Losing a Baby to Miscarriage or Stillbirth

Both miscarriage and stillbirth refer to the loss of a baby during pregnancy. Whereas miscarriage occurs before 20-24 weeks of gestation, stillbirth is when a baby is born dead after 20-24 weeks of pregnancy.  

Statistics in Singapore

In Singapore, about 20% of pregnancies end up in a miscarriage while stillbirth happens in 0.5%-1% of pregnancies. In most cases, the cause cannot be established. Some known causes include infection, umbilical cord accidents, and placental complications.

A word from our clinical psychologist:

Perinatal loss is a term broadly used to describe losses before, during and after pregnancy. There are different types of losses during pregnancy, including miscarriage, stillbirth, ectopic pregnancies and medical termination for various reasons. No matter when or how the pregnancy loss happened, losing a baby has been described by some of the clients I have worked with, to be the worst kind of pain. Their loss experience defied their assumptions and expectations of a "normal" course of pregnancy through the trimesters until the smooth delivery of their healthy baby, just like everyone else! A "typical" path towards parenthood, towards forming a family (with children) is all that they had hoped for. Given this, a range of emotions - anger, sadness, grief, shock, guilt amongst others may result, as a part of the grieving parents' mourning process. 

For there is so much to mourn - the loss of their "healthy" baby, the loss of sense of "normalcy" in their lives, the loss of that anticipated future with baby as a part of the new family, and the loss of the new identity, hopes, dreams as soon-to-be parents. Instead of celebration of their baby's arrival, some grieving parents may find themselves confronted with the starkest reminder of their loss, in the form of a symbolic farewell ritual, or funeral ceremony and burial event for their baby. For some families who choose these practices, they shared that it can be very helpful for their grieving process and closure. But, there is no one way to grieve, so honour your own needs, beliefs, emotional and physical capacity to decide what is best for your unique situation. 

What can complicate perinatal grief is also in part due to the "invisible" nature of pregnancy loss, especially in the early stages. This can make it very hard to talk about it with others and for loved ones to fully acknowledge the deep, emotional and psychological impact of such losses. Hence, it is necessary to remind all that perinatal losses are as worthy of care and compassion as other types of relationship losses. This is because attachment relationship bonds has already formed between conceiving parents and baby, as soon as they learn about being pregnant. 

Given the tough, unbearable pain of perinatal losses, much compassion is needed all around. Grieving mothers/fathers need to learn to be more self-compassionate and manage their own harsh self-talk, especially those about failure and being unworthy as parents. Given that the nature of perinatal losses are often unexpected, resulting in a big sense of loss of control, it can be beneficial to find little ways of taking charge, for instance, of daily routines, or setting of boundaries about what you are comfortable discussing. This can assist with restoring some sense of normalcy and control as you navigate grief. 

A journey shrouded by shame and silence

Given that pregnancy losses are common, some women may feel that they do not deserve to grieve. On the other hand, despite the substantial occurrence rate, resources to support these women are scarce.

There has also been stigma and blame attached to pregnancy loss, where mothers are implied to have failed to take good care of their babies. Even well-intentioned advice could come across as insensitive and dismissive. This unspoken roller-coaster journey can feel unforeseeably lonely and difficult. 

An unimaginable pain

The loss of a child, no matter how brief they have been in your life, is profound. It goes against the natural order of life and no parent can ever be prepared for it. The loss of a child is also the loss of an imagined future with them – the hopes and dreams that cannot be fulfilled.

With the devastation, there may also be guilt that you could have been more attentive to your diet and body, and anger that it had to happen to you. Mothers may also feel alone thinking that their partner does not understand their pain since their partners are not the one who carried the child.

How can I cope with a miscarriage or stillbirth?

Everyone grieves differently – in different ways and on different timelines.

Here are some ways we hope can help with your grief.

Ψ Make room for your feelings

Allow yourself to feel all that you feel – guilt, anger, confusion, panic. Observe where you are feeling these emotions in your body – aches in the stomach, tightness in chest? Let yourself be where you are at the moment. There is no prescribed timeline which states the stage of grief you should be at at any point of time.

Ψ Be compassionate to yourself

Understand that it is not your fault nor a personal failure.

As mentioned earlier, there is no timeline for grief; you will move along with your grief rather than moving on from it. Do not expect yourself to forget. Instead, expect yourself to feel triggered on the anniversaries or when you see other families with children. When that happens, allow yourself to take short breaks to grieve – it can be in a toilet cubicle or in a corner of a park. This place should be somewhere you feel safe and comfortable to express your emotions. 

Ψ Pay attention to unhelpful thoughts

Certain narratives may start playing in your head: “My life is worth nothing if I do not have children”, “I am not complete without children”, “It is all my fault”, “I’m a useless mother”. When played enough times in your mind, these thoughts may seem convincing. But they are not true.  

You could challenge these thoughts by asking these questions.

• What's the evidence for and against these thoughts?

• What would I tell a loved one who is going through the same situation? 
  
  

Ψ Grieve with your partner

An event like the loss of a child could bring a couple closer to each other or lead them to drift apart.

You and your partner may respond to the death of the baby differently – one may turn to crying, one may turn to work to avoid thinking about the pain. Some couples may not want to burden their partner with their anguish so they choose to keep their feelings to themselves. When you are unsure of how your partner feels about the loss, there is a chance that you feel that they are less affected by the loss. And this, will lead to emotional distance and tension in the relationship. 

Recognise that this is uncharted territory for both of you. Seek your partner to grieve as a team. Communicate with each other your sorrow, and try to understand how both of you will grieve in different ways, but together. 

Ψ Consider a grief ritual

For some, a grief ritual gives some form of closure to the episode. The symbolic ritual could be in the form of a scrapbook, memory box, journal entry or even a remembrance trip. 

Ψ Look after yourself

The miscarriage or stillbirth takes a toll on your physical body. The grief and emotional pain may take hold of your life, leaving you with no mental capacity to plan for your day. A routine may be helpful to ensure that your physical well-being is taken care of. You need your sleep, food and physical activity.

Ψ Seek support

Reach out to your family and friends. Be with your loved ones even if you do not feel like talking about the loss; their company in itself may be comforting.

To ease your return to work, we encourage you to speak with your bosses to let them know how you want your return to be managed (e.g., shorter hours, work-from-home arrangement, inform your colleagues to not broach the topic).

The pain of grief could be overwhelming. But you are never alone. Consider seeking professional psychological help in the forms of support group and therapy. Some support groups include:

• Child Bereavement Support (Singapore)

• Angel Hearts

• Miscarriage, Stillbirth, & Child Loss Support Group

• Pregnancy and Infant Loss Support Group Singapore

• Pregnancy After Loss Support (PALS)

How family members can support their loved ones

This key idea should underlie all of your efforts to support them: Acknowledge and validate their pain.

Understand that the loss hurts them deeply, and it will take time for the pain to feel more bearable. Some may feel comforted by phrases like “I’m so sorry it happened”, “I cannot imagine your pain but I’m here for you”.

The aim is never to cheer them up – you would be disappointed if you want to do that because you cannot take their pain away; rather, it is to join them in their pain as they struggle with their intense and painful emotions.

On anniversaries or in situations where the parents may be reminded of their loss, you could check in on them gently by asking how they are feeling or if they want to spend time together.

If you notice that their grief has affecting their daily life for a concerning amount of time, let them know why you are concerned (i.e. what did you notice and explain why it is concerning), and encourage them to ask for professional help. You could also go the extra mile and accompany them to visit a psychologist.

Gaslighting: Subtle Psychological Manipulation

There never seems to be a way out that you can find without slamming face first into your own reflection. Some mirrors even make you appear distorted, and you begin to questions which parts of this experience are real. To victims of gaslighting, this is an analogy of what it might feel like to be gaslighted.

What is Gaslighting?

(clue: it is not lighting a fire using gas)

Gaslighting is an insidious form of psychological manipulation that can have a profound effect on the individuals affected by it.

Gaslighting is a term used to describe when someone intentionally, and often successfully, manipulates another person into questioning their own memory, judgement, or reality. It is a form of psychological manipulation that occurs over a gradual period where the perpetrator takes advantage of a target by sowing seeds of doubt within them.

So how does gaslighting look like? 

A gaslighter (aka the abuser) may use tactics such as making false statements (which they will strenuously deny if challenged), disagreement with factual information and downplaying emotions, all in an effort to make the victim doubt their own perceptions.

Over time, victims are not only unsure about their perceptions of reality and even their own thoughts, but come to rely on the abuser to tell them the “truth” about.

The ultimate goal of gaslighting is to de-legitimise a victim’s thoughts and to cause them to question themselves. This can occur via a variety of techniques and behaviours that the gaslighter employs, which may look like: 

• Lying – “That’s not what I said, I said this…” 

• Discrediting – Telling people around you that they are concerned about your recent behaviour and that you might be “crazy”. 

• Distracting/Deflecting – “Why did you bring this up? What about the time you….” 

• Minimizing thoughts and feelings – “Why are you so sensitive?” 

• Shifting blame – “I only behave this way because you did so first. I wouldn’t do it if it weren’t for you.” 

• Denying wrongdoing – “I didn’t do anything wrong”  

• Changing the storyline – Retelling stories by changing it so that the storyline is in their favour.  

While gaslighting often occurs in romantic or familial relationships, it can sometimes occur in the workplace, with friends, or in schools. Several teachers in Singapore even complained about being “gaslighted” by an AI Chatbot designed to provide “AI therapy”!

Why do people gaslight? 

Gaslighting is often employed by narcissistic individuals looking to evade accountability.

By redirecting attention onto the supposed flaws or shortcomings of others, it reduces the likelihood of their own flaws being discovered. They might also believe that they are never at fault, naturally it would be easier to put the blame on others when things don’t go their way. As long as the victim believes they are flawed and need help, the gaslighter would never have to take responsibility for their actions and can continue behaving in the way they do.   

What are the effects of gaslighting 

Ψ Isolation  

Being gaslighted can make you feel extremely alone and dependent on the abuser. It may feel as if everyone around you thinks you have issues or even to the extent of feeling crazy, just as the abuser would describe. As you begin feeling more isolated, the behaviour of the abuser becomes more normal since there is nothing else to compare it to.  

Ψ Emotional Trauma 

Gaslighting has significant negative effects and can cause emotional trauma to the victim. Children exposed to traumatic events and abuse in childhood can become hypersensitive to such threats, and reduce their resistance to stressful events in future. Trauma can also lead to difficulties in emotional regulation in adulthood, alongside other physical issues such as somatic symptoms or heart disease. 

 Ψ Reduced self-esteem 

Prolonged emotional abuse can also lead to a loss in self-esteem, as you constantly feel that you’re never enough. You might begin wondering if you can believe in yourself to do anything correctly, or if you’re to blame for everything that has gone wrong. You might feel incapable of judging the situation realistically, and if you can accurately remember the details of situations. You might feel obliged to continue to stay in the abusive situation because it might feel like no one would believe you or want you anyway.  

Ψ Psychological issues

You might even feel nervous or afraid to say things, lest the abuser retaliates or no one believes you. Gaslighting can lead to psychological disorders such as anxiety, depression or even psychosis.  

Signs that you are being gaslighted

Unfortunately, gaslighting can be incredibly hard to detect without an outside perspective which could make it incredibly difficult for victims to identify what’s happening and take action before it’s too late. On the surface, what might seem as an innocuous quarrel between a couple or might in reality be more complex than a mere argument between two individuals.

It can be difficult to spot gaslighting within a relationship as the signs can appear “normalised” to you after some time. Recurring manipulation and abuse, coupled with the feelings of isolation and reduced self-esteem, causes the individual to constantly doubt themselves and the reality that surrounds them.

If you identify with some of these emotions and suspect that you are being gaslighted, the following are several signs that can indicate gaslighting behaviour. 

Ψ Repeated patterns of manipulation  

“Nope, that didn’t happen” 

“Your memory is getting so bad!” 

“You’re being so sensitive”  

These statements are often used by gaslighters to manipulate you.

While they might be common statements used in many arguments, it is important to note that these statements are often used throughout by the gaslighter in the relationship. This happens often enough such that it forms a consistent pattern in a relationship.  

Ψ Being invalidated constantly

When expressing your needs or concerns, the gaslighter often invalidates you by calling you oversensitive, convincing you that you’re unstable, and how everyone around you thinks you’re crazy.   

Ψ Deflection

When it comes to finger pointing, no one can beat a gaslighter. As soon as you bring up a topic that is concerning to you, they either change the topic or manage to turn it around to pin the blame on you for something completely irrelevant.   

Ψ Losing a sense of self 

When you begin second guessing your own judgment and perceptions of events that happened, it almost feels as if you lost your identity and status as an individual. Perhaps you begin wondering if everything the gaslighter is saying is true, that you’re weak and not enough, that you’re too sensitive, and you cannot stand up for yourself. You start to wonder if you’ve been like this all this while. Perhaps it’s true and you begin to accept it.  

Ψ Walking on eggshells

What happens when you start convincing yourself that it is not as bad as it seems? You just have to be careful every time you interact with them and ensure not to say the wrong thing, right? You become afraid to voice your opinions for fear of getting shot down or because you’ve learnt that your opinions don’t matter anymore. You live as though you’re always on the edge of your seat and get spooked by every little thing.  

What can you do if you are being gaslighted?  

Here are a few steps you can take to protect yourself from being gaslighted.  

Ψ End the conversation  

When you find yourself being gaslighted, understand that the abuser might be overwhelmed and unable to control the words that they use. That does not mean that it is okay, hence you should try to end the conversation as soon as possible. Set appropriate boundaries and let them know that you do not wish to continue the conversation if they are only going to continue to berate you.  

Ψ Save evidence for yourself  

Recording conversations and saving receipts of text messages can help you remember that your reality is not based off of what one person says. It helps you recall that you’re not the one that remembered things wrongly or did something that you didn’t. Do be careful when confronting an abuser with evidence, for it might result in an even more explosive outburst.   

Ψ Getting an outsider’s perspective  

When you’ve lived in the world of the abuser for too long, it can be difficult to identify what’s real and what’s not. A trusted individual outside of the relationship (perhaps an old friend of yours) can help to give a different perspective from yours, helping you untangle the web of distortion.  

Being a victim of gaslighting can feel invalidating, dismissive, and most of all, lonely. Keep in mind the abuser wants to make you forget about who you once were, before the relationship. This process can be gruelling especially if you’ve been a victim for a long time. Do not hesitate to reach out to us for help!

Living with A Narcissist

Leaving a narcissist may not always feel like an option, especially if the narcissist is a loved one.

Does this mean that you have no choice but to quietly tolerate the other party’s behaviours that may at times be selfish, hurtful or manipulative?

We will be discussing what it’s like to live with someone who engages in frequent narcissistic behaviours and what you can do to protect your own emotional well-being.

Are you living with a Narcissist? 

Everyone prioritizes themselves and their own needs to some degree. Putting one’s own needs first is actually healthy when it is not at the expense of others. However, narcissists are self-absorbed to an extreme extent. Some hallmark signs of narcissism is the tendency to disregard the needs and feelings of the people around them and fail to comprehend the effect of their behaviour on others. While narcissism varies on a spectrum, people with high levels of narcissistic traits may have Narcissistic Personality Disorder (NPD) and they exhibit more extreme self-centred behaviours. 

If you are unsure whether you are living with a narcissist, here are some signs in the person that you can look out for – a narcissist often possesses or exhibit the following: 

Ψ Lack of empathy: They are often unwilling or unable to empathize with the needs, wants or feelings of others. 

Ψ Unapologetic for hurting others: As they do not understand the effects of their behaviour on others, they do not take responsibility for their actions. They rarely apologise, unless the apology brings benefits. 

Ψ A grandiose sense of importance and entitlement: They believe that they are superior and have to be treated specially. Others should obey their wishes. 

Ψ Often overreact to criticism: They react strongly or may become abusive to the slightest criticism. 

Ψ Manipulative behaviour: They may gaslight and mislead you into thinking that you or your own experiences were wrong. They might deny saying things or claim that you are being overly sensitive. They might accuse you of misunderstanding the situation. 

How to Cope with Living with a Narcissist

It is natural to feel helpless when dealing with a narcissist. While changing a narcissist could be a potential solution, another more viable solution would be to make peace with the fact that you are living with a narcissist. Here are some suggestions on ways to cope with living with a narcissist:  

Ψ Refrain from blaming yourself 

Narcissism occurs due to a multitude of reasons such as genetics, early maltreatment or abuse, trauma and parenting.  

It is natural and even easy to feel that their behaviours are a personal attack or that you are responsible for their actions. This feeling of responsibility is experienced especially when emotions run high or when the narcissist exhibits blaming behaviour. Such thoughts may occur even if you are fully aware that their narcissistic behaviour has nothing to do with you while you are in a logical and calm state of mind.  

It is important to effortfully and constantly remind yourself that you are not responsible for their actions and recognize that while you can try your best to encourage them to get help or communicate with them, their behaviours are ultimately still beyond your control. 

Ψ Get in touch with your feelings  

Be honest with yourself without any judgement. It may feel uncomfortable at first especially if your feelings have been invalidated for most of your life. Know that it is normal to feel hopeless about your relationship with your narcissistic parent, and helpless that you can’t change them or guilt due to feeling like you should have done more. Be aware of any narcissistic habits you may have picked up from them over the years or any tendencies to be attracted to narcissistic partners. 

If you find yourself experiencing a lot of negative emotions and feeling overwhelmed, instead of pushing them away, simply let yourself sit with these emotions. It is natural to want to shun away from difficult emotions, however avoidance will only cause these emotions to perpetuate or even escalate in the long run. Difficult and negative emotions are like a cactus you hold in your hand. If you try to push them away, the cactus will prick you. But if you just observe it and let it be, you will not get pricked. Try pausing, taking a breath and noticing your emotions. 

Ψ Set healthy boundaries 

Setting firm boundaries on what you are willing and not willing to accept or tolerate. These boundaries are created not with the aim of changing the person, but to build a relationship that is both physically and psychologically safe. Communicating (and reminding) the other party of the boundaries you wish to establish is important. Staying firm with your boundaries with no guilt and shame is important too. Enforcing these boundaries may be difficult especially at the beginning but remember that they are essential. Click here for more tips on setting and enforcing boundaries!

Ψ Seek social support 

Living with a narcissist can be draining, both mentally and emotionally. Surrounding yourselves with people that care for you and are supportive is therefore pivotal. Talk to you close ones whom you trust that would offer you some emotional support and perspective. Let them know how they could best support you.   

Ψ Get professional help 

Whether you are currently living or used to live with a narcissist, we encourage you to speak to a therapist.

Your therapist can offer you a psychologically safe space to offload some of the emotional stress you experience or have experienced. They may offer new perspectives and help you reconcile with difficult experiences. If you are currently living with a narcissist, they can problem-solve with you and help you develop interpersonal skills that are effective when communicating with a narcissist. You could learn how to identify signs of gaslighting, discuss ways to set clear boundaries and develop assertiveness under the guidance of the therapist. They can also help to target any emotional repercussion that may have result due to your living environment. 

Let’s Recap 

Living with a narcissist is not easy. Keep in mind that what you are experiencing is never your fault. Remember that you are not the problem and be gentle to yourself. You may feel alone but remember that there are options and support. While you have less control of the narcissist’s actions towards you, you are in control of the solutions you seek for yourselves. It’s okay to seek help from a professional or create strong boundaries for yourself to protect your mental well-being. 

Coping with Insecurities

You may feel a lot of self-doubt, questioning your capabilities and achievements. You may be engaging in negative self-talk – “No one wants to hang out with me because I’m ugly, boring, and useless”.

Interacting with an emotionally insecure person may also be difficult because (1) you may find it challenging to think of an appropriate reply to their expressed negativity, and (2) some individuals can get very defensive when topics of their personal insecurities are brought up, regardless of intentionality.  

Why do people feel insecure?

Ψ Insecure parent-child relationship and attachment

Emotional security develops from as early as childhood, when personal parent-child relationship(s) are critical.

When an individual does not have a secure base during childhood (inconsistent support, caregivers(s) not readily available to meet their needs, lack of validation and comfort during distress, etc), they may grow up with an insecure attachment. An insecure attachment refers to feelings of uncertainty and fearfulness of what is to come. During adulthood, this manifests as individual charactered by a poor self-image and high levels of anxiety.

People who experience high levels of insecurity also tend to have a highly critical inner voice. This critical inner voice may stem from traumatic or painful early life experiences that the individual either experienced or witnessed firsthand, or indirectly through close others.These experiences can be unconsciously integrated as one grows up and expressed as patterns of destructive/sabotage-like thoughts towards oneself and/or others. 

The expression of negative affect from one’s parents during childhood until adolescence also contributes to emotional insecurity. Examples include hostility and/or irritability expressed towards the child or another individual in the presence of the child. 

Ψ Personal experience coupled with internalization problems  

Emotional insecurity can stem from negative experiences encountered by an individual. Examples of such experiences include: failing a task, being rejected by another individual, lack of validation for effort and results). While the effects of negative experiences differ from person to person, we can all agree that being judged by another individual is often daunting and discouraging. 

Ψ Personal difficulties 

An individual with anxiety or depression may be more prone to emotional insecurity due to their core beliefs about themselves and/or others. Perfectionist may also find it difficult to keep up to their high and sometimes unrealistic expectations consistently, which leads to feelings of insecurity. 

Managing your emotional insecurities

We are often our biggest and harshest critic.

“How can I be so stupid?” 

“If only I did this and that, it is all my fault.” 

Sounds familiar?  

Getting out of a spiral of negative self-talk is easier said than done. It may seem almost impossible to manage these discouraging thoughts. They can be loud and incredibly persuasive. That said, with sufficient practice, this can be overcome.

1. Establish a clear boundary when it comes to negative self-talk. Instead of having your inner voice speak in first person, attempt to have them in second person. For example, instead of “How can I be so stupid?”, try “How can you be so stupid?”. This allows you to internally process the critics as external rather than internal criticisms. This may be a tough and emotional first step but trust the process.  

2. Think about what thoughts and feelings are triggered when you speak critically towards yourself in a second person perspective. Does it trigger some memories in the past? Do some of the words sound familiar from early life experiences, be it from your parents or friends? This step is helpful in revealing some root causes of the harsh self-criticism(s) and some discrepancies between your true and critiqued self. 

3. This next step may feel a little awkward or unnatural, but stay with us. Pick up a pen or a recorder and write or vocalize in second person one criticism or insecurity. Answer the criticism or insecurity truthfully just like you would to a friend. This step can help debunk some deep-rooted untrue fact(s) about yourself in the present moment. For example, you could have an insecurity about your bloated tummy after a meal. Think about how much your body has done and is doing for you, and the natural processes that occurs before, during and after a meal. Writing or speaking to yourself just like how you would to a friend can bring out the rational and logical side of you, easing the process of debunking some negative self-talks you may experience in your daily life. 

4. Think about how these negative self-talks are influencing/affecting your day-to-day life. Do you catch yourself being highly defensive when someone speaks to you about an insecurity? Catch how these negative self-talks is affecting your life  in terms of your thoughts, opinions, feelings and actions. 

5. This is the last, and possibly the hardest step. Take small actionable steps to change the influence your negative self-talks have on your behavior. For example, if you are internally thinking: “You are going to be rejected from that job.”, and if this usually deters you for going for a potential opportunity, attempt step three, and go for it. It is time to interrupt those negative thoughts depriving you from new opportunities and experiences, unleash your true self. You will feel some form of internal discomfort, from greater anxiety to louder negative inner voice. However, do not give into those voices, pull yourself apart from what they are telling you and through perseverance, they will weaken over time. Think of negative self-talks as evil creatures trying to lure you into their little bubble, depriving you of potentially good life experiences and fruitful learning opportunities.  

Emotional insecurities are normal… until it’s not 

Everyone goes through periods of uncertainty and doubt for various reasons. So, when do you know that your emotional insecurities are getting out of hand?

Ask yourself the following questions:

• Does it affect your day-to-day functioning?

• Are you able to get out of the rut and move on with your day after getting your work proposal rejected?

Should you find yourself struggling to move on with this feeling of inferiority that is disrupting your daily living, reach out for professional help. Our clinical and counselling psychologists strive to create a safe and non-judgemental space to work with you through this journey towards confidence and well-being. Being your vulnerable authentic self helps your psychologist help you.   

Seeking professional help  

Differing based on each individual’s needs, wants and goals, the psychologist will work closely with you to help you better manage your underlying and present difficulties. Behavioural, cognitive and/or affective approach(es) may be adopted. These approaches all have one overarching aim: 

• To challenge unhealthy thoughts/feelings you may have towards yourself 

• Teaching you techniques to overcome these thoughts/feelings 

• Making actionable steps to change your behaviour caused by those thoughts/feelings 

These insecurities may seem tough, or even impossible to overcome. If you find yourself struggling to get by the day due to those internal voices, do not feel afraid to reach out to a mental health professional. Take it day by step and applaud all that progress you make, regardless of how small it may be. You’re not alone in this battle.  

We're Mental Health Workers but our Mental Health Matters Too

With the added demands brought about by the pandemic, healthcare worker abuse has been dominating the headlines in recent times, in both public (https://www.straitstimes.com/singapore/politics/more-healthcare-workers-in-public-institutions-getting-abused-or-harassed) and private settings (https://www.todayonline.com/singapore/clinic-assistants-abuse-patients-gps-be-better-protected-1878696).

 In April 2022, a video (https://www.todayonline.com/singapore/police-probe-clinic-staff-kicked-pram-woman-flung-brochures-1878606) of a clinic assistant shouting and damaging the property of a customer surfaced and made its way around social media. It was later reported that the clinic assistant had suffered physical and verbal abuse from the patient prior to her outburst. 

As a mental health clinic, we empathise with the distress that our patients face. Many of the issues that might bring a person into a mental health setting are immense and debilitating. 

But abuse of healthcare workers, including mental healthcare workers, is also a concerning issue and has been on the rise in recent years. 

The Different Types of Healthcare Worker Abuse

Though we often think of physical abuse as the only form of abuse, abuse presents itself in many guises. The most common form of physical abuse is when a patient makes physical contact with a healthcare worker or throws objects at them. These actions are often unprovoked and can result in serious injury and embarrassment to the healthcare worker.  

More commonly in a mental health setting, healthcare workers experience verbal abuse. Verbal abuse can occur either as outright verbal abuse or what is sometimes known as 'borderline' abuse. Outright verbal abuse happens when a patient berates healthcare workers by shouting, hurling expletives, or making discriminatory or racist remarks. 

Borderline abuse is often less obvious but equally insidious. Such abuse often arises from backhanded or snide comments to healthcare workers, insulting their abilities and qualifications, or being disrespectful. While borderline abuse in isolated incidents might not seem to be as damaging or severe as outright verbal abuse, such abuse can have long-lasting on healthcare workers if sustained over a period of time. 

Mental Health Impact of Abuse on Healthcare Workers

We often forget that healthcare workers are human too.  

We experience and go through the same emotions that you feel. When a mental healthcare worker is constantly dehumanised or verbally assaulted by patients, it takes a toll on our mental health. 

In 2021, the Ministry of Health reported 1,400 cases of healthcare worker abuse, a 16% increase when compared to 2019, prior to the Covid-19 pandemic. In the same span of time, healthcare workers seeking counselling services have increased by 169%. Separately, it was also reported that the safety and well-being of front-line healthcare workers in private clinics are often overlooked as compared to those working in the public healthcare setting. 

Prolonged abuse and lack of appreciation can be traumatic for healthcare workers, resulting in mood and emotional difficulties. Healthcare workers suffering from constant abuse from patients are left feeling unmotivated to carry on with work or plagued with feelings of dread, increasing the possibility of occupational burnout as well. More importantly, such difficulties affect the ability of healthcare workers to provide their best at providing healthcare services to patients and reduce the quality of care received by patients. 

The frequent toll of abuse ultimately results in resignations or leaving the healthcare industry altogether. This phenomenon can have a lasting impact on the healthcare industry, such as longer waiting times due to a lack of manpower, overworked healthcare workers that can compromise on providing a quality healthcare service, and rapidly rising healthcare costs. In the long run, abusive patients ultimately result in lower healthcare quality.

Why do patients abuse healthcare workers?

There are several reasons why patients might unknowingly abuse healthcare workers.  

Some patients might act out due to mental health conditions or because they are not used to seeking medical help. Others might be angry about their condition or the lack of progress made, and some might have faced abuse in similar settings and are projecting their anger onto healthcare workers. 

When someone you care about is suffering from a mental health condition, it's difficult not to be worried. The unknown and a lack of understanding about a medical or mental health condition and its prognosis can be frightening. This overwhelming fear coupled with limited healthcare resources might lead to patients and their caregivers believing that a healthcare worker has uncaring attitudes toward their needs. While this perceived neglect varies by patient and caregiver, they may feel justified in expressing their anger if they feel their medical or psychological healthcare needs are neglected. 

Whatever the reason, it is important to remember that healthcare workers are not responsible for the patient's condition, and abuse towards them will not result in a better outcome for the patient.

Help us help you

At times, it might feel as if the staff is deliberately resisting a patient’s wishes, especially when a patient request is not in line with legal regulations or an internal policy.  

We ask that patients understand that mental healthcare workers have a duty of care to all patients and must follow certain ethical and legal guidelines in order to ensure quality care for all. These guidelines are in place to protect patients, staff, and the healthcare organisation from potential harm. 

Sometimes, what a patient perceives as mistreatment might be adherence to guidelines. For example, a therapy modality might not be clinically indicated or advisable or a patient might want to see a specific healthcare worker when it is not possible due to scheduling conflict.  

Other examples might include:

1. not being able to perform a requested therapy modality, assessment or test.

2. not being able to support a diagnosis or management plan where it is clinically inappropriate.

3. seeking a parent or guardian's consent in respect of a minor before providing non-emergency services.

4. in a private healthcare setting, enforcing a last-minute no-show or cancellation policy to ensure that patients have fair access to limited healthcare services.

5. an obligation to verify that a patient has consented to receive a healthcare service.

How can we work together without abuse?

Healthcare workers usually choose to work in this demanding industry because of our passion for helping those in need. It is important to remember that healthcare workers and patients work on the same team; both share a common goal of providing every patient with the help and support they need.  

If you are feeling frustrated, try to communicate your feelings in a calm and respectful manner. We want to help you, but we can only do so if we can understand what you need. If you remain unhappy with a response made by staff, we recommend that you speak to a manager or supervisor about your concerns rather than expressing their frustrations to the healthcare worker in question.  

We take each and every complaint seriously. When a complaint is received, our management conducts a thorough investigation into the circumstances of the complaint. If a complaint is valid, we will take the appropriate disciplinary action against our member of staff. Disciplinary outcomes for staff include counselling, supervision by managers and/or clinical supervisors, compulsory refresher or training courses, issuance of verbal and written warnings, being placed on administrative leave, or in appropriate circumstances, being asked to leave the organisation. 

At the same time, we have an obligation to ensure that our colleagues feel safe in their work environment. We do not tolerate any form of abuse towards our staff whether physical or verbal. We will refuse service to anyone who engages in abusive behavior. 

We're Mental Health Workers but our Mental Health Matters too.

Coping with Betrayal: Healing from Broken Trust

中文版

When someone you love breaks your trust & heart

Betrayal can hurt as badly as a physical wound. Do you allow the hurt feelings to hold you captive or put them behind you? How do you move past the hurt and begin to heal?

What is betrayal?

Betrayal comes in many forms. Not limited to infidelity, betrayal can include breaking promises, lying or withholding information, not prioritising a relationship, or disclosing information that was shared in confidence. It can be experienced by anyone, and is not exclusive to any gender. 

Why does betrayal hurt so much?

Betrayal entails the violation of someone’s trust and confidence. When people enter a committed relationship, they agree to live by the core values of a relationship (e.g., trust, commitment, respect). When one partner breaks the bond of trust, it erodes the foundation of the relationship. It affects the betrayed partner’s self-esteem and makes them doubt their self-worth. It also leaves the betrayed partner feeling confused as they begin to doubt everything the betrayer has said and done. People who have been betrayed may find it difficult to trust people, which hinders them from forming meaningful relationships.

View this post on Instagram

A post shared by Annabelle Psychology (@annabellepsychology)

How do I cope with betrayal in a relationship?

Ψ Acknowledge the betrayal

The betrayal might have come as a shock to you. It is often difficult to wrap our minds around how and why a trusted confidante would betrayed you. However, to heal, you need to recognise and accept that the betrayal has happened. This does not mean that you are fine with it but as a stepping stone, you need to acknowledge that the act took place. 

Ψ Name your emotions 

Anger, sadness, disgust, insecurity, and loneliness — You might experience a whirlwind of emotions in the aftermath of a betrayal. These are legitimate feelings of betrayal. Do not deny or suppress them. Label these feelings. You may even want to write them down. 

 Ψ Spend time apart 

Avoid the person physically and electronically, if possible. Taking time away will reduce the intensity of your negative emotions, placing you in a better position to rationally think and process what had happened. You should not feel pressured to make a decision in response to the betrayal.

Ψ It’s ok to grieve

Allow yourself to grieve the relationship that you have lost. In some cases, you may also be grieving the future that you had imagined. During the recovery process, you may experience the five stages of grief: denial, anger, bargaining, depression and acceptance. Note that this is not a linear process. You may find it helpful to journal your thoughts and what you felt are your losses.

Ψ Resist the temptation to retaliate 

It is normal to feel the urge to get back at the person who betrayed you and make them suffer. Planning revenge will only delay your healing process, and prolong your pain. 

Ψ Talk to a confidante 

Emotional support from your loved ones will be crucial during this stressful time. Speak with someone whom you trust. If you are not comfortable, you need not share what happened. You can share your feelings and thoughts about the incident, or just seek companionship from your loved ones. It would be best to find someone who can stay neutral, and not add fuel to the fire. 

Ψ Reflect on the relationship  

Examine your relationship, and be realistic about it. Some issues might have existed in your relationship before the betrayal. Your relationship did not turn sour overnight. It would be a good time for you to figure out how much the relationship means to you to determine if you should salvage or end the relationship. After gaining insights into the problems, you could then think about how things need to change should you and your partner wish to continue the relationship.  

An example of a thought journal to help you to better understand the links between your thoughts and feelings, and make sense of them

Ψ Have a conversation with the person 

When you feel ready, have a conversation with the person who betrayed you. Let the person know how their actions made you feel. To prevent the person from getting defensive, try to focus on the impact on you rather than what they did. One way would be to use the “I” statements which starts with “I”, e.g.., “I felt hurt and angry when you…”. 

Allow the person to share their side of the story too so that you can understand how the betrayal came about. Note if they are trying to defend their actions or genuinely seeking forgiveness. 

Ψ Try to forgive 

See if you can forgive the betrayer. Forgiveness does not mean condoning the action; it is deciding to move past the hurt and move on with your life. Forgiveness is for you, not for the other person. Feelings of resentment and bitterness from the lack of forgiveness will take a toll on your physical and emotional well-being. 

If you wish to continue the relationship, forgiveness will be crucial to bring the relationship forward. You could let the person know that you have decided to forgive them but explain that it will take time for you.

Ψ Decide how to take the relationship forward 

You have to decide if you want to forgive the person and rebuild the relationship, or end it for good. You may also consider a temporary separation as an option. Some considerations underlying this decision include: 

• Is the person a repeat offender? 

• Was it unintentional? 

• Does the person acknowledge the pain that they have inflicted on you? 

• Is the person genuinely remorseful? 

• Has the person accepted responsibility for their actions? 

Ψ Be kind to yourself 

You may feel somewhat responsible, and wonder what you might have done wrong. Do not blame yourself for the betrayal. The person has to take responsibility for their actions. 

Forgive yourself for saying and doing things on the spur-of-the-moment when you discovered the betrayal. 

Be patient with yourself. Recovering from the hurt is a tough journey. Do not rush yourself to move on. Engage in self-care activities such as eating well, getting enough sleep, and spending time doing things you enjoy. 

Ψ Seek professional help 

If you find yourself ruminating on the betrayal and hurt, or your behaviours have changed since the betrayal and they are impairing your daily life, seek guidance from a mental health professional. Professional help could also address the damage the betrayal has caused to your sense of identity, self-esteem, and sense of security. Seeking help is a sign of strength, not weakness.  

If you are dealing with romantic betrayal, you could speak with our marriage and family therapists (Ling Ling and Wendy) and our clinical psychologists who have experience working with couples who struggle with marriage and family difficulties (e.g., Yuka).  

Moving past from the hurt of a betrayal is a painful and difficult journey. Some days may be tougher than the rest where you just wish to wallow in self-pity and wound the betrayer back. These responses and acute negative emotions are normal. The key is to remain kind to yourself and lean on your loved ones throughout this recovery process.

Coping with Suicidal Thoughts: You Are Not Alone

You’re in pain. You feel numb. This is a time in your life that the pain is so overwhelming that it seems like there is no way out. When this happens, suicidal thoughts may swarm your mind, (erroneously) presenting itself as the only solution.

Often, it’s not that you want to end your life, but rather, are seeking an escape from the unbearable pain and numbness.

You are not alone. Many others have experienced this pain and entertained suicidal thoughts – in 2020, Singapore recorded 452 suicide deaths while Samaritans of Singapore (SOS) reported over 39,000 suicide and crisis related calls. 

Many, however, struggle alone with their pain in our local mental health landscape where suicide is deemed taboo. It’s high time we embrace conversations around suicide. Let’s start by going through what may keep you afloat in what appears to be a rip current.

How to Cope with Suicidal Thoughts

Ψ Focus on getting through today

Your pain and suicidal thoughts may seem overwhelming in the moment. You don’t have to act on your thoughts now. You may have had them previously. Recall how the distressing emotions and suicidal thoughts came and left. How you feel today may not be how you feel tomorrow or the week later - feelings will pass.

Ψ Create a crisis/safety plan

The gist of a safety plan is to list the key things you can do to keep yourself safe during a crisis. This is an extremely important step, and we care for you and have created a template for your own safety plan. Fill in the plan and keep it somewhere you can easily access and refer to it whenever the urge to hurt or kill yourself arises.

You could write down the people whom you can contact to help you feel better and the places where you would feel safe (e.g., your bedroom, friend’s house).

Stay away from things that you could use to harm yourself, such as pills and razor or even keys that unlock your window grills. Get a trusted friend or family member to safeguard them on your behalf until you are more in control of your thoughts and feelings.

View this post on Instagram

A post shared by Annabelle Psychology (@annabellepsychology)

Ψ Ground yourself in the present reality

Grounding techniques work when we might feel like our mind’s just spiralling out of control, and we’re being pulled in all directions because of it.

To gather back the control of our minds or focus, take a few moments to try out the 5-4-3-2-1 grounding technique:

• Name 5 things you can see (like the colours on this page),

• Name 4 things you can feel (like the phone or device in your hand),

• Name 3 things you can hear (like birds, music or people talking)

• Name 2 things you can smell (like hand creams, perfumes, coffee)

• Name 1 thing you can taste (like a mint, tea, food)
  

Ψ Engage in activities you enjoy (or once did)

This could look like spending time with your family and friends even if you do not talk about your feelings, going for a walk in the park, watching a movie and playing games. 

Engage in those activities even if your body and mind tell you not to, and note how you feel after.

Ψ Create a gratitude (or ‘reasons why’) list

Make a list of the things that you are thankful for in your life. Think about your family and friends whom you love, the sights and sounds that you can experience and delight in. You could also affirm your strengths.

These are the reasons you continue going, the kind of reality you wish to build for yourself that helps make space for your pain, but also comforts you in the hard moments. This is the version of you, and your life, that you would be proud of.

Ψ Seek support and reach out

Don’t fight this battle alone.

Asking for help is hard, but it is the bravest thing you can do for yourself. Reach out to someone you trust to share your feelings and how you have been coping or struggling. They may be startled when they first hear about it but know that they want to help. Let them know how you want them to support you if you have an idea (e.g., check in on you every night, call the emergency hotline for you during a crisis). 

Besides approaching your friends and family, you could join a support group. It is a powerful tool that helps you feel supported. People with similar experiences would come together to share their struggles and tips to overcome them.

If you find it too hard to talk to a loved one and you just want to hear a voice, call the crisis helpline. They could help to direct you to relevant resources or professional help. 

Lastly, connect with an experienced mental health professional who will work with you to manage your difficult emotions and suicidal thoughts in a safe, nonjudgmental, and supportive space.

Cognitive Distortions

What are Cognitive Distortions?

And how can we try to reduce them?

“Nobody likes me.”

 “I just failed that exam. I am such a failure in life.”

“I can’t trust anyone; everyone is going to end up hurting me.”

Credit: Just Passing Time

Do these thoughts sound familiar to you?

They are all prime examples of cognitive distortions – thought patterns that can cause you to perceive yourself, others, and the world in inaccurate and negative ways!

Cognitive distortions are habitual errors in thinking and most of us experience them from time to time. Although we develop these cognitive distortions to help cope with adverse life events, these thoughts might not be rational nor healthy for us in the long-term, as they can increase the risk for anxiety, depression, and other relationship difficulties.

Understanding Cognitive Distortions: A Comprehensive Guide

The different types of cognitive distortions

There are at least 10 different types of cognitive distortions we experience. These include:

1. All-or-nothing thinking

“If I am not a total success, I am a failure.”

Also known as “polarised” or “black-and-white” thinking, all-or-nothing thinking occurs when we habitually think in extremes, viewing a situation in only two categories instead of on a continuum.

This kind of cognitive distortion is unrealistic and often unhelpful for us because most of the time, reality exists somewhere between the two extremes.

2. Catastrophizing

“I stuttered so much during the job interview, I must surely be rejected. I will never be able to get a job.”

Also called “fortune-telling”, catastrophizing involves assuming the worst when faced with uncertainties, predicting the future negatively without considering other, more likely outcomes. When we catastrophize, ordinary worries can quickly escalate.

While it is easy to dismiss catastrophizing as an over-reaction, people who have developed this cognitive distortion may have experienced repeated adverse life events, such as childhood trauma, so regularly that they have learnt to fear the worst in many situations as a coping strategy.

3. Disqualifying or discounting the positive

“I might have scored well on that exam, but that does not mean I am competent; I just got lucky.”

A negative bias in thinking, you unreasonably tell yourself that your positive experiences, achievements, or qualities do not count, explaining them away as a fluke or abnormality. When we do this often and believe that we have no control over our circumstances, this thinking can diminish our motivation and cultivate a sense of “learned helplessness”.

4. Emotional Reasoning

“I feel like a failure, therefore I must be a failure, otherwise why would I feel this way?”

Emotional reasoning is the false belief that your emotions are the truth, and they are an accurate depiction of reality, whilst ignoring or dismissing evidence that suggests the contrary. Although it is important to listen to, validate and express your emotions, it is equally crucial to judge reality based on factual evidence! This is a common cognitive distortion even amongst people without anxiety or depression.

5. Labeling

“Since she arrived late, she must be a lazy and irresponsible person.”

You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less negative conclusion. This often happens when you judge and then define yourself or others based on an isolated event. The labels assigned are usually negative and extreme.

Assigning labels to others can impact how you interact with them. This, in turn, could create friction in your relationships. When you assign those labels to yourself, it can also hurt your self-esteem and confidence, leading you to feel insecure and anxious.

6. Magnification / Minimization

“Getting a mediocre evaluation just proves how inadequate I am.” -- Magnification

“Getting high marks doesn’t mean I’m smart.” -- Minimization

Have you heard the popular phrase, “Don’t make a mountain out of a molehill?” Well, there is a reason why many often do that! When you evaluate yourself, another person, or a situation, you might unreasonably magnify the negative and/or minimize the positive.

7. Mental Filter

Is the glass of water half full or half empty?

“Because I got one low rating on my evaluation [which also contained several high ratings], it means I’m not performing good enough.”

Mental filter is also known as selective abstraction when you dwell excessively on one negative detail instead of seeing the whole picture. Even if there are more positive aspects than negative in a situation or person, you focus on the negatives exclusively. Interpreting circumstances using a negative mental filter is not only inaccurate, but it can also worsen anxiety and depression symptoms. There is research that having a negative perspective of yourself and your future can cause feelings of hopelessness. These thoughts can become extreme enough to even trigger suicidal thoughts.

8. Mind Reading

“What a grim expression he has! I must have done something bad to offend him! This must be why he seemed so distant from me nowadays.”

Also known as “jumping to conclusions”, mind reading involves you believing that you know what others are thinking or feeling, while failing to consider other evidence or more likely possibilities. Then, you react to your assumption. This thinking error is often in response to a persistent thought or concern of yours.

9. Overgeneralization

“Because I felt so uncomfortable and awkward during the meeting, I don’t have what it takes to make friends. Oh no, I am destined to be alone!”

When we overgeneralize, we tend to make a negative conclusion about one event and then incorrectly apply that conclusion across other different situations in the future. Overgeneralisation is associated with Post-Traumatic Stress Disorder (PTSD) and other anxiety disorders.

10. Personalisation

“My parents are fighting again. It’s all my fault.”

One of the most common thinking errors is taking things personally when they are not connected to or caused by you at all. You might be engaging in personalisation when you blame yourself for negative circumstances that are not your fault or are beyond your control. Another instance is when you incorrectly believe you have been intentionally excluded or targeted, without considering more plausible explanations for others’ behaviours. This distortion is associated with heightened anxiety and depression.

11. “Should” and “Must” statements

“It’s unacceptable that I was late – I should always be on time.”

These imperatives are subjective ironclad rules you set for yourself and others without considering the specifics of a circumstance. You have a precise, fixed idea of how you or others should or must behave with no exceptions, and you overestimate how bad it is that these expectations are not met. Yet when circumstances change, and things do not happen the way you want them to – they really depend on many factors – you feel extremely disappointed, angry, or upset.

12. Tunnel Vision

“My life sucks. I have the worst life.”

Just like being in a dark, isolated tunnel, you only see the negative aspects of a situation when you have tunnel vision.

---

How to reduce cognitive distortions: A guide

Remember that it’s often not the events but your thoughts that upset you in many instances. You might not be able to change the events, but you can work on redirecting your thoughts!

What do you see these thinking errors as having in common? Does it strike you that a common thread among these distorted automatic thoughts is the failure to take in all known information and to explore realistic outcomes based on evidence? 

The good news is that cognitive distortions can be corrected over time. Here are some steps you can take if you want to change thought patterns that may not be helpful.

Steps to Identify and Challenge Distorted Thoughts

Ψ Identify the distorted thought: the first step to change

• When you notice your self-talk is causing you anxiety or worsening your mood, you can practise mindfulness and recognise what kind of cognitive distortion is taking place.

Ψ Conduct a reality check

• Ask yourself if your thoughts are really accurate and check if there is any existing evidence that supports or contradicts it.

Ψ Reframing the situation

• Look for alternative explanations, objective evidence, and shades of grey to broaden your interpretations.

• It might also be helpful to create a thought record by writing down your original thought, followed by three or four alternative explanations based on the evidence available to challenge the cognitive distortions.

• Example: Instead of thinking “I have a miserable life since all my plans are ruined”, try reframing your thoughts to “It’s okay; it’s just a bad day, not a bad life. Plans change and I can adapt.”

Ψ Putting things in perspective

• Even if your negative thoughts about yourself, others or the situation are accurate, ask yourself if it will still be important in the grand scheme of things, and whether it will matter a week or month from now. Chances are, they most likely won’t.

Ψ Perform a cost-benefit analysis of your thoughts

• Behaviours are often reinforced and repeated when they are perceived to be beneficial in some way.

• If you find yourself often engaging in cognitive distortions, you might find it helpful to analyse how your thinking patterns have helped you cope in the past. Do they invoke a sense of control in situations where you feel helpless? Or do they allow you to avoid taking responsibility or necessary risks?

• You can also identify the potential costs are of engaging in cognitive distortions. Weighing the pros and cons of your distorted thinking might motivate you to replace them with more balanced, positive thoughts.

Ψ The role of Cognitive Behavioural Therapy (CBT)

• What is CBT? CBT is an evidence-based psychotherapy where people learn to identify, challenge and change unhealthy thinking patterns. If you need additional guidance in identifying and altering cognitive distortions, then you may find CBT helpful.

• CBT usually focuses on specific goals. It generally takes place for a predetermined number of sessions and may take a few weeks to a few months to see results.

• You may consider looking for a therapist who is properly certified and trained in CBT, and ideally has experience addressing your type of thinking pattern or issue.

In summary, cognitive distortions are negative thinking patterns that impact how you see yourself and others. When our thoughts are distorted, our emotions are, too. By becoming aware and redirecting these negative thoughts, you can significantly improve your mood and quality of life.

Reach out to a mental health professional if you need additional help!