OFFENSES AND DEFENSES AGAINST PATIENTS - A PSYCHOANALYSTS VIEW OF THEBORDERLINE BETWEEN EMPATHIC FAILURE AND MALPRACTICE

The behaviour of physicians is increasingly coming under scrutiny and attack, both from patients and from institutions that represent the pu blic interest. This social process is partly a necessary and healthy q uest for healing and partly a retaliatory response to inevitable failu res on the part of physicians to live up to the standards expected of them. The process can assume such ruthless and pervasive forms that ph ysicians are becoming exposed to impossible demands and even abuse at the hands of those they are trying to help. As a result, many physicia ns become defensive, withdrawing from patient care or reasserting thei r own needs in regressive ways that further offend or injure their pat ients. This increases public anxiety and outrage resulting in regressi ve and even violent ''solutions'', creating a vicious cycle in which m utual trust and respect is eroded and true health eludes our grasp. Ph ysicians who practise psychotherapy are particularly aware of such reg ressive emotional pressures and therefore their experience can be take n as a bellwether of social change. Stirred by recent encounters with colleagues who have undergone public inquisition, humiliation and puni shment, and drawing on personal clinical experience with patients whos e regressive self-expression could at times be considered ''borderline '', the author attempts to understand the nature of the emotional forc es being experienced by members of the profession at large. As in ther apy, so in social change; the outcome depends on how well we understan d, contain and channel the powerful feelings that underlie whatever ac tions are taken. Failure to do so makes the situation worse, while rec ognition of empathic failure at all levels can provide an opportunity for healing and for reintegration rather than polarization of opposing forces at the border between what is acceptable and what is not.