In psychotherapy, an important task is not only the interpretation of the patient’s verbal expressions but also careful observation of their actions, which may reflect underlying internal conflicts.
One of the key phenomena the therapist encounters is acting out.
Acting out is the expression of an unconscious conflict in action rather than in emotional experiencing, remembering, and verbal communication. Acting out may provide fundamental information about the patient’s conflicts, but by the same token, it prevents insight or personality change by its defensive functions. Because it serves to reduce internal tension around conflict and therefore can be highly gratifying, acting out tends to perpetuate itself. Acting out should be systematically explored and, ideally, resolved by interpretation.
There are many types of acting out.
Patients may act out between sessions or in sessions. Impulsive and self-destructive behaviors outside the sessions may include, in addition to self-harm, provoking aggression in others or hurling oneself impulsively into chaotic, ill-thought-out “love” affairs. Frequent risk-taking behaviour, substance abuse, self-harming actions, and eating disorders represent only a partial list of chronic
Forms of insession acting out include yelling, throwing something, coming late, or leaving early, instead of expressing oneself in words.
Acting out can also take the form of very brief actions in the sessions, sometimes taking a minute or less, in which the patient does something that leaves the therapist off guard and feeling paralyzed. The patient may suddenly say something that apparently changes the entire situation—for example, “Oh, I forgot to tell you that I’ve been pregnant for 3 months”—and then proceed to talk about something else. This represents two forms of acting out:
– concealing something that has been going on for a long time outside the sessions
– making a sudden statement that has a powerful effect on the session.
Interpretations must sometimes focus on how the concerns of external reality are being ignored in the service of satisfaction in the patient’s internal world.
The therapist might say, for example, “We’ve got to the idea that your sitting in silence may provide the experience of your being stronger than I am and being in control. The question is the price you pay in the real world for that inner sense of satisfaction. Because your speaking in session would help us advance our work, the sense of power may be at the expense of moving ahead.”
In contrast to the ordinary types of acting out, which are relatively easy to diagnose and treat, there are more subtle forms. One type is usually expressed outside the sessions and is reflected in split-off, long-term behavior patterns that often predate the beginning of treatment; this form is seen in “living-out” rather than acting-out patterns, such as chronic morbid obesity. The therapist has to remain alert to what is going on in the patient’s external life to diagnose these forms of acting out, which is sometimes difficult because they can occur subtly and may gradually increase over time.
Understanding the nature of acting out, its variations, and its impact on the dynamics of therapy is one of the central tasks of psychotherapeutic work.
Recognizing these manifestations enables the therapist not only to identify the patient’s hidden conflicts but also to formulate interpretations that help transform behavioral reactions into a space of reflection and personal growth.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy