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The paper deals with acting out in the sense of repetitive compulsive gratification of unconscious impulses as seen in impulse neuroses rather than with the acting out which begins in therapy as a regressive defence. Like Greenacre, Carroll relates it to disturbances in the second year and emphasizes the failure to develop adequate means of linguistic communication.
This failure he attributes to participation in acts of gross duplicity on the part of the parents or guardians, so that the real facts have seemed to the child to differ from what was said about them. An example would be the passive witnessing of sexual scenes in which a nurse is involved and the child rewarded for secrecy. As a result orientation to reality through action and through speech develop independently of one another. The failure to assimilate language as a concise method of conceptualization means that whole dramatic sequences have to be acted out instead of details being selected for symbolic representation. Related to this there is a chasm between reality and fantasy, which cannot be integrated with reality by such means as artistic creativity.
Treatment requires an extensive preliminary period of ego education. Considerable tolerance must be given to the patient's motor behaviour, and the relevance of verbal communication must be constantly checked against it. Standard analytic procedure can only be introduced when the acting out tends to be replaced by psychosomatic anxiety equivalents and verbal communication.