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The acting-out patient is seen as being unable to internalize his conflicts but as involving other people in them because of a developmental defect in the differentiation between his ego and the ego of his mother. The defect is described as a continuation of the symbiotic stage of development wherein
mother and child directly respond to the id of the other. Normally with separation and individuation of the child from his mother, communication is carried on only through the agency of the ego. Bird amplifies the theory of Johnson and Szurek in regard to acting out; he thinks that the mother does not allow the ego of the child to become an independent operating agency but continues to maintain direct contact with the child's id and directly influences his ego with her id representatives. Thus the child retains an unconscious method of communication, which results in an uncanny ability to sense the hidden impulses of others, as if each new person were his mother. The analyst's unconscious is an open book to the patient and cannot be concealed. Treatment is invariably complicated by the patient's acting out with other people, including the analyst. When this occurs the analyst should suspect his own part in it. Examples are given.
Acting-out patients are seriously upset by the transference due to the great threat to narcissism of object formation. Therefore, the analyst of this type of patient should help him to develop an infantile narcissistic symbiotic relationship in which he is one with the analyst. From this 'strange transference state' work can proceed to help the patient overcome his narcissism. Interpretations that threaten the patient's narcissism can cause an attack of acting out. Rather than interpret the transference meaning of feelings, one interprets the purely narcissistic meaning of the patient's acting out. The frequent existence of a split self-image in these people can sometimes be brought to light by talking to them in the third person,