Narcissistic Abuse in Medicine: When the Control Is at Home

Behaviors to notice, the limits of labels, and support that doesn’t ask you to decide first.

The message in the changing room

Angel is an illustrative composite, not a real client. She’s 51, and she’s an anesthesiologist at a large hospital. It’s a little after seven on a Wednesday morning, and she’s sitting on the bench in front of her locker in the staff changing room. Her badge is still clipped to her scrub top. One work shoe is off, and the other is still on. She’s been at the hospital since yesterday afternoon.

Her phone buzzes on the bench beside her. It’s her husband: You said you’d be done by 7.

That message alone doesn’t establish abuse. They’ve shared locations for years, and they both agreed to it. A message about when someone’s getting home isn’t a verdict on a marriage.

What Angel is sitting with isn’t the message. It’s everything around it. Last spring he moved her paycheck deposit into an account she can see only when he logs in for her. When she wanted to send money for her sister’s birthday, she had to ask. She used to text a colleague between cases on long nights. She stopped after he started reading her phone when she was asleep and asking about every name. And in November, when she mentioned she’d been thinking about talking to someone, he said that if she did, he’d call her department chair and say she wasn’t safe to be in an operating room.

She hasn’t mentioned therapy since.

She types Leaving now, deletes it, types it again and sends it. Then she sits there with the phone in her lap and doesn’t reach for the other shoe.

I watch every number in that room, she thinks. How did I stop watching this?

If some part of that feels familiar, this guide is for you. It’s for physicians who are worried about what’s happening at home and aren’t sure what to call it. It covers what this article means by “narcissistic abuse” and what it doesn’t, how to look at behavior and context rather than labels, how ordinary strain can differ from control, some of the questions a demanding medical role can raise, and some options for support that don’t ask you to decide anything first.

A quick note on where I’m coming from. I’m a licensed therapist, and I also work as an executive coach. This article is general education. It isn’t therapy, a safety assessment, or legal or medical advice, and Angel and the other physician in this guide are illustrations, not people.

Before you go further, a note on safety. The HHS Office on Women’s Health warns that anyone with access to your phone or computer can check which websites you visit, and that it isn’t possible to completely clear your browsing history. If it’s safe for you, you might read this, or reach out for support, on a device your partner can’t get into. Using another device isn’t a guarantee of privacy.

What this guide means by “narcissistic abuse”

This guide uses the phrase in its title as a starting point, then focuses on behavior rather than diagnosing a partner. It isn’t a diagnosis, and this article isn’t diagnosing your partner, or anyone’s partner, from a distance.

Narcissistic personality disorder is a clinical diagnosis. The APA Dictionary of Psychology classifies it as a personality disorder and notes that it’s included in the DSM. Having that diagnosis isn’t the same as being abusive, and being abusive doesn’t require it. A label about who someone is can’t tell you whether you’re safe. What happens between the two of you, and what it costs you, can tell you a lot more.

So this guide looks at behavior instead.

That definition is useful for what it points to and for what it leaves open. It points to things you can see and describe: access to people, access to money, being monitored, threats. It doesn’t ask you to know what’s going on inside your partner’s head, and it doesn’t ask you to prove anything to anyone before you’re allowed to ask for help.

It also isn’t a checklist you’re supposed to score yourself against. An article can’t tell you whether what you’re living with is abuse, a relationship in serious trouble, or something else. What it can do is give you language for the parts you’ve been noticing and not saying out loud.

Looking at behavior and context

A lot of writing about abuse talks about patterns, and patterns matter. But it’s worth being clear about something first: you don’t have to wait for a pattern before you ask for help.

The CDC’s overview of intimate partner violence says it can vary in how often it happens and how severe it is, and that it can range from one episode of violence to chronic and severe episodes over multiple years. One physical assault, one serious threat, or one time you were pressured or forced into a sexual act is enough reason to reach out on its own. You don’t have to wait for it to happen again, and you don’t have to feel afraid first.

Context matters in the other direction too. A single ambiguous text, on its own, doesn’t establish abuse. Neither does location sharing you both chose. A partner who’s tired, short-tempered after a hard week, or frustrated by your schedule isn’t automatically abusive. Looking at one message or one habit without the rest of the context can mislead you, in either direction.

What tends to be more telling is what surrounds those moments. The National Domestic Violence Hotline describes domestic violence as a pattern of behaviors one partner uses to keep power and control over the other. So instead of trying to read intent, it can help to look at a few plainer questions:

• What’s being restricted? Your money, your car, your phone, your time with friends or family, your ability to get care.
• What happens after you disagree? Whether there’s a cost you’ve learned to manage, a punishment, a threat, days of fallout.
• What’s being threatened? Your safety, your children, your pets, your job, your reputation, your license.
• What have you stopped doing? Friendships you’ve let go, plans you cancel, things you no longer say, to keep the peace.

None of those questions is a test with a passing score. They’re ways of describing your life more accurately, to yourself first, and maybe later to someone who can help you think it through.

In Angel’s changing room, the text about seven o’clock isn’t the thing. The account she can’t see into, the colleague she stopped texting and the threat about her chair are the things. They’re behaviors with consequences she’s been quietly working around for months.

A different kind of hard night

Kristy is also an illustrative composite, not a real client, and her scene stands on its own. She’s 47, and she’s a pediatric emergency physician. It’s 11:40 on a Sunday night, and she’s standing in her kitchen after a ten-hour shift, eating cold pasta out of the container with the refrigerator door still open.

Her husband comes downstairs. He’s been solo with their two kids all weekend because she picked up an extra shift, and he’s done. “You said you’d stop saying yes to these,” he says. “I can’t keep doing every weekend.”

She snaps back that she didn’t have a choice, that the department was short. He says she always has a choice. It’s loud for about a minute. Then he goes back upstairs, and she stands there with the pasta.

On Monday morning, before she leaves, they talk again. She tells him she thinks he’s wrong about the choice part. He tells her he still thinks she’s saying yes too easily. Neither of them fully gives ground. Their money sits in accounts they can both see. She texted her closest friend about the argument at midnight, the way she usually does, and nothing about that is secret. He asks if they can look at the schedule together on Thursday.

This disagreement is hard, and I don’t want to wave it away. Resentment about call schedules, exhaustion on both sides and fights at midnight can wear a relationship down, and they deserve attention of their own.

But I also want to be careful about what this scene is and isn’t. It isn’t a clean bill of health, and it isn’t a way to check your own relationship. An article can’t certify that anyone’s marriage is safe, and not feeling afraid doesn’t prove there’s no abuse. What the scene shows is a different set of behaviors from Angel’s. In it, Kristy’s access to money and to her friend is intact. She disagrees out loud, he disagrees back, and in this scene the disagreement doesn’t come with a threat or a restriction she has to manage afterward.

If you’re reading both scenes and you can’t tell which one your life looks more like, you don’t have to sort that out alone, and you don’t need to sort it out before you talk to someone.

What control can look like inside a medical life

Control doesn’t look the same in every household. If one partner is a doctor, it might attach itself to parts of that life. None of what follows is a diagnosis. It’s a set of examples of what the behaviors in the definitions above might look like when one partner is a doctor.

• Your schedule gets held against you. Your call nights, your late cases and your pager get brought up in every argument, and the cost of every shift shows up later at home.
• Your income isn’t yours to see. You earn it, but a partner decides where it goes, changes passwords, or makes you ask for what you need.
• Your colleagues become a problem. Texts from work get questioned, friendships at work get discouraged, and you start keeping your professional life smaller to avoid the questions.
• Your career gets used as a threat. A partner says he’ll call your chair, your hospital or your licensing board, or tell people you’re unstable or impaired, if you talk to anyone.
• Your tiredness becomes the explanation for everything. Every concern you raise gets answered with “you’re just exhausted” or “you’re not thinking straight after call”, until you stop trusting your own read.

If your partner does some of these things, it doesn’t automatically tell you what’s going on in his mind, and this guide can’t tell you what your relationship is. But these are behaviors with real effects on your safety, your money, your relationships and your work, and they’re worth describing to someone who can help you sort through them.

Angel would recognize at least three of them. She hasn’t said any of them out loud yet.

Questions a demanding role can raise

I want to be careful here. Nothing in this section explains why abuse happens. The Office on Women’s Health is clear that violence and abuse are never the victim’s fault, and that a partner is responsible for his or her own behavior. Medical training doesn’t make you responsible for a partner’s abusive behavior.

What I can do is describe a few of the questions that come up in Angel’s illustration. They may or may not fit you.

Angel is used to setting her own reactions aside until a case is done. At home, she’s been setting this aside too, and later hasn’t come.

Angel is used to asking what she could’ve done differently when something goes wrong at work. At home, she’s started asking the same question about his behavior, as if the next fight would go better if she managed it better.

Angel is used to being the one who helps. She finds it strange to picture herself on the other side of that conversation.

And when she raises something, her husband tells her she’s just exhausted after call. She often is tired, so she lets the conversation end there.

If any of that sounds familiar, it doesn’t mean something is wrong with you. It may mean it would help to have someone outside your own head to help you look at what’s happening, the same way you’d want a second set of eyes on a hard case.

Both/And: a steady physician, and not okay at home

You can be the calmest person in a crashing room and still feel lost in your own kitchen. Both of those can be true at the same time, and one doesn’t cancel the other.

Both/And means you don’t have to pick which version of you is real. The Angel who manages every number in an operating room is real. The Angel who deletes and retypes a two-word text on a changing-room bench is real too. Her competence doesn’t prove her home is fine, and what’s happening at home doesn’t erase her competence.

For Kristy, Both/And might look different. She can love her husband and be angry at him. She can think he’s wrong about the choice part and still wonder whether he’s right about how often she says yes. Those feelings can live in the same body on the same Monday morning.

You might also find yourself holding feelings about your partner that don’t fit together neatly. You might care about him, miss who he used to be, feel sorry for how stressed he is, and still not feel okay about how he treats you. Caring about someone doesn’t make his behavior acceptable, and naming his behavior doesn’t mean you’ve stopped caring.

That can be hard to allow, especially if you’re used to needing one clear answer before you act. But you don’t need to resolve every feeling before you ask for support. You can bring all of them with you.

The Systemic Lens: when your time isn’t fully yours

So far this guide has looked mostly at what happens inside one relationship. That’s only part of the picture.

If your role asks you to be available for call, nights or weekends, those constraints may make some practical things harder. Finding an hour that’s private can be harder. So can finding a time to make a call when nobody’s listening, or arranging practical support like childcare, a ride or a place to go. That isn’t a personal failing. It’s a real limit on your time, and it’s worth naming when you plan anything.

If your schedule is genuinely hard on your family, a partner who uses it against you can sound reasonable, to him and sometimes to you. It can help to separate the two: the real strain the schedule puts on a household, and what he does with it.

The Office on Women’s Health says abuse can happen to anyone, whatever their education, their neighborhood, their age, their sexual orientation, or whether they’re married, dating or single. A medical degree isn’t protection, and it isn’t a reason to stay quiet.

If worry about your license, your privileges or your job is part of what keeps you from reaching out, that worry deserves a real answer, not a reassurance from an article. Before you share details with any provider, you can ask what they keep private and what they may be required to share. If you have questions about what your state or your hospital asks, someone who knows the rules where you practice, such as an attorney who works with physicians, can give you advice that fits your situation. I can’t promise how any of that will go, and neither can anyone writing in general terms.

Support that doesn’t ask you to decide first

One of the heaviest things about this can be the sense that asking for help means you’ve already decided to leave. It doesn’t.

The Office on Women’s Health says you don’t have to leave today or do it all at once, and that even if you don’t leave right away, a safety plan can help you know what to do if your partner abuses you again. The National Domestic Violence Hotline describes a safety plan as something personalized and practical that can improve your safety while you’re experiencing abuse, while you’re preparing to leave, or after you’ve left. A safety plan isn’t a commitment to go. It’s a way to be a little more prepared wherever you are.

Before you call, text or chat with anyone, it may help to think about who can see your phone, your call history or your messages. The Hotline’s safety plan page notes that internet use can be monitored and is impossible to erase completely.

A few options, none of them required and none of them in a particular order:

• Talk with an advocate. The Hotline’s safety planning page says its advocates are available around the clock to discuss your situation and help create a personalized safety plan, and that they can offer support, education about domestic violence, and community resources and referrals. You can reach them at 800-799-7233, by texting START to 88788, or by chat.
• Find individual support. If you’re not sure what you’re in, individual support from a therapist with domestic violence experience can be a reasonable place to start. The National Institute of Mental Health suggests a few places to begin looking, including a primary care provider, who can do an initial mental health screening and refer you on, and it suggests preparing a list of questions to help you decide whether a provider is a good fit.
• Reach out to someone you trust. If it feels safe, consider reaching out to someone you trust, and talk about what you do and don’t want shared.

You might be wondering about couples therapy, especially if you’ve been hoping a professional could help the two of you sort this out. The Hotline’s page on couples therapy with an abusive partner says it doesn’t encourage anyone in an abusive relationship to go to counseling with their partner, because abuse isn’t a relationship problem. It explains that counseling can’t fix the unequal power at the center of an abusive relationship, and that an abusive partner may later use what was said in a session against the other person. If you’re unsure what’s happening at home, it can make sense to start with support that’s just for you, rather than a joint session or a big confrontation.

A note on the difference between kinds of help. Therapy is clinical care from a licensed professional, and it can include assessment and treatment. Executive coaching is nonclinical work toward professional goals, and a coach doesn’t diagnose or treat. If you want to understand that line better, my explainer on trauma-informed executive coaching goes into it. Neither coaching nor a course is a crisis service or a domestic violence safety service. If safety is part of the question, consider starting with an advocate or a clinician who has domestic violence experience.

In the U.S., if at any point you’re in immediate physical danger, call 911. The Hotline’s own site says the same thing.

Where the two illustrations end

Back in the changing room, Angel’s husband has replied with a thumbs-up. She puts her work shoes in the locker, unclips her badge and closes the door. She hasn’t told anyone about the account, or the colleague, or what he said in November. But as she walks toward the elevator she thinks, for the first time in a while, that she might.

In Kristy’s separate illustration, it’s Monday morning, after the conversation in the kitchen. She’s rinsing her coffee mug before she leaves for work. She and her husband haven’t agreed on the schedule, and they may not agree on Thursday either. She’s still turning the argument over. She doesn’t have an answer yet.

Neither of them is finished. That’s a real place to be. You don’t have to have a name for what’s happening before you’re allowed to talk about it, and you don’t have to know what you’ll decide before you ask for support.

What I hope you’ll keep is this: noticing what’s happening to you is not the same as making a decision about it. You’re allowed to notice first.

Warmly,
Annie.