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Freud said of acting out that 'the patient reproduces instead of remembering'; therefore, Spiegel says, 'a basic understanding of acting out cannot be achieved without having at hand a psychoanalytic theory of memory'. In two patients for whom 'acting out was a way of life', Spiegel observed that the acting out gratified exhibitionistic and masochistic impulses. 'This instinctual gratification is defensive, it is mobilized against narcissistic injury arising from nonfulfilment of infantile genital wishes, not against guilt or anxiety.' It is a means of preserving the 'narcissistic equilibrium'. The author adds that 'defensive instinctual gratification as a form of acting out is but one aspect of the broad field of acting out'.
In treatment it is necessary to link the sexual humiliation in the transference to the humiliation in the acting out. 'Only after the connection between the necessary transference frustration and the acting out (defensive instinctual gratification) has been solidly established does it become possible to analyze the more usual defensive mechanisms…'
Freud suggested that a displacement of psychic energy from one drive to another may occur. Spiegel suggests that in patients of the kind he describes, 'any rise in Oedipal wishes in the transference is quickly displaced onto the partial drives'. 'With the development of infantile genital wishes toward the father, the primary relation to the mother appears to be turned defensively against the new frustration of these wishes experienced at the hands of the father.' The primitive relationship to the mother has been chiefly narcissistically exhibitionistic and masochistic. The preservation of the patient's narcissism involves a breach between inner and outer reality. Reality testing is defective. Such patients 'must necessarily approach borderline conditions'.