by Martha Stark, MD / Faculty, Harvard Medical School


What is the distinction between acting out and enactment?


Classical psychoanalytic theorists have long believed that whenever the patient “acts out,” she is violating the unspoken rule that requires the patient to put into words (not actions) whatever she might be experiencing.  The patient who acts out is thought to be a bad patient who needs containment.


Contemporary psychoanalytic theorists conceive of things a little differently.  For them, the patient’s activity is seen as an enactment, the intent of which is to communicate something for which the patient may not yet have found words.


Perhaps the patient is communicating her need for containment; but, more probably, the patient may be attempting to communicate something about her internal experience that, at this point, is outside the realm of words.  The patient’s activity is therefore seen as offering patient and therapist the opportunity to understand something they might not otherwise have been able to understand.


So when the patient’s activity is seen simply as acting out, then it becomes an obstacle to treatment; but when the patient’s activity is seen as an enactment (with intentionality), then it becomes a powerful therapeutic tool that conveys important information to both patient and therapist about the patient’s internal state.


Clinical Vignette – Desperately Trying to Be Heard


The following vignette demonstrates the power of conceptualizing the patient’s activity as an enactment, the intent of which is unconscious communication of something the patient cannot (in the moment) acknowledge consciously.


The patient, Carol, is engaged to be married.  She is delighted that she has finally found a man, Tom, who would seem to be a perfect match for her – appropriate, available, a fine man, and very much in love with her.  All her friends are excited; her family is proud; her therapist is pleased.  Indeed, Tom, a successful lawyer who works long hours, appears to enjoy her, to delight in spending whatever time he can with her, and to love her; he is clearly eager to share the rest of his life with her.


But as the wedding date approaches, Carol finds herself becoming more and more jealous – even the slightest attention Tom pays another woman drives her wild.  When he is watching a movie and an attractive woman appears on the screen, unless he averts his gaze, she throws a fit and, at such times, can become quite verbally abusive.


Carol is not entirely sure why she reacts as she does – but she does know that if Tom even looks at another woman it devastates her and makes her feel completely out of control.  One time, in the midst of her outrage, she threw a potted plant at him; another time, she broke a vase by throwing it at the TV; she has also, on occasion, struck him with her fists – in exasperation and anger.


The therapist, alarmed, attempts discreetly to remind Carol, in as nonjudgmental a fashion as possible, that Carol may end up losing Tom unless she can learn to contain herself.  The therapist encourages Carol to try to put into words just how painful it is for her when Tom shows interest in another woman.


Intent upon unearthing the genetic underpinnings of what would appear to be Carol’s inappropriately intense jealousy, the therapist also encourages Carol to talk about what it was like for her to have to bear witness to her father’s constant flirting with other women.  Carol speaks with some affect about how outraged she was that her father would ogle other women and attempt to engage them in conversation; she also talks about how much it pained her to see how passively ineffectual her mother wa in the face of her husband’s repeated betrayals of her – mother simply endured the constant humiliation of having a husband who was obviously more interested in other women than he was in his life.  Carol recognizes that she may be identifying herself with her long-suffering mother and may be identifying Tom with her betraying father.


She also acknowledges how deeply it had hurt that her father was so often away.


But despite the therapist’s cautionary word and Carol’s willingness to talk in a heartfelt manner about her father’s dalliances, Carol continues to abuse Tom – her periodic meltdowns increasing in frequency and intensity.


It is only when the therapist, with the help of her supervisor, begins to recognize Carol’s obsessive jealousy (and consequent abusiveness) as an enactment – as an unconscious effort to convey something about her internal state that she might not otherwise have realized – that patient and therapist come to understand Carol’s jealous tantrums as an attempt to communicate something important, namely, that Carol is not entirely sure she wants to marry Tom after all!  Even though he would seem to be a perfect mate for her, it may well be that Tom is not, in fact, the man with whom Carol wants to spend the rest of her life.


With this permission given to talk about the negative side of her ambivalence about Tom, Carol talks first about how much of a workaholic he is and how driven he is to find success, power, and money.  Although she recognizes that he spends as much time with her as he can, she acknowledges that she had hoped he would want to spend much more of his time with her.


But as Carol continues to explore her angry disappointment in him, it also becomes clear that she is equally afraid that he will be disappointed in her, that he will eventually find her lacking, not a suitable partner for him.  She talks about her fear that she will not be able to hold his attention, that she will lose him.  As she admits to how frightened she is, she begins to cry.


But as she continues crying, she begins to recognize how much Tom really does matter to her and how devastated she would be were she to lose him.


Interestingly, as Carol gets in touch with the positive side of her ambivalence toward Tom, her jealous rages ease considerably and the abusiveness stops entirely.  As she acknowledges to herself how grateful she is to have him in her life, she begins to let herself appreciate and enjoy him.  As Carol gets back in touch with how much she loves Tom, she finds herself wanting very much to marry him – and feeling ready to take that step.


…which she then does!