Not infrequently, fellow doctors enter my psychiatric practice in bewilderment. Some of them won’t immediately say, “I’m addicted.” Instead, they say things like, “I’ve been working a lot… and I’ve been drinking a lot, too.”
They are here because they cannot come to terms with the way they got caught up in it. Addiction was meant for other people.
Addiction is not a lack of intelligence or drive – which is exactly why it is so disorienting for us
It would be helpful if addiction respected IQ or postgraduate degrees. But data – and clinical experience – tell us otherwise. Not only are doctors not immune to addiction; we are more vulnerable to it. High-performing professionals report above-average rates of substance use disorders. For example, the point prevalence of alcohol use disorders among female surgeons is 26%, compared to the overall prevalence of 8% among women in the US.
The truth is that knowledge and training do not protect against addiction. In fact, they can camouflage it longer and make it more difficult to deal with.
Stress is a factor – but not the mechanism
Yes, practicing medicine is inherently stressful. Long hours, emotional burdens, regulatory demands, existential responsibility. . . they all add weight. But if stress alone caused addiction, every internist, surgeon and nurse would have an addiction.
In addition, populations with low income and low education are associated with enormous chronic stress. But data shows that substance use increases with higher education levels. We need to look beyond the simple story that stress is the main driver.
What actually seems to play a role are personality traits and psychological patterns that predate our careers. Or, to put it another way: those factors that preceded us are often leading for us inside our careers.
More information here:
Seeking mental health care as a doctor
Carrying the scars of my upbringing as I turn hardship into success
Doctors and the psychology of overdrive
Most doctors did not end up in medicine. We pursued it with intensity and purpose. That’s not random. The qualities that allow someone to thrive in this area (hyper-responsibility, delayed gratification, internalized validation systems, a love of rewards from our intelligence and dedication) also create risk factors for compulsive overwork and addictive tendencies.
It’s not just about long working days. It is when emotional regulation, identity and security become fused with performance. It’s when rest brings guilt and productivity becomes compulsive.
Development contributors: the hidden factors
Now let’s go through some frameworks to understand the common paths to this problem. One or both of these are often present in high-achieving addicts, but these obviously do not include all.
#1 Early life stress and the desire for control
Difficult childhood experiences – such as being bullied or excluded, abuse, neglect, emotional absence and highly critical environments – often cause people to overachieve as a defense mechanism in adulthood. For some, medicine does not just represent a profession. It is also a fortress for control, security or to prove our worth. No one wants to feel inferior or forgotten.
The problem is: what protects us early on becomes maladaptive if it is never updated. Worse, when our adaptations are rewarded in young adulthood, we only further reinforce a life built around overfunctioning. This positive feedback loop continues later in life until it ultimately destroys us.
#2 Childhood environments that prioritized results
Some clinicians with addiction have not experienced overt trauma, but were raised in an environment where performance was paramount. From grades to awards, success was equated with value. Emotional needs, downtime, acceptance and self-attunement took a back seat.
The problem is that these people often feel a deep internal pressure to achieve something, but at the insidious price of not having internal permission to simply exist. They are productive, but disconnected. This is fertile ground for behavioral addictions, because action feels safer than silence.
The professional identity crisis of addiction
When the very cognitive and behavioral traits that made someone successful become the cause of dysfunction, it is no wonder that high achievers become confused about why they have an addiction and see no way out.
And that’s where treatment often fails. Advice to “slow down” or “set better boundaries” may sound logical, but it completely ignores the complexity of this psychological architecture. If someone’s doctor or therapist offers this as a primary solution, you may want to look for a deeper model.
You cannot brute force your way through an addiction. Of course, that method appeals to someone who thrives on that style, but to no avail. Setting rules for yourself or using logic to reason your way out of addiction simply doesn’t work. Unfortunately, the persistence and cognitive strength of a doctor that produces results in the hospital does not translate into reasoning our way out of the more abstract and emotional struggle of addiction.
More information here:
Burnout is expensive: The financial case for prioritizing mental health
Thriving at Work: What Doctors Get Wrong About Career Happiness
A new path forward: extend the operating system
Here’s the good news: healing doesn’t mean dismantling your professional life or giving up your ambition. Major internal changes lead to different ways in which we deal with our current lives, and not necessarily dramatic outward movements. We want to control our strengths and not throw them away.
I often teach the metaphor of “widening the socket” (an Eastern philosophical concept) in recovery. You still retain the characteristics that led to addiction – your drive for perfection and high performance – but with a greater capacity for emotional presence, calm, connection and other aspects of being human.
The first thing most people do with that idea is strive for a balance between work and play. The problem, however, is that if one’s character is unchanged, the old work ethic can still be played with: playing with too much expectation, pressure, efficiency, goal setting, disappointment, etc. That can be like sports or sports with too much emphasis on efficiency, or perhaps not enjoying them after certain goals or obstacles become stressful. It’s work disguised as play.
Although superficial balance is better than no balance, the ultimate development is to fulfill almost all activities (work or play) with a balance between pressure and calm. Imagine the top athlete who can laugh right after he loses. Or a manager who likes funny jokes or misses an opportunity to attend a children’s event.
It is not ‘out with the old, in with the new’, but ‘some of the old, some of the new’. In practical terms for physicians, that might mean knowing that our work is high-stakes and important, but relinquishing our grasp on complete control over any outcome. You may take patient care seriously enough to be good and diligent, but you should not try to improve a patient’s life much more than the patient himself tries. Or still be a leader and make an impact, but only to the extent that feels healthy and natural to you.
To address the sublayer of this concept, it’s about no longer having to use achievement as a way to feel more valid or more secure. Instead, we need to develop a more stable and internal sense of who we are, allowing us to more freely decide what we want to achieve in accordance with our natural interests. We want to be guided by a healthy sense of who we are, not by an invisible force trying to heal old wounds. That’s what helps us leave a drink alone, enjoy a quiet evening and maybe laugh a little more.
What do you think? Have you or has someone around you dealt with addiction as a doctor? What methods did you or she use to get through it?
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