“I explored a patient’s feeling toward me and this led her to resist closer contact. As I continued, her rage rose toward me. She pictured an impulse toward me then something surprising happened! She stood up from her chair, approached me and took an intimidating posture toward me, standing really close. I reached out my hand, signaling her to stop and asked her to sit down in her chair again.
We kept exploring her angry impulse but my intervention to have her sit down contributed to a significant cool down of her feeling and impulse. What would you have done? Where do you draw the line from portrayal to acting out in the session?” Thanks for this important question!
When we invite patients to explore their feelings as deeply as possible a moment occurs when the patient experiences her impulse. At this moment we invite her to experience her impulse physically in the body and then picture what would happen if that impulse came out in FANTASY: “If that impulse came out onto me, how do you picture that in your IMAGINATION, in THOUGHTS, WORDS, and IDEAS?”
We never encourage the patient to act out rage in reality, for that defense leads to destructive results. Acting out rage is always a defense against tolerating the internal experience of it. In therapy we help patients experience the full extent of their rage so: 1) they can channel their rage into healthy self-asserting; and 2) they can access the complex mixed unconscious feelings linked to the rage. As a result of facing the previously avoided unconscious feelings, their anxiety and defenses will drop. They will now be able to feel and deal rather than avoid and be symptomatic.
In this case, the patient suddenly stood up, a sign of having difficulty tolerating the rise of rage internally. The therapist correctly asked her to sit down and then invited her to experience her rage internally rather than act it out externally. Did he do anything wrong beforehand? We can’t know without the data. However, one mistake therapists often make is one of timing. As soon as the patient has the impulse, intervene: “If that impulse came out onto me, how do you picture that in your imagination, in thoughts, words, and ideas?” If you say it right away, the patient understands that she is not to act out her impulse, but to channel it into her imagination. This immediate support will help her avoid acting out.
Sometimes a patient has no history of acting out and we don’t see any evidence of acting out until this point in the therapy. Thus, this simple intervention of helping her tolerate her feelings while sitting down will be enough for her. Other patients show signs of impulsivity earlier in the session: rapid speech, interrupting the therapist, rapidly changing topics, fidgeting and bodily movements, loud speech, yelling, cursing, rapid projection, pounding movements with the arms, and stamping of the feet. These signals tell us the patient has a low capacity for feeling tolerance requiring the graded format. Explore feeling until each regressive defense occurs and then restructure repeatedly to build structure in the patient. As we block and restructure each regressive defense, the patient gains the capacity for feeling tolerance so that when we get to portrayal, he will be able to bear his feelings rather than act out.
Portrayal or acting out?
Acting out: the patient acts out an angry impulse physically in reality.
Portrayal: the patient imagines acting out an angry impulse in fantasy.
Acting out in reality versus imagining in fantasy.
Acting out must always be blocked. Otherwise, we reinforce the patient’s defense of acting out and increase his burden of guilt over any damage he causes.
Take home point: as soon as the patient experiences the impulse, immediately intervene: “If that impulse came out onto me, how do you picture that in your imagination, in thoughts, words, and ideas?” That provides her with the support she needs and will block any tendencies to acting out.