The Psychotherapy of the Impulsive and Acting Out Patient

All would agree that acting out and impulsive patients are hard to treat. Freud first used the term “acting out” in 1905 to describe the precipitous termination of therapy by “Dora,” and interpreted her behavior as resistance to therapy, saying, “She took her revenge on me as she wanted to take her revenge on him [Herr K.] and deserted me as she believed herself to have been deceived and deserted by him. Thus, she acted out an essential part of her recollection and fantasies instead of reproducing it in the treatment.” This remains one of the most common outcomes of acting out, and with it, of course, the treatment ceases. I have often wished that an acting out patient of mine would find this solution and relieve me of the anxiety and grief resulting from more dangerous forms of acting out.

In 1914 Freud elaborated on acting out in his paper entitled, “Further Recommendations on the Techniques of Psychotherapy, Remembering, Repeating, and Working Through,” saying, “The greater the resistance the more extensively will acting out (repetition) replace remembering.” Since then, there have been many post-Freudian elaborations of the concept, including those of Alexander (1930), Fenichel (1945), Sacks (1957), Kanzer (1957), Abt (1965), Milmen (1973), and Wishnie (1978). Furthermore, acting out has been the subject of symposiums in 1963, 1968, and 1973, as well as of a group study report in 1968.

The concept of acting out has been broadened so that now it refers to any behavior not acceptable to an individual or to society. As I will use the term, acting out is “a circumscribed yet complex and significant act (or short series of acts with a common intention) carried through to completion resulting in at least partial