From Acting Out to Enactment
Used worldwide, the concept “acting out” is the translation of “agieren,” the term Sigmund Freud coined in 1914 to signify the expression of unconscious conflicts in actions rather than words by the patient in psychoanalytic treatment (Freud, A 1968).
Over time, the term has acquired a pejorative tint and has been misapplied to a wide range of disruptive, inappropriate, and anti-social behavior from criminal acts to missing sessions to terminating treatment (Reports of Discussions of Acting Out; Boesky 1982). In the therapeutic process, acting out is much more than the intrusion of impulsiveness: it is a way patients communicate content that they cannot put into words (Reports of Discussions of Acting Out).
The misuse of the term by the public, the gradual accretion of clinical experience with the phenomenon, the variety of clinical behaviors observed and the difficulties caused by them in the analytic setting (DeBlecourt 1993), and the difficulty of dealing with acting out within the evolving psychoanalytical theory (Boesky 1982) created a need for clarifying the concept in a way that makes it useful for discussing problems that occur in the analytic situation. Although this is not an easy task, many psychoanalytic researchers have risen to the challenge.
Acting out has been used to describe a range of behavior from posture changes, intonation changes, and silences to shouting and gross motor activity (Boesky 1982). It has been of continuing concern to analysts because of its ability to disrupt the analytic process, at the least because patients who are acting out are not following the rule–to communicate associations in words–and at the most because a relatively common form of acting out is for a patient to abruptly leave the treatment (Reports of Discussions of Acting Out).
Many have wondered whether the attempt to classify such an array of behaviors as one phenomenon would not over generalize the term into meaninglessness. McLaughlin captured the complexity of the phenomenon, saying that acting out is “a compromise formation consisting of components contributed by the drives, the defenses, the superego, unpleasant affects, and by considerations of reality” (McLaughlin 1992).
Issues that have arisen in the attempts to arrive at a useful definition include: whether acting out should refer only to behavior that occurs within the analytic setting (Reports of Discussions of Acting Out); whether acting out should refer only to behaviors that are the expression of unconscious conflicts and wishes; whether acting out should refer only to behaviors that are part of the transference; and whether acting out should refer only to the behaviors of neurotic patients, whose defenses have been lightened by the analytic process or whether it should include pre-existing behaviors brought by patients into the analysis (Reports of Discussions of Acting Out).
Questions have also been raised as to whether the primary goal of acting out is to communicate a preverbal conflict or memory for which the patient has no words, or whether the primary goal of acting out is to discharge tensions.
DeBlecourt (1993) offered this succinct description: “Acting out, therefore, is doing something without experiencing why one wants to do it.” Fenichel described “acting out as a cohesive piece of behaviour, not experienced as bizarre by the patient, an ego-syntonic repetition of a piece of the past in a distorted form as a wish-fulfillment, while only the analyst considers it strange” (Reports of Discussions of Acting Out). Others have observed that patients sometimes find their own impulsive acting out to be out of character and incomprehensible (Penot 1997) and that in such cases the acting out is less likely to endanger the course of treatment.
In 1945, Fenichel offered a definition that removed acting out from the confines of analytic treatment, but retained its original connection to the expression of unconscious conflicts: “a general tendency to relive the past in present situations in life or to perceive present conditions as if they were a repetition of the past” (Naiman). At the 1967 Copenhagen symposium, Anna Freud differentiated between acting out as a transference resistance of neurotic patients and the “habitual” acting out of “the delinquent, the addict, and the psychotic” (Stein 1973).
Stein (1973) proposed a second term, “the tendency to act out,” to describe a character trait of certain neurotic patients, who “give a history marked by repetitive, complexly patterned behavior, generally precipitated by frustration. This pattern offers a contrast to their usual mode of life; it has certain features distinctly at variance with what appear to be the dominant modes of the personality.” Lacan distinguished between acting out and the “passage to the act,” the former being an attempt to communicate and the latter being the replacement of communication with action (Penot 1997).
Acting out has been considered from the point of view of the ego and defenses, the id and the discharge of aggressive and libidinal infantile fantasies, and the superego and the need for punishment. Many researchers call attention to the id’s special place in acting out, hypothesizing a causal role for oral conflicts and disruptions in the oral phase in the development of the tendency to act out (Reports of Discussions of Acting Out).
Fenichel focused on the ego’s role, emphasizing the impairment of reality testing aspect of acting out. Kanzer (1968) examined the role of ego deformation in the phenomenology of acting out. Bird suggested that the egos of those who act out are hypersensitive to other’s id impulses (Naiman). Defenses observed to be active in acting out include: Identification, projection, projective identification, denial, avoidance, and isolation (Reports of Discussions of Acting Out). Acting out has been discussed as the manifestation of a great need for an object and a simultaneous need to “deny a sense of loss, helplessness, and abandonment and the sense of objectlessness for which the acting out is considered an attempt at restitution and a defense” (Reports of Discussions of Acting Out).
Naiman gave two examples of acting out that showed the “unconscious pressures of the superego and the need for punishment.” The patients were unconscious of their desire for punishment, but they were conscious of their need for satisfaction. When a patient acts out, primary process infantile impulses take over from ego-controlled secondary process methods (Reports of Discussions of Acting Out).
The importance of distinguishing neurotic acting out in the analytic situation from habitual acting out and acting out to communicate from acting out to discharge tensions has deepened over time because the weight of the clinical evidence indicates that each requires something different from the analyst.
Most agree that chronic acting out indicates a low tolerance for frustration and tension, thought to be rooted in symbiosis and separation anxiety (Reports of Discussions of Acting Out). Greenacre (1950) listed three factors Fenichel thought to be significant in the genesis of chronic acting out–low tolerance for frustration, oral fixation and the accompanying narcissistic demands, an early trauma which produced a repetitive, abreactive acting out—and added two more: an inclination towards dramatization produced by “visual sensitization,” and a “largely unconscious belief in the magic of action.”
Franco (2006) suggested that the development of acting out as a character trait may have some connection to specific developmental deficits, particularly those caused by a troubled early mother-child relationship where the mother is unable to successfully relieve her child’s great fears and anxieties and the child resorts to action, leading to early, but fragile, ego development. In the case discussed, one early action led to a serious physical trauma at an age (between 2 and 5) when thinking is in the process of transforming from action into words (Franco 2006).
According to Grinberg (1968), projective identification plays its part in acting out. Patients who act out may not have worked through early experiences of object separation and loss and the concomitant intensely painful affects. The relationship between the two participants in an episode of acting out is usually narcissistic. To understand the dynamics of acting out, Grinberg (1968) looked to Bion’s model of the mother-child relationship, specifically to the case in which the mother is not able to contain intense fear and anxiety that the infant projects onto her. In such a case, the infant feels a terrible and intolerable dread (Grinberg, 1968).
This pattern of looking for an external object to project anxiety onto is repeated between the patient and analyst when circumstances in the analysis cause the reawakening of the patient’s fears of loss and separation, suggesting one reason why interruptions in treatment often precipitate episodes of acting out (Grinberg 1968). Grinberg (1968) has described the dynamics of acting out as observed in narcissistic patients who are either regressive or in a regressive period. When these patients experience an increase in psychic pain, usually from loss, they try to “evacuate” this pain in external objects, including the analyst (Grinberg, 1968).
Grinberg (1968) compared acting out to dreaming, calling it “a dramatized dream acted out during wakefulness—a dream that could not be dreamt.” In the “dramatized dream,” patients use secondary process elements to change external reality into primary process elements—inner objects that can then be handled as dreams (Grinberg 1968). This has an analogue in the way children use hallucinatory daydreams to fulfill wishes (Grinberg 1968).
Others have hypothesized that the more a patient dreams, the less he will be inclined to act out (Reports of Discussions of Acting Out). “Some have noticed that, like dreams, the scene enacted transforms a memory into a wish” (Reports of Discussions of Acting Out).
But to S. Freud, the great significance of acting out, like dreams with which it has much in common, was that it was a path towards remembering: “Patients do not remember what has been forgotten; they act it out. As long as the patient is in the treatment he cannot escape from this compulsion to repeat; and in the end we understand that this is his way of remembering.”
Acting out was an inevitable and invaluable part of transference and resistance. In fact, “transference itself is only a piece of repetition, and the repetition is a transference of the forgotten past not only onto the doctor but also onto all aspects of the current situation” (Freud, S.). Overcoming this resistance was the path that led back to remembering (Freud, S.). Working through the resistance was the activity that led to change. Effectively, this replaced the abreaction of treatment under hypnosis (Freud, S.).
DeBlecourt (1993) distinguished two types of repetition which may be useful in interpreting acting out:” (1) repetition compulsion as an attempt to learn to control earlier traumatic experiences and perceptions; (2) repetition compulsion as an attempt to return to a real or imaginary condition of lust or fulfillment (in or outside the analytic situation).”
Although acting out is often discussed as a characteristic of particularly “difficult” patients or confined to a vaguely defined category of resistance, it is a phenomenon that occurs in all analyses, sooner or later. As DeBlecourt (1993) says, “Resistance and acting out are cornerstones in the application of the psychoanalytic technique. The interpretation of certain patterns of behavior during the analytic hour leads to awareness of experiences inherent to this behavior.
Only after this can these experiences be integrated in the entirety of the personality. If the acting out is too violent and undiscussable, and irreplaceable by inherent memories, there is the risk that the therapeutic alliance in the analysis is broken, and the patient ends the analysis prematurely.”
While it does constitute a particularly challenging form of resistance, analyzing acting out can be one of the most productive tasks undertaken by the participants: analyst and analysand. Franco (2006) showed that analyzing episodes of acting out can reveal the level of psychic and mental process organization and provide evidence concerning the progress of the analysis. Careful attention must be paid to the defenses, the wish, and “the degree of concreteness (versus symbolization) of the mental processes” (Franco 2006). He gave examples of two acting out episodes that occurred at different stages of a patient’s analysis.
This patient regularly used denial and action as a way of ejecting unwanted feelings. In the first episode, which occurred early in the treatment, the patient, who had split positive and negative self-images, ejected the negative self image by literally throwing out something that she associated with it. When she did so, the uncomfortable internal feelings lessened. The second example, which occurred later in the analysis, was not characterized by splitting and denial. Rather, it was an attempt to fulfill an infantile wish. The “language” of the episode was less concrete and more symbolic (Franco 2006).
Acting-out places the analyst under a great strain because it is likely to arouse troublesome counter-transference conflicts.
If an analyst is distressed by the way a patient lives, or fears the patient may harm himself, he may resort to authoritative injunction against the behavior rather than adequately analyzing it (Bernstein 2001).
In the context of transference, the patient’s acting out can cause the analyst to act out (Grinberg 1968). The patient’s projective identifications can cause a counter transference response called by Grinberg (1968) “projective counter-identification.” Defenses Grinberg (1968) commonly observed in these patients were a combination of manic mechanisms and a specific type of splitting: “Manic defences are mainly organized through the identification with an idealized and omnipotent object from which the patients debase the external objects. Splitting consists in isolating that part of the self identified with the omnipotent and aggressive aspect, from the part that is better adapted to reality.” When the patients experience loss, their psychic balance falters.
One split part of the psyche takes on the role of a primitive superego; the other part of the psyche plays the submitting ego. Tension increases to a level the patients cannot withstand and they “evacuate violent projective identifications which massively break through into the external object. The patients thus project the tyrannical relationship into the object, inducing it, in turn, to act out” (Grinberg 1968). Acting out, in structural terms, is the id dominating the ego by means of the primitive superego (Grinberg 1968).
Acting out can be viewed, not in isolation, but as part of the larger enactment that is the transference. As Boesky (1982) reminded us, “Essentially, Freud was saying in 1914 that the entire transference was an acting-out.” In Boesky’s view, whether or not motor activity is involved in enacting transference fantasies is of minor importance. Not all episodes of acting out—silence for example–involve motor activity. Another familiar example is when a patient tries, using conversation only, to make the analyst play a certain role (Boesky 1982).
In this enactment, the patient has a new experience whenever he hears a new interpretation (Sandler 1976). This contributes to the progress of the resolution of the transference and therefore to the progress of the analysis. Transference is resolved by careful scrutiny of everything in the analytic situation, including allusions to the transference, even in associations not seemingly connected to it (Sandler 1976).
Wilcock (1990) has shown that responding to the acting out of severely disturbed children can change their behavior for the better. It is useful to conceptualize the acting out of hyper aggressive children as a distorted version of play (Wilcock 1990). It is well known that these children have a marked tendency to run away (Wilcock 1990). This can seem like a direct expression of dislike towards the analyst, especially if accompanied by verbal abuse (Wilcock 1990).
But closer observation revealed that running away is a distorted version of the game “chase me” (Wilcock 1990). The child is not so much determined to escape as he is hopeful that the analyst will follow him. If the analyst “plays” along—a tiresome process—it is sometimes possible to make contact with the child and see the aggressive bolting change into something more playful (Wilcock 1990).
Kernberg (1987) also found it useful to consider the transference as an enactment. (He also pointed out that “enactment” is a closer translation of Freud’s “agieren” than “acting out.)” He described the analysts participation in the enactment by conceptualizing three “frames” in the analytic situation. Each “frame” calls for a specific type of acting between the patient and the analyst. The first frame is the setting, defined by location and time of the sessions, division of labor between the analyst and the patient. This is a frame for a professional relationship between a person who wants assistance and a person with the training and experience to provide that assistance.
The second is the psychoanalytic frame, defined by the analyst’s neutrality, and his “analysis of the defensive operations militating against free association and the activation of transference regression.” The transference enactment quickly pulls this frame away from “reality.” The third frame is created by the analyst’s two positions: one as an observer of the transference/ counter-transference and the other as participant in it (Kernberg 1987).
Following Bass, Aron (2003) suggested that there are enactments and there are Enactments . Capital “E” Enactments are specific occurrences of between the patient and the analyst that are highly charged by the mutually influential unconscious actions of each (Aron 2003). This is a difficult subject for many classically trained analysts who were taught that Enactments of this sort were mistakes that only occurred if the analyst was “improperly analyzed” himself (Aron 2003).
Further, Aron (2003) hypothesized that “Enactments may well be a central means by which patients and analysts enter into each other’s inner world and discover themselves as participants within each other’s psychic life, mutually constructing the relational matrix that constitutes the medium of psychoanalysis.”
This is not to say that analysts throw down their conventional tools. Rather, that they use them to analyze the Enactment in progress without detaching themselves from it, thereby retaining a connection with the patient without being forced into a role assigned to them by the patient’s unconscious needs (Aron 2003). Aron (2003) described how this looked in action by recounting a story in which an analyst, Black,
“refused to give up her own point of view and join the patient empathically in a way that would leave her submitting to the patient’s dominant view. She also refrained from interpreting her patient’s view as nothing but a resistance to her own, more accurate view, thus forcing her patient into submission.
As Black suggests, more important than what she was thinking was that she kept thinking without detaching, and she used psychoanalytic ideas, categories, and conceptualizations to help her keep to think through the crunch. This capacity to think while remaining affectively engaged, and to maintain the tension between a tendency to dominate and to submit to the patient, enabled her to occupy a position of thirdness and to repair the relational disruption (Beebe and Lachmann, 1994) thus creating intersubjective space in which to promote mentalization (Fonagy et al., 2002)” (Aron 2003).
Redefining acting-out in terms of an Enactment that is an expectable part of the transference gives the analyst additional tools beyond interpretation with which to ameliorate the symptoms manifested in the acting out. By remaining affectively engaged with the patient, the analyst can go some way in the here and now towards providing the patient with a new experience in interpersonal interactions that may have more power to change the patient than the more distant interpretations do.
Aron, L 2003, ‘The paradoxical place of enactment in psychoanalysis: Introduction,’ Psychoanal. Dial., 13:623-631.
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Greenacre, P 1950, ‘General problems of acting out,’ Psychoanal Q., 19:455-467.
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Kanzer, M 1968, ‘Ego alteration and acting out,’ Int. J. Psycho-Anal., 49:431-435.
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Reports of Discussions of Acting Out
Sandler, J. 1976, ‘Dreams, unconscious fantasies and identity of perception,’ Int. R. Psycho-Anal., 3:33-42.
Stein, M.H. 1973, ‘Acting out as a character trait—its relation to the transference,’ Psychoanal. St. Child, 28:347-364.
Willock, B. 1990, From acting out to interactive play,’ Int. J. Psycho-Anal., 71:321-334.