Offenses and defenses against patients: a psychoanalyst's view of the borderline 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 public interest. This social process is partly a necessary and healthy quest for healing and partly a retaliatory response to inevitable failures on the part of physicians to live up to the standards expected of them. The process can assume such ruthless and pervasive forms that physicians are becoming exposed to impossible demands and even abuse at the hands of those they are trying to help. As a result, many physicians become defensive, withdrawing from patient care or reasserting their own needs in regressive ways that further offend or injure their patients. This increases public anxiety and outrage resulting in regressive and even violent "solutions", creating a vicious cycle in which mutual trust and respect is eroded and true health eludes our grasp. Physicians who practise psychotherapy are particularly aware of such regressive emotional pressures and therefore their experience can be taken as a bellwether of social change. Stirred by recent encounters with colleagues who have undergone public inquisition, humiliation and punishment, and drawing on personal clinical experience with patients whose regressive self-expression could at times be considered "borderline", the author attempts to understand the nature of the emotional forces being experienced by members of the profession at large. As in therapy, so in social change; the outcome depends on how well we understand, contain and channel the powerful feelings that underlie whatever actions are taken.(ABSTRACT TRUNCATED AT 250 WORDS)