The Ones We Carry: When Clients Don't Make It Out of Narcissistic Abuse
- 21 hours ago
- 9 min read
I couldn’t sleep last night. I was thinking about a client—as we often do. A couple weeks ago, she called to tell me she was terminal and likely had less than nine months to live. She cried as she told me she hadn’t gotten out of the relationship in time and felt her health was a direct result of the stress he had caused her. That it was too late. That at the end of her life, she wouldn’t find peace.
We agreed to keep working together as she processed the news and explored treatment options.
She canceled our next session for an emergency surgery. After a couple attempts to reach her, I didn’t hear back.
Last night, with a sense of dread, I searched local obituaries. She had passed a couple weeks ago.
As I read the obituary, I felt anger rise in my chest. It described her “loving husband.” The same man she had been desperate to get away from.
This is the part of the work we don't talk about enough.
The reality that sometimes, despite insight, effort, and support, not everyone makes it out.
The Ones We Carry as Therapists
Client deaths are heart-breaking. Therapists think about their clients more often than people might realize - even long after sessions end. We spend more time with you than our own families and friends sometimes and we are invested in your health, goals and successes. But this means we also feel your disappointments, injustices and grieve your setbacks, losses and even deaths.
This client is the 4th client I have lost to death since becoming a therapist. Each one has left an imprint on my heart. I wish I had begun seeing them sooner, under different circumstances, that things had ended differently.
One had died of a heart attack after calling in that week to get back on the schedule and take back their life.
One died of cancer after successful therapy treatment but died alone as he had taken too long to make amends and his family had passed away.
The last, had argued with me in a relapse prevention class that he had overdosed three times, but didn't want to die. This was the last conversation I had with him before he died of an overdose.
When Clients Don't Make It Out of Narcissistic Abuse
But these are not the only client stories I carry. As I moved away from addiction to the domestic violence arena, I've often held my breath when stories of murder-suicides come out in the areas I work, skimming articles to confirm it wasn't a client. I have worried for client safety outside our sessions often, breathing a sigh of relief when they arrive safe during the next session.
While our goal is always growth and successful treatment outcomes, we have to acknowledge the other side of the coin; sometimes clients aren't fully ready, run into obstacles that prevent counseling follow-ups such as financial set-backs or moving out of a counselor's licensure limits, or relapse (both in addiction and to toxic relationships).
We do not get to see every client to the end, and these clients are often the ones I think about the most. The ones who fall off while I continue to hope and dream for their health and peace one day, without ever knowing if they get there.
The Reality of Narcissistic Abuse and Why Leaving Is Complex
It is never as simple as it seems. The tactics of coercive control, manipulation, and abuse create power cycles that lead to trauma bonds, physiological responses like dopamine surges, and an inability to freely walk away.
Leaving is also the most dangerous time for someone trying to escape a controlling relationship. And beyond safety concerns, many clients are navigating deeply rooted beliefs, fears, and practical barriers that keep them stuck.
Why Someone Might Stay
Clients often wrestle with a combination of emotional, cognitive, and external factors:
Emotional & Psychological Barriers
Fear of being alone
Not trusting themselves to choose a better partner
Shame around a “failed” relationship
Belief they don’t deserve better
Hope their partner will change
Cognitive & Relational Patterns
The relationship feels familiar or normalized
Minimizing the severity (“others have it worse”)
Fear of dating again or starting over
Attachment to the chemistry or connection
External & Practical Constraints
Financial dependence
Fear of retaliation, stalking, or harassment
Concern about the partner’s mental or physical health
Lack of a support system
Cultural, religious, or familial pressures
Shared responsibilities (children, vows, obligations)
What Actually Leads to Change
Despite these barriers, research by Murray et al. (2015) identified several turning points that often precede separation. These are not quick decisions, but shifts that build over time:
Facing the threat of severe or escalating violence
A shift in perspective about the relationship or abuse
Learning and understanding the dynamics of abuse
External intervention or consequences
Recognizing the impact on children
The relationship ending by the abuser or other circumstances
In my work, I often begin with education—helping clients understand what abuse is and how these dynamics function. This awareness can create the foundation for perspective shifts and deeper insight, including recognizing the impact on themselves and their children.
Even then, leaving must be a client’s own decision. When it is driven by outside pressure—from family, friends, or even professionals—the risk of returning to the relationship remains high.
Understanding Femicide and Escalation Risk
While most of my clients do not report physical abuse, and swear up and down they do not believe their partner would physically hurt them, emotionally abusive relationships do not need to escalate to a physical thresh-hold to maintain control. Loss of control in a relationship, typically as a victim prepares to leave, upsets this balance and can lead to new tactics (including physical violence) to reset the power.
The most dangerous time for a victim is when they are preparing to leave.
Femicide is a term that refers to gender motivated homicide, most often committed by intimate partners such as boyfriends or partners. Jane Monckton-Smith (2020) has studied patterns of intimate partner femicide particularly in the UK. Her research, based on a femicide census, Counting Dead Women (studying over 372 femicide cases between 2012-2015) in the UK found an alarming pattern, where relationships that included intimate terrorism were at the highest risk for homicide and noticed an 8 stage pattern that predicated femicide.
Her research identified a clear pattern that often precedes intimate partner homicide:
Stage 1: Pre-Relationship-History of controlling patterns, domestic violence and stalking was present in every case where a pre-relationships history was recorded. Many victims hear reports of previous abuse but discount them or do not believe them
Stage 2: Early-Relationship-The relationship was sped up for commitment, and there was a marked change from before commitment to behavior after commitment.
Stage 3: Relationship-Controlling patterns are seen in every case, including stalking and monitoring, lack of trust, strict rules, and comments like "its better to just do what he wants". Consequences at this state are not always violent, but there is regularly a potential for violence. Certain types of abuse maybe justified or minimized because victim "acquiesced" to the pressure and therefor would blame themselves. When control is maintained, the man typically would not move to end the relationship.
Stage 4: Trigger Event - Overwhelmingly this was around withdrawal of commitment or separation, whether real, imagined or threatened. Statements made such as "If I can't have you, no one can" and "I'll decide when this marriage is over and I will let you know my decision" or "You're mine and you always will be"
Stage 5: Escalation-When the control begins to slip, there will be an increase in frequency, severity or variety of abuse, stalking or control. A victim might see them flip through manipulative tactics from sentence to sentence, and may alternate between loving and hateful language very quickly. You might see begging, crying, love bombing, threats, violence, stalking and even suicide threats. Stalking was highly correlated with this stage, whether following or information gathering.
Stage 6: Change in Thinking-May be due to a perceived loss of control, status or at the end of the escalation, and the perpetrator may begin to shift thinking to homicide. These shifts are likely to be connected to feelings of injustice, entitlement to act, and cultural or social beliefs that there would be solidarity with the perpetrator. This paired with ideologies of the system is against them, the ex-partner is to blame and the perpetrator is the victim all raise the level of threat.
Stage 7: Planning-Planning varied in the cases studied but the duration was anywhere from a couple hours to 12 months.
Stage 8: Homicide-There did not seem to be any consistency in manner of death, but sometimes included extreme levels of violence, even in cases where the perpetrator was a previously non-violent person and was not related to the level of violence in the relationship.
Most cases I work through in narcissistic abuse check the boxes from 1-5, and very often include stage 6 which is highly evident in high-conflict divorce and custody cases, where post-separation abuse continues long after separation. While the UK has done their research and began criminalizing coercive control and stalking, the US has a long way to go. Each state has different laws regarding what Domestic Violence is, and many do not include coercive control, stalking or harassment.
The impact of femicide and domestic violence extends beyond the victim—it ripples through families, communities, and the professionals who work with survivors, but it is preventable.
The Long-Term Effects of Chronic Fight-or-Flight in Narcissistic Abuse
The study of adverse childhood events was a landmark study that connected trauma (particularly in childhood) to long-term health issues. Clients caught in the cycle of toxic relationships (often beginning in childhood) end up living in a state of constant stress. Their baseline becomes fight-or-flight which breaks down the body over time, leading to serious health problems. It is not uncommon for my clients to suffer from one of the following:
Cardiovascular disease
Immune system suppression-including autoimmune disorders
Anxiety and depression
Chronic pain and fatigue
Digestive disorders
Hormone related disorders
and more
We already reviewed why someone might stay, but the physical and emotional toll accumulates over time, sometimes resulting in premature death or severe illness as in the case of my client who just passed.
A Final Reflection on Narcissistic Abuse and Survival
If you’ve made it this far, thank you. This has been a heavy post, and I don’t take lightly what it means to sit with stories like this.
And while this work holds grief, it is not without hope. Counselors would not continue showing up if we didn’t also witness healing. Many of my clients do find peace, clarity, and self-compassion—often discovering things they didn’t yet know they needed.
Counselors walk alongside their clients through the full gamut of life—and sometimes, that journey includes death. My work now is to sit with my own emotions, lean on my coping skills, and utilize my support systems so I can continue to show up for the clients who are still here.
I believe knowledge is power. The more we understand about narcissistic abuse, coercive control, and the realities of these relationships, the more opportunities we have to intervene earlier, to support more effectively, and in some cases, to prevent harm.
If this resonated with you, consider sharing it with someone who may need it. Thank you for taking the time to read, to learn, and to be part of a broader shift toward awareness, compassion, and change.
What Can You Do?
If you find yourself in patterns of control, emotional abuse, or fear, consider seeking professional support. If not with me, there are many qualified therapists who can help guide you through this process.
Raise awareness about types of abuse, femicide and the warning signs
Share this post!
Check out my free download "Types of Abuse" on my website store or consider purchasing my first two workbooks to begin your journey.
Continue to support your loved ones that may be in this space, even when it is frustrating that they continue to go back or don't leave, your withdrawal of support could further isolate them, driving them further into their stuck place
Support organizations that provide safe spaces and resources for survivors.
Check my resource page for some of these organizations
Encourage community involvement in changing state policies to better protect victims
Research your domestic violence laws in your state, visit womenslaw.org for more information.
Explore the growing US Femicide Census, visit: womencountusa.org/home.
*Felitti, V., Anda, A., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998). “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults”. American Journal of Preventative Medicine. 14 (4) p245-258.
*Monckton-Smith, J. (2020). Intimate Partner Femicide: using Foucaldian analysis to track an eight stage relationship progression to homicide. Violence Against Women, 26 (11). Pp 1267-1285. Doi: 10.1177/1077801219863876
*Murray, C. E., Crowe, A., & Flasch, P. (2015). Turning points: Critical incidents in survivors’ decisions to end abusive relationships. The Family Journal, 23, 228-238. DOI: 10.1177/1066480715573705
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