicts of interest also arise if a client is seeing two different individual therapists.

Broadly, therapists are obliged to decline to see a client if they already have an individual therapist they are actively working with.

Having two therapists engaged in the same work exposes clients to confusion, anxiety and conflict, and is likely to disrupt a client’s progress in their therapeutic journey.

If you are considering seeing two therapists for individual therapy, it would be helpful to clearly articulate why you think this will assist – and to discuss this openly with the therapists.

Some clients may change therapists to “find the right answer”; the “best answer”; or the answer that fits their “view of the world”. That “view” may be the same “view” that has been causing them the trouble – and motivated them to seek therapy in the first place.

All this is worthy of open and honest discussion and exploration.

Another situation in which other therapists may be involved occurs when a client has an individual therapist and also attends group therapy. Group therapy can be a very effective way to continue the therapeutic journey, once progress has been made in individual therapy.

Again, therapists commonly use specific modes of therapy for groups.

Working with Multiple Therapists 

If you are working with multiple therapists, it is helpful to let them know who else you are working with, and what goals you (e.g. as an individual, couple or a family member) have agreed to pursue with the other therapists.

From time to time, it will assist to share with your therapists what you took away from the other therapy sessions, how the sessions are progressing and what plans you have agreed with the therapists.

It is always open to you to ask the therapists to communicate with each other and to coordinate treatment.

It is also your right to maintain confidentiality and not to coordinate treatment – but “dovetailing” these different therapy sessions is more likely to help optimize your outcomes.

The Promises Healthcare website provides assistance to clients to identify their issues and provides photographs, names, languages, qualifications and experience of the specialists who can assist: https://promises.com.sg/our-team/

We hope that you will be able to find the right help from us.

1. Horvath, A.O., Del Re, A.C., Fluckiger, C., and Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16. Doi:10.1037/a0022186
2. Duncan, B. (2014). On becoming a better therapist – evidence-based practice one client at a time. (2nd Ed.) Chapter 1, pp.23-24. The American Psychological Association, Washington DC.
3. Stiles, W.B., Barkham, M., Mellor-Clark, J., & Connel, J. (2008). Effectiveness of cognative-behavuoural, person-centred and psychodynamic therapies in the UK primary-care routine practice. Psychological Medicine, 38, pp 677-688. Doi:10.1017/S0033291707001511
4. Benish, S.G., Imel, Z.E., & Wampold, B.E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychological Review, 28, 746-758. Doi:10.1016/j.cpr.2007.10.005.
5. Duncan, B. (2014). On becoming a better therapist – evidence-based practice one client at a time. (2nd Ed.) Chapter 1, pp.9-12. The American Psychological Association, Washington DC.

Happily-ever-after is an ideal that many believe and pursue and numerous studies have suggested that the key to happiness lies in a thriving marriage. I am also convinced that when couples come together and decide to get married, they do not have the thought of a divorce on the horizon.

To many, marriage is not a frivolous decision but one where he or she has deliberated and decided to entrust oneself to the other legally. Imagine the horror when shortly after the wedding bells, you discover that your spouse turned out to be someone that you don’t recognise and ends up hurting you so deeply that you wonder how you even got to this point: being romanced to being discarded. This is what it is like to be in a relationship with a narcissist.

Let’s explore the traits of a narcissist.

The following are the 9 official criteria for Narcissistic Personality Disorder (NPD):

• grandiose sense of self-importance
• preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• believes they’re special, unique and can only be understood by, or should associate with, other special or high-status people or institutions
• need for excessive admiration
• sense of entitlement
• interpersonally exploitative behaviour
• lack of empathy
• envy of others or a belief that others are envious of them
• demonstration of arrogant and haughty behaviours or attitudes

In essence, a narcissist has an excessive sense of self-importance over and above the needs of others. There is a sense of grandiosity and arrogance; and a lack of ability to empathise and experience reciprocity within intimate relationships. They are typically charming and charismatic. The early stages of the relationship are almost always exhilarating, romantic, powerful and intense. Love-bombing is a tactic where NPD makes you feel so special and loved that you can’t help but fall deeper in love with him or her. Most narcissists only reveal their true colours when they are in conflict. And when you no longer serve their needs, they discard you from their lives or make it a living hell for you.

Imagine the adverse and trauma that one experiences when you wake up one day and realises that the love you’ve received is not real and permanent.

The following are the lasting psychological and emotional impact of being in a relationship with a person with NPD:

1. “I don’t know what is real anymore.”
   Survivors of persons with NPD have the inability to trust their own judgment. Because gaslighting is a key feature in this toxic relationship, they lose touch with what is the reality. Gaslighting is defined as a form of manipulation, emotional and psychological abuse that results in a slow dismantling of a victim’s self-trust and judgment.
2. “It is all my fault. Everything I do is wrong. I trigger him/her. I deserve his/her anger.”
   Because a person with NPD will never assume responsibility for anything (they believe they do no wrong), they turn it around and project their emotions on the survivor. The survivor is the one who is over-sensitive and would ask irritating questions that trigger them to react. The consequence of this is that the survivors feel powerless and start to blame themselves for not being good enough for their partner.
3. “I am worthless and deserve nothing
   From the constant criticizing and undermining from a person with NPD, the survivors begin to accept the narrative that they are the problem and suffer from low self-esteem. They may start to withdraw from their family and friends who are concerned and question the relationship. They also hide their partner’s behaviour and lie about it.
4. “I am going crazy”
   This is related to point #1. Because a person with NPD constantly lie and intentionally say things that make the survivors question their reality, they start to think that they are crazy for having those questions. They feel confused and lost all the time.
5. “I don’t know. I can’t decide. It will be wrong anyway.”
   They have great difficulty in making decisions because they start to believe that they can’t do anything right. This is the message that is drummed into them persistently and this could extend into other aspects of life, such as in their work.

One of the common frustrations that my clients, who have survived persons with NPD, have often expressed: ‘how is it possible that they missed the warning signs’. Because of the suffering that they have been through, they have asked for the warning signs to be shared so that more can be aware and watch out for them in their relationships.

1. Self-centeredness
   They believe that the world revolves around them. They are not able to empathise and therefore can only see from their point of view. When things do not go their way, they get very upset and may threaten to end the relationship. Everything is on their terms. For example, my client shared that when they were dating, the partner dictated when to meet according to his schedule. Not knowing better, she accommodated. That is a red flag. Also, when they no longer have use of the partner, they have no qualms to simply discard them by being emotionally unavailable, refusing to communicate and abandoning the partner.
2. Frequent threats and emotional blackmail
   If you feel like you are perpetually walking on eggshells not knowing when your partner will explode on you, chances are he/she has NPD. Threats and emotional blackmail are their tools to control and get you to submit to their wants. E.g., Go ahead and leave, I never needed you anyway. I’ll tell everyone what a mean person you are.”
3. They act entitled and rules don’t apply to them.
   They believe that their needs are more important than their partner’s. There will be no reciprocal gestures unless there is an ulterior motive to get what he or she wants. Because of the self-importance and arrogance, they believe that they can do as they please as long as they don’t get caught. They deserve special treatments.
4. Obsessive focus on the external
   This applies to how they dress and carry themselves. Typically they are attractive, have material possessions and are of certain social status. They appear to be an excellent “catch”. They will go all out to inflate their status and standing. Another client told me that her husband, a covert narcissist, was charming and social. His real self only surfaced when they were on their own and when he felt threatened by her. This creates problems as people may not believe her when she tells her challenges.
5. They are master manipulators and schemers.
   The key emotions that you feel when you’re with a narcissist are guilt, shame and confusion. The hallmark of a person with NPD is the inability and unwillingness to take responsibility for any action and word. Consequently, they project their emotions onto the survivors and make them feel guilty and responsible. They can also be verbally abusive and are good liars. They scheme and twist the words of the survivors to their advantage. They have no issue in making their partners the bad guy and spread rumours that paint themselves as the victim. The bottom line is this: they need to make themselves feel good at the expense of everything and everyone. When they don’t get what they want, they will withdraw either physically and /or emotionally from the partner. They may give the silent treatment, be passive-aggressive, stonewall and/or ignore the partner. At the end of it, the partner will accept the blame and promise to not upset them next time.
6. They are hot, then cold.
   When they want something, they will go all out to get it. As such, in the early stages of the relationship or when they are on a mission to keep you under their control. They will pull out all the stops to make you feel wanted, admired and loved. One moment, you could be the most important person in their lives and in the next, when you don’t agree with them on something, it could be a trivial matter, you would become a worthless person that is undeserving of his/her respect and love. The switch from hot to cold is unnerving and they will make the survivors think that the problem lies with them.

In spite of the detrimental impacts of being in a relationship with a narcissist, the good news is that it is possible to heal from it. I have supported and seen my clients live a meaningful and flourishing life following the breakup with a narcissist. Though the journey may not be easy, if one is willing to work with a professional to go deeper and understand the pattern of relationships in their lives, they can find healing and freedom.

What are the steps to heal?

1. Educate yourself on NPD and accept that it is a disorder. Know that you are not alone and you are not the problem. Raise awareness for it. The World Narcissistic Abuse Awareness Day is on 1 June. Get involved and when you are ready, share your story. You can empower and help others by sharing your experience courageously.
2. Get professional help as dealing with trauma can be complicated. Learn to connect the past to the present; typically, the dynamics between the person with NPD and the survivor is one that the latter is familiar with. It is not uncommon that upon the realization that the partner has NPD, the survivor can see that a family member could be one as well. Those who persist in such toxic relationships are usually accustomed to such dynamics from childhood.
3. Practice boundaries – physical and emotional. Have zero contact or keep it to a minimum should you share the care of the children. The survivors are usually empathic and attuned to the feelings of others. Be mindful not to take on feelings that are not yours. Have clarity on what is your responsibility and discard those that are not yours.
4. Build a strong foundation – focus on one’s strengths and resilience, in ending the relationship and working through the issues. Find meaning in it by rewriting the narrative.
5. Forgive and work on self-love. Self-compassion is a critical component in recovering. Learn to take good care of yourself – physical, emotional, psychological, spiritual, social.
6. Pay attention to your body as trauma is stored in your body. Practice mindfulness to bring yourself to the present moment when you’re triggered by difficult memories. The triggers will still be there, and the healing process will be imperfect and a work-in-progress.
   
   
7. Focus on the good – that is in you; the work that you have put in to heal and maintain your well-being by learning new skills and maintaining good habits. Celebrate quick wins when you are able to enforce boundaries or not take on responsibility for how others are feeling.
8. Embrace a healthy relationship. After being in a toxic relationship for a long time, being in a healthy relationship can feel weird and scary. You aren’t sure what to make of it. The lure to get back to what is familiar albeit negative for you is high. Be aware of it and put measures in place so that you can recalibrate when you feel threatened.

Let’s remember that significant relationships in our lives will impact our mental well-being. Even as we focus on the benefits of positive relationships and promote it, we also need to provide support for those who have been through traumatic and toxic relationships. The key is to remember that relationships should enhance your lives and motivate you to be a better version of yourself. When there are disempowerment and manipulation in the relationship, it is not healthy, and you can make the decision to get out of it.

Healing comes with returning your focus to yourself, acknowledging your feelings and emotional experience and taking responsibility for yourself. Through the right help and therapy, you can learn new skills, to regulate your emotions, have better communication and understanding, and help yourself break the cycle of unhealthy patterns. Your resilience can be enhanced, and a flourishing life is once again within your reach. 

1  DSM-IV and DSM-5 Criteria for the Personality Disorders