Suicide and Drug Abuse

in the Medical Community

Bernard Bressler, M.D.

Duke University Medical Center

ABSTRACT: In the United States each year the equivalent of an average-size

medical school graduating class commits suicide, with the highest incidence oc-
curring in the decade following the completion of training. Of these suicides,
20% to 30% are associated with drug abuse and 40% with alcoholism. Various
problem areas are considered. Role strain, leading to excessive drug use in an at-
tempt to increase work efficiency, is coupled with a denial of the physician’s
own dependency needs and gratification. The problem of identity occurs in rela-
tion to the exaggerated sense of duty and obligation the physician feels in attend-
ing to the demands of the patients and their families. Medicine as magical think-
ing is also discussed, revealing the physician’s belief in his own immunity, which
is strenuously tested when he actually sets up in practice. The community’s high
regard for the physician further complicates the situation. Too little has been
done about working with emotional problems of medical students during their
training and after they begin to practice. Unfortunately, physicians feel uncom-
fortable in turning to colleagues for help; rather, they tend to isolate themselves,
resorting to alcohol and drugs. One should question the selection of medical stu-
dents and their overall training, not only in terms of academic learning but also
with more consideration for the stresses and strains of the future career.

Perhaps the most important function of a medical school is the

transmission of knowledge to the next generation. Yet in the United
States each year the equivalent of an average-size medical school grad-
uating class commits suicide (Vincent & Robinson, 1969), with the
highest incidence of such suicides occurring in the decade after the
completion of training (Freeman, 1968). Of these suicides, 20% t o
30% are associated with drug abuse and 40% with alcoholism (Blach-
ly & Disher, 1968; Ross, 1973; Margalis, 1968; Mendlewicz & Wilmet-
ter, 1971). Equally alarming is the incidence of drug and alcohol
abuse by physicians, even when it does not involve suicide. This was
discovered in about 50% of the physicians hospitalized for psychiat-
ric illness, with drug abuse found to be much greater in physicians
hospitalized for psychiatric illness (Vaillant & Brighton, 1970). Drug

Suicide and Life-Threatening Behavior Vol. 6/31, Fall 1976 169

170 Suicide and Life-Threatening Behavior

abuse is found to be much higher in physicians than in the general

population, with the average onset of addiction occurring at a time
remarkably similar to the peak suicide years, namely, at age 38 (Mod-
lin & Montes, 1964). In other words, 5 to 1 0 years after they had
completed medical training and left their medical institutions, the
value of these highly trained professionals was either much curtailed
or wholly lost t o the community. Many authors have noted the seri-
ousness of the problem, and although their estimates differ, the fig-
ures vary from two to three times those for the general population
(Margalis, 1968); Mendlewicz & Wilmetter, 1971). The problem is a
large one and has become a matter of concern not only in this coun-
try, but in other countries as well (Carse, 1974; Kline, 1974; Austra-
lian Medical Association, 1970).
Yet, despite these data, in one instance in which a physician tried
to have provision made by two state medical societies for supervision
of those who had become addicted, he was told, “The problem is too
small to merit attention” (Vaillant & Brighton, 1970). Although these
problems afflict only a minority of the medical community, it is a
fairly large minority and one that would have a great potential for
good if it were able to continue to function. Moreover, cases of sui-
cide and drug and alcohol abuse have rarely been reported in their
totality. Concluding his paper on physician use of mind-altering drugs,
Vaillant stated:

Medical schools must assume greater responsibility for teaching their stu-
dents they represent a high-risk population for drug abuse, and that un-
checked, the virtues of the good physician can increase the risk. (Vallant &
Brighton, 1970)

Role Strain

The concern of this study is not morbid pathology but rather the
association of the hard work and stresses of the physician’s profes-
sional life with a relative excess of drug use, even among well-adjust-
ed physicians. For the less well-adjusted physician, these stresses may
become overwhelming. Role strain, in terms of long hours, demand-
ing patients, overwork, and fatigue, is a prevalent cause of physician
suicide (Margalis, 1968; Modlin & Montes, 1964) and is frequently
offered by addicted physicians as the conscious reason for their use
of drugs (Margolis, 1968; Modlin & Montes, 1964; Australian Medical
Association, 1975).
Role strain, the result of having to perform despite admitted diffi-
culties, is one of the occupational hazards for physicians. In contrast
Bernard Bressler 171

to subculture addiction, physicians may turn to drugs to maintain

their work loads and efficiency, as a means to an end, not an end in
themselves. As Sherlock (1967) pointed out in his study of a small
group of physician addicts, the preferred method of injection was in-
tramuscular, because that route provides a “slower, more manageable
reaction . . . a plateau effect which will reduce tension [and] facili-
tate professional performance. They felt capable of sustained and
even superior effort under trying circumstances.”
These “trying circumstances” are more often due to emotional
conflict and the resulting energy drain than they are to the work per
se. The need to engage in “impression management” exacerbates the
conflict. For even when the physician is faced with fatigue or inse-
curity he feels, because of his esteemed position in the community,
that he must be and appear to be energetic, competent, certain, and
expert at all times. Unready and unwilling to cut down on his work
load, to reduce his practice, or to modify his performance, the vul-
nerable physician insulates himself from stress by turning t o narcot-
ics which, Sherlock found, were preferred to alcohol because the out-
ward signs of usage are less evident.
Sherlock provides an enlightening example of the physician’s need
to perform despite the pressure of inner uncertainty in a senior surgi-
cal resident who, while preparing for his specialty examination, be-
gan to overwork to a marked degree. His accompanying emotional
disturbance was not noticed even when he was actually observed in-
jecting himself with Nembutal. Despite the fact that the signs of this
resident’s problems were obvious, so that his addiction could havc
been dealt with and prevented at an early state, nothing was done.
Unfortunately, in medical school hard work, even excessively hard
work, is approved and rewarded with no apparent awareness of a pos-
sible maladaptive factor. As Vaillant and Brighton (1970) aptly stat-
ed, “Willingness to care selflessly for others may conceal a greater
than average (read ‘greater than healthy’) need to be given to.”
Another aspect of drug use by physicans to increase their work ef-
ficiency (Vincent & Robinson, 1969; Vaillant & Brighton, 1970; Mod-
lin & Montes, 1964; Sherlock, 1967) is the unrealistic belief all too
frequently held by physicians that a drug such as Demerol is nonad-
dictive. This resembles the illusion of many physicians that they can-
not catch their patient’s illness by exposure to it. This attitude, how-
ever, is rooted in magical belief, about which more will be said be-
low. Modlin and Montes (1964) observed that physicans had become
addicted because they believed “it won’t hurt me” and “I can stop
any time I want to.”
Even physicians who initially made a good adjustment have be-
172 Suicide and Life-Threatening Behavior

come addicted in what they called “the safe way.” They use drugs
cautiously until some event brings about their injudicious use, as the
following summary of a case history presented by Vincent (1969)
shows:

A 42-year-old general practitioner had been heavily addicted to Demerol

and barbiturates for 2 years. A sensitive, insecure child, he had adjusted
quite well to medical school. Prior t o his narcotic usage, his marriage was
stable, and he was a prominent member of his community. However, since
childhood, he had suffered from migraine headaches. When he had a severe
attack and found himself confronted with a full waiting room, he obtained
prompt relief with an initial injection of Demerol. This treatment, which
he considered harmless, he continued at 1-to 2-month intervals for 2years.
Then, due to personal events, he suffered a mild reactive depression, but
continued to practice nevertheless. But the next time he had a migraine,
he found to his surprise that the Demerol also relieved his depression. He
began t o treat for his depression-then for his fatigue. . . .

In other words, the altruistic, service-oriented work of a physician

can serve deep emotional needs, and for some it can also heal child-
hood wounds. For others, if the vulnerability is left unattended, it
can be an emotional drain and a mental health hazard. As Vaillant
points out, these vulnerable physicians also need to be needed, but
in their case, the required care of their patients can cause emotional
conflicts. Thus one idealistic physician, who had been rejected by
both parents in his childhood and who regularly turned to mood-
altering drugs, complained that his particular patients were absolute-
ly overwhelming in their dependence on him and that his profession-
al work was the hardest he had ever had to do because it took so
much out of him emotionally. An addicted pediatrician stated the
problem even more succinctly when he said that he took morphine
“because all day long, I’m giving out pity. At night I found that I
needed some pity for my own self” (Little, 1971).

Dependency Problems
In their study of 30 addicted physicians at the Menninger Clinic,
Modlin and Montes (1964) found that their patients’ dependency
needs drained them emotionally to such an extent that they had no
incentive left for seeking renewal by satisfactory relations with spouse,
children, friends; by recreation; or by interest in community affairs.
“Many of these men, consciously or unconsciously, demonstrated
ambivalence towards medical practice which somehow failed t o pro-
vide them with what they neededsatiety.”
Bernard Bressler 173

The same theme is to be found in physician suicides. Suicide is, of

course, irreversible. In about 75% of these instances, the suicide is
preceded by depression. However, drug and alcohol abuse also figure
prominently in physician suicides where similar premorbid signs have
been noted: a rushed existence under continuous pressure, doubts as
to one’s professional competence, endless doctoring, and the appar-
ent inability to relax and recharge the batteries through interpersonal
relationships (Ross, 1973; Margalis, 1968; Vaillant & Brighton, 1970).
Most people strive to achieve financial and emotional independence
through work. The physician, however, attempts to deny his intense
dependency needs, far too frequently through overwork. When a
physician becomes addicted or turns to suicide, his trouble is often
traceable to childhood problems. Thus Montes and Modlin (1964)
reported that the addicted physicians in their study had fathers with
whom they could not identify, and that 84% of them harbored ex-
tremely negative feelings toward and intense resentiment of, as well
as equally intense dependence, on their mothers. Yet often the con-
scious reason given for their addiction was overwork combined with
the inability to cut down on their practice.
In his study of successful physicians who had originally been se-
lected for their psychological health, Vaillant and Brighton (1970)
found that almost 50% had bad marriages and that some 33%got re-
lief from drugs. Further, as many as 40% of these physicians, com-
pared with 14% of the controls, were divorced. Vaillant adds that al-
though frequently mentioned, the divorces were not caused by their
hard work and long hours. He found, conversely, that many a physi-
cian accepted late and long hours as a response to his unhappy mar-
riage.

Identity Problems
Many men in executive positions in fields other than medicine suc-
cumb to the temptation to be authority figures rather than human
beings. An additional problem for the physician is the fact that his
work often involves long-term and close contact with his patients, at
times exposing him to a barrage of anxieties from their families as
well. He is expected, and indeed aims, to render t o his patients’ well-
being, even to their very lives. He may, from an exaggerated sense of
duty and obligation, feel himself under constant pressure from a
schedule that threatens to overwhelm him.
The majority of physicians find that coping with patient anxiety
becomes part of their everyday work. Some, however, find them-
174 Suicide and Life-Threatening Behavior

selves unable to cope and consequently reach a situation that endan-

gers their own mental health. They must feel for the patient, in order
to be able to bring him relief, but for many complex reasons of which
they may be totally unaware, they begin to feel like the patient-
weak, sick, dependent-and ultimately the physician may reject him-
self. The suicide figures for physicians provide dismaying testimony
to this type of rejection.
The self-rejection of physicians is discussed in a paper written al-
most half a century ago by Ernest Simmel(l926) on “The Game of
Playing Doctor.” Simmel noted that children frequently play doctor,
using a doll as the patient. The doll represents all children, and the
doctor is a parental figure who cures the sickness by some aggressive
act against the patient, such as giving the doll an enema, cutting it
open, or removing its arms and legs. The game becomes the reenact-
ment of the child’s experience of having incurred parental disapprov-
al, at the same time allowing the child to act out some of his own ag-
gression. The child thus learns to master his conflicts and frustrations
by imitating and identifying with the parental figures. The child pro-
jects his problems onto the doll, and the doll receives the punishment
instead of the child himself.
In later life these early feelings, especially those of anger and de-
struction, can be revived through the actual practice of medicine, es-
pecially if the person remains on the immature level. In those, how-
ever, who have developed maturity, such negative feelings are inte-
grated with other positive feelings, facilitating the physician’s work.
The surgeon, for example, has found a socially acceptable form for
his aggressions. But, as Nunberg (1938) points out, the surgeon’s
compassion for his patient permits him to perform the necessary op-
erations without feeling destroyed himself by pangs of guilt at having
inflicted pain.
This compassion is a mixture of understanding and tenderness and
thus draws on both “feminine” and “masculine” feelings. If a physi-
cian is still unconsciously functioning on the “sissy ”-scoring level of
boyhood, an admission of tenderness would be as threatening as an
admission of dependency. Thus another dimension of the immature
doctor’s dilemma appears in the whole spectrum he is called on to
use (Zaberenko & Aaberenko, 1970). Under the best of circumstances,
he makes an unconscious compromise, allowing feelings into his work
that he might find threatening because they might be mistakenly
identified with gender. If he avoids dependency feelings by opting
exclusively for these aspects of his chosen profession generally asso-
Bernard Bressler 175

ciated with masculinity, such as skill, authority, and mastery, his

identity as a physician will remain immature.

Medicine as Magical Thinking

Since earliest times, the healing arts have been associated with mag-
ic. Until recently, we thought and spoke of “wonder drugs.” Magical
thinking also plays a part in physician addiction and suicide. Although
he has gone through years of scientifically oriented training, the
young physician’s unconscious belief in magic appears to provide him
with an immunity from addiction that few lay persons would dare t o
assume. The identity established by the physician during training is
not tested until he actually sets up in practice, at which time he finds
himself subjected to all the stresses and frustrations that others expe-
rience, perhaps even more. His own unresolved emotional conflicts,
past and present, become almost unbearably painful, because of his
identification with his patients. However, due to his emotional imma-
turity and his inability to handle his feelings adequately, he cannot
protect himself by establishing the proper distance between himself
and his patients and their relatives. He is still unconsciously displac-
ing onto his patients his childhood feelings, so that he develops nega-
tive feelings toward them. He resents their excessive demands on his
time and emotions as well as their unrealistic expectations of him.
He finds himself in a difficult position, feeling that he does not like
the practice of medicine. This explains why the onset of addiction
and the peak suicide rate occur after the physician has been practic-
ing only a few years.
The community’s exceptionally high regard for the physician fur-
ther explains the impossible position in which so many young physi-
cians find themselves. The physician is looked upon as the giver and
the taker of life. Yet even with the well-developed state of medical
science at the present time, what is expected of him is more of a re-
sponsibility than the average young practitioner can meet. He begins
believing that he is indeed the savior of mankind, that he must be
able to work wonders and accomplish miracles, so that unconsciously
he starts seeing himself as a magician rather than as a man of medi-
cine. Once a doctor unconsciously regards himself as a magician, he
is faced with a great danger because he enters the unrealistic realm of
magic. The role of a magician is exhibitionism, fooling his public; and
his public, in turn, depends on him in an unrealistic and unhealthy
way. On the other hand, he may begin to lose confidence in himself,
176 Suicide and Life-Threatening Behavior

so that he may turn to an escapist course; when a crisis arises, addic-

tion and possible suicide can be but a step away.
Ernest Simmel(l926) was one of those who pointed to the rela-
tionship between medicine man and magician. The medicine man
turned to curative herbs to supplement his very limited power of sci-
entific observation. He used the faith his position in the tribe gave
him to help his patients. The same holds for the physician today. His
power, too, is limited, yet he is fully aware that his patients’ faith in
him is a cornerstone of the healing art of medicine, and he, too, makes
use of their faith for their benefit. If the young practitioner today
unconsciously identifies with the medicine man in this respect, he
will be able to do his job appropriately, in a mature fashion.
By now, much has been learned and transmitted to medical stu-
dents regarding the emotional problems of their patients and the need
to take these into account. Alas, far less has been learned and trans-
mitted regarding the emotional problems of the medical students
themselves, during their training and after they get into practice. Lit-
tle has been done in medical schools to make students aware of their
own vulnerabilities. It is estimated that 25% to 50% of students are
emotionally disturbed and yet do not seek or get such professional
help (Ross, 1973).
Once the young practitioner finds himself in serious emotional
straits, it would be natural to expect that his colleagues would be the
first to help him. As a matter of fact, however, it is his colleagues
who have the greatest difficulty in accepting him as a patient, and
instead of providing him with the psychiatric referral that would be
used for almost anyone else, they are more likely to treat him as a so-
cial outcast. It is difficult to explain why a physician who is well ad-
justed and readily finds compassion for a patient cannot do the same
for a colleague. Perhaps it is the result of the evolution of the myth
that the physician is a man apart, holding a special position of high
regard in the community, which implies that he is not subject to the
difficulties of other mortals.
Time and time again in clinical practice, estimable and well-mean-
ing physicians have been observed exacerbating the condition of a
disturbed colleague who has made a suicide attempt by keeping quiet
about it and merely exhorting the colleague with a “Pull yourself to-
gether and straighten yourself out.” As a result, seeking the profes-
sional help he needs becomes more and more difficult and even de-
grading, and the tendency to conceal or deny his condition is only re-
inforced (Ross, 1973; Margalis, 1968; Mendlewicz & Wilmetter, 1971;
Bernard Bressler 177

Vaillant & Brighton, 1970; Zaberenko & Aaberenko, 1970; Glauber,

1953).
In studies of varying suicide rates among physicians, psychiatrists
have the very highest rate, sometimes estimated as twice or even three
times the rate for physicians in general. The question is often asked
whether their emotional relationship and their responsibility to their
patients may be a contributing factor, and whether they were uncon-
sciously motivated in their choice of a specialty because they were
seeking solutions to their own needs and conflicts and felt that train-
ing in psychiatry would help them solve their own problems (Mendle-
wicz & Wilmetter, 1971).
In 1972, a series of letters to the Journal of the American Medical
Association pointed out that in psychiatry the therapy is apt to be
prolonged, gratification for the physician is apt to be less, and results
may be insufficient or mediocre as compared to the results in other
specialties. It may be that among those who choose this field, the
personal ideals are too high; so the results obtained fall far short of
the expectations (Freeman, 1968).
In one of these letters, the suggestion was made that there should
be more selectivity in choosing less compulsive medical students for
psychiatric training (Diamond, 1972). Another question was whether
these self-demanding, self-critical, and self-assertive people cannot be
identified before they are accepted as candidates for psychiatric train-
ing (Cohen, 1972). It would appear that the very traits that are re-
warded in a medical career-namely, high aspirations, compulsive at-
tention to detail, readiness to defer gratification-are the very ones
that lead to a proneness to depression, especially if these needs are
not satisfied. This depression, in turn, can lead to drug and alcohol
abuse and to suicide (Thomas, 1969).

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