The physician who becomes patient: when the narcissistic wound is the greater resistance

There is a specific paradox of the medical profession that is rarely named with the clarity it deserves: physicians, who spend their lives caring for others’ health, fall ill more often and treat themselves worse. Consistent studies over the past decades show elevated rates of depression, anxiety, alcohol use, and suicide in this population — always above the general average. More striking than the incidence is the resistance to seeking help when the condition sets in. Depressed physicians tend to postpone for years the moment of seeking treatment. When they do seek it, they tend to interrupt early. And, often, they self-prescribe along the way.

The current explanation for this pattern turns on two hypotheses: professional stigma — fear that colleagues will talk and that the career will suffer — and lack of time to take care of oneself. Both hypotheses hold part of the truth, but they are not the core of the matter. The core is something else, and its root is in the psychoanalysis Freud left behind. It is what he described, in another context, as narcissistic wound: recognizing oneself in the position opposite to the one on which identity had been sustained. For the physician, that opposite position is the position of the patient. And what resists treatment, in most cases, is not the external world. It is the internal structure that organized itself around a specific identity that being a patient threatens.

This text is about that internal resistance. Not because naming it resolves the problem — the defense operates precisely by not being seen — but because, when the physician recognizes the mechanism in themselves, something loosens. And it is in that loosening that the office door begins to open.

Medical identity is organized around the opposite place

To understand the specific resistance of this group, it is worth recognizing what medical training constructs. The medical profession is organized, from the first years of medical school, around a precise position: the one who knows, who cures, who holds knowledge-power over the body of the other. That position is not merely learned technically — it is internalized as an identity structure. The white coat is not a professional accessory; it is a marker of a symbolic place. The hierarchy within the hospital, the relationship with the patient, the medical language others do not understand, all contribute to consolidate that identity over years.

The problem is that this identity, sustained over decades of training, comes into direct collision with the experience of falling ill. Recognizing oneself as sick requires accepting oneself in the position opposite to the one identity had sustained: dependent, in need of another, without control over one’s own body, without the knowledge that would place the professional in the curer’s position. That collision is not ordinary suffering. It is what Freud described as narcissistic wound — not a passing humiliation, but a rupture in the very structure that had sustained self-esteem and professional identity.

That is why physicians, with a frequency psychiatry has observed for decades, find varied ways of not going through that acceptance. Each of these ways looks rational on the surface. All of them, deep down, serve the same function: keep the identity intact at the cost of one’s own treatment.

The specific defenses of this population

The first defense is self-prescription. It is the most obvious, and the most studied. Physicians with depressive or anxious symptoms frequently write prescriptions for themselves — antidepressant, anxiolytic, sleep inducer. From a practical standpoint, self-prescription is known as poor clinical practice: lack of objectivity, lack of second opinion, lack of follow-up. From a psychic standpoint, it serves a different function: it keeps the physician in the prescriber’s position. He continues to be the one who takes care, even when the care is directed at himself. Identity does not need to be reorganized. The narcissistic defense holds.

The second defense is indefinite postponement. Symptoms that any physician would recognize as an indication for psychiatric evaluation in any other patient are attributed, in themselves, to “excess work,” “difficult phase,” “this heavy week.” Each circumstantial explanation is reasonable in isolation. Added up over months or years, they form a pattern of systematic denial. This is not laziness or lack of time — it is the psychic structure delaying the encounter that would require identity reorganization.

The third defense is the strategic choice of professional. When the physician finally seeks help, they tend to choose a young psychiatrist, from another specialty, from another city — someone not in the same professional circuit. The rationalization is confidentiality, and that part has some truth. But the secondary psychic function is avoiding hierarchical inversion: seeking a psychiatrist who would be peer or senior in the medical hierarchy usually activates more defense. It is more tolerable to be the patient of someone who does not threaten professional identity in other contexts.

The fourth defense — and the most frequent cause of relapse — is premature abandonment of treatment. After two or three consultations, with initial symptom improvement, the physician convinces themselves that they have “already resolved it on their own” and stops. Clinically, it is a premature interruption that almost always worsens again. Psychically, it is the defense doing what it needs to do: reestablish the position of the one who cares before the position of the one who is cared for consolidates.

The role of social stigma — real, but secondary

It is worth honestly recognizing that social stigma also exists, and is not irrelevant. The medical world is small, information circulates, and there is real fear that colleagues will talk, that promotion will be affected, that one will end up seen as fragile in an environment that values resilience. That fear is grounded — it is not paranoia.

The point clinical experience sustains is that, even when external stigma is neutralized — when the physician has access to a psychiatrist outside the circuit, with absolute confidentiality guaranteed, without real risk of exposure — resistance usually continues. Less intense, but still present. This indicates that external stigma is an amplifying factor, not a determinant one. The determinant is internal.

Recognizing this changes what is done clinically. It is not enough to offer confidentiality — though that is necessary. It is also necessary to recognize, in the office, that the very process of accepting oneself in the patient’s position is clinical material, not a preliminary step. It is direct therapeutic work. And that is why treatment of physicians, done well, has its own particularities.

What changes in treatment when this is recognized

A psychiatrist who treats physicians and recognizes the narcissistic dynamic at play does three things differently from generic treatment.

First, they name the defense. Not as accusation, but as recognition. Recognizing that self-prescription, postponement, and premature abandonment are manifestations of a comprehensible psychic structure — not signs of ill will or weakness — frees the patient from feeling ashamed of their own pattern. And shame, once named, ceases to operate in silence.

Second, they propose a setting that respects the psychic hierarchy at play. Longer consultation time, records outside any shared system, care in an environment that is not the same as the colleagues’, clear communication about what stays confidential. This is not preciousness. It is the condition for the defense to loosen.

Third, they integrate the psychotherapeutic dimension from the start. Pharmacotherapy alone, for this population, tends to reinforce the medical model of “take medication and improve,” which is precisely the model within which the defense operates. Integrated psychotherapy opens space for reading one’s own structure at play, allowing elaboration of layers that pharmacotherapy alone does not touch.

The way out passes through recognizing oneself in the place

There is no shortcut for this treatment. What is asked of the physician-patient is that they accept, over the course of the process, an identity reorganization: recognizing themselves as a person before recognizing themselves as a professional, accepting dependence without letting it destroy self-esteem, allowing themselves to be cared for without letting it delegitimize the caregiver they also are. It is not instant acceptance. It is work of months, sometimes years.

But it is possible. And when it happens, the outcome is notable — not only in symptom improvement, but in quality of life, in recovery of the capacity to rest, and in a different relationship with one’s own vulnerability that usually reverberates, including, in a better relationship with one’s own patients.

If you are a physician who has been postponing this treatment for a long time, it is worth recognizing that the resistance you feel is not weakness of character. It is a psychic structure functioning as it has always functioned — protecting an identity it itself sustains. Recognizing that is the first step. The second is looking for someone who understands that dynamic and can accompany it without judgment. That is what a psychiatric evaluation attuned to this profile sets out to do.

Dr. Leonardo Sodré is a medical psychiatrist in Brasília (CRM-DF 14,206 · RQE 14,761), with formal training and interest in psychoanalysis. This content is informational and educational, and does not replace individual clinical evaluation, diagnosis, or treatment.