Not sure this is the right thread .
An interesting X post turning a previous thread focusing on patient bias re iatrogenic harm in psych/ patient relationship to that of clinicians .
Pretty much nails it .
Long thread . The original is worth a read to frame context .
For those not able to access X
Thanks
@ahimsa
What Are the Psychological Drivers Behind Clinicians' Reactions to Iatrogenic Harm – Lessons from John Banja’s ‘Medical Narcissism’
Sanil Rege’s recent thread explored the psychology of how patients respond to iatrogenic harm.
But what about the other side of the equation -the psychology of the clinicians who cause, witness, or learn about this harm?
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Clinicians are human too.
They have their own fears, blind spots, and maladaptive defences.
Yet in medicine, we rarely turn the psychoanalytic lens inward onto the profession itself.
Why is that?
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What happens inside a clinician when confronted with harm they may have caused or when they are confronted with harm at a systemic level?
Does it trigger deeper fears - of incompetence, exposure, humiliation?
What defences kick in to protect the self-image of “good doctor”?
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The medical ethicist John Banja calls this 'Medical Narcissism'.
Not self-love - but the need to protect one’s self-esteem and reputation as a capable, trustworthy professional, even at the cost of honesty, empathy, and patient safety.
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Banja defines medical narcissism as:
A healthcare provider’s need to preserve their self-esteem and public image of competence, leading them to deny, minimize, or rationalize mistakes rather than admit and address them.
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When this kicks in, clinicians often display behaviours familiar to anyone harmed by the system:
-Denial: Admitting the error = admitting a flaw.
-Minimization: “It’s just one of those things.”
-Hostility to feedback: Even gentle critique feels like attack.
-Empathy collapse: Focus shifts inward to self-protection.
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Banja also identified common rationalizations:
a) Euphemistic language e.g. “emotional lability” for drug-induced suicidality.
b) Deflecting responsibility – “It’s the patient’s underlying condition.”
c) Outcome bias -"untreated depression is dangerous" (to justify drug harm)
d) Fragmentation of identity – “All drugs have risks.”
e) Moral justification – “antidepressants save lives” trumps any harm done.
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Over time, these individual defences become
normalized inside institutions.
➡ Individual defence → routine practice → cultural norm.
A culture of denial emerges — one that pathologizes
those who report harm rather than facing the harm itself.
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In this culture, harms that are obvious to an outsider are
invisible to insiders.
And because harm triggers more self-protection, the cycle escalates:
More harm → stronger defences → more denial → more harm.
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Medical training reinforces this.
Trainees are taught - implicitly and explicitly - that perfection must be projected and vulnerability avoided.
Those who admit uncertainty are punished; those who exude invulnerability are rewarded.
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This creates a “narcissistic adaptation” - traits that are rewarded inside medicine but corrode professional integrity and harm patients.
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Which brings us back to psychiatry and iatrogenic harm.
When patients report devastating, disabling outcomes, how much of the profession’s reaction is shaped by
medical narcissism?
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Could the elaborate reframing of these harms - as personality issues, developmental wounds, “rigid narratives” - actually be projective identification?
A defence where the profession attributes its own conflicts and flaws to the patient?
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From this perspective, the clinician - unconsciously aware of the harm they’ve caused - projects that damage onto the patient.
Using the power imbalances inherent to the therapeutic role, they reframe, pathologize, and dismiss the patient’s account, sometimes creating the very distress, confusion, or “rigidity” they then claim to treat.
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In this frame, harmed patients become “irrational,” “ideological,” “antipsychiatry.”
Their reality is recoded as pathology.
The result: institutional gaslighting that protects the profession’s image while further traumatising the harmed.
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If we can psychoanalyze harmed patients, we can also psychoanalyze those who treat them.
Because until we address the clinician’s and institution’s own defensive loops, the cycle of harm and denial will continue - at great cost to those who clinicians claim to be helping.
