What is acting out?

It is widely accepted that the psychotherapeutic relationship is different from other relationships we may have. In psychodynamic work, this is even more apparent. The regular slots for sessions, the therapist's consistent breaks on the calendar and invoices presented at the same time every month provide a framework for reflecting on the therapeutic relationship, the vehicle for change.

The stability of the therapeutic boundaries aims to create space for doubts, confusions and uncertainties to be worked through. The psychoanalyst Marion Milner describes this structure as the "analytic frame", a boundary marking off external reality from the internal world. The frame may also bring about certain pressures within patients to deviate from the boundaries or cause the frame to collapse. Challenges to the frame is the essence of acting out.

Some common examples of acting out include: late/early/non-attendance; contact between sessions; late payment, non-payment, partial payment; bringing gifts; seductive behaviour; and taking holidays before or after the therapist's break. A more current example could be scanning the internet for traces of the therapist. 

A hypothetical example in a session: A patient brings a gift for the therapist the session before a break. The therapist pauses and invites the patient to think about the gesture. At first this might seem odd but the patient reflects and suggests that it represents an act of gratitude. Upon further exploration, he describes other desires such as a wish for the therapist to remember him over the break; or perhaps a way of making the therapist feel looked after; or it might be a reminder for the therapist to think about him rather than someone else.

Acting out could represent an attempt by the patient to avoid thinking about his or her feelings, to abide by a familiar pattern of relating. It may seem tempting to disapprove of it; however, we might overlook its value then. Instead, it might be worth inviting patients in an interested and sympathetic fashion to explore the more sensitive and vulnerable parts of themselves. Bringing together an understanding of the powerful, hidden messages of acting out could therefore allow for a new relationship to emerge.

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