Approaches to “Acting Out” Behavior

Acting out behavior (a term not used in the pejorative sense) refers to maladaptive behaviors’ ranging from self-mutilation, swallowing objects, cursing and striking out at other people, etc. This category of behaviors shares commonality in that their intended purpose is the attempted alleviation of distressing feelings through inflicting damage on one’s self or on another person.

The integrative model consists of the interactive cognitive, affective, and motivational systems. The cognitive system consists of dysfunctional beliefs such as “If I hurt myself it will make my anxiety go away” or “I must swallow an object right away to control my unpleasant state”. The affect ranges from nervousness and anxiety to dysphoria, disappointment to irritation and anger. The motivational system is expressed in terms of needs, urges, impulses, etc. and culminates in the maladaptive behavior. The maladaptive coping represents a “safety behavior” which translates into believing the unpleasant affect for the time being, the affect recurs because the system to extinguish it is still in place waiting for the belief to be re-activated, starting the sequence to the maladaptive behavior. Importantly, there is often an accompanied idea that the belief will not go away without the destructive action taking place.

A typical chain analysis would include the following: the stimulus (often not ascertainable) > distressing feeling (anxiety, dysphoria, depression or anger) >cognition/motivation (“I must do something to alleviate this feeling”) >acting out behavior. Analysis: Acting out behavior involves a massive shift of attentional resources to the behavior and its consequences — specifically, an activity directed against the self and the other person. The experience of pain, when it is part of the cycle, also serves to shift the focus away from the unpleasant feeling.

The linear approach to this destructive behavior depends on a thorough chain analysiswith each link on the chain being a potential point for intervention. In terms of the initial provocative stimulus, determine whether the initial affective reaction occurs in response to a negative interpretation (usually a misinterpretation) or the negative stimulus may be internally generated by a thought such as: “ I am a total failure… unable to control myself…looked over all the time”. These thoughts are evaluated by the clinician and the individual and following, resiliency responses are generated such as “I can do things to get over this problem and then I won’t need to feel bad anymore”. The next link in the chain analysis deals with the distressing feelings. The experience of dysphoria, anxiety, and depression may in themselves generate dysfunctional beliefs such as “I don’t have any control over my behavior” or “I am totally helpless”. The person is then taught a strategy such as Look, Point, Name which focuses the attention elsewhere, thus alleviating the focus on the negative feeling and also serves to have the individuals prove to themselves that they have more control over their emotions than previously thought. Following the experience of negative affect, the individual is subject to a number of dysfunctional thoughts such as “I must get rid ofthis feeling right away or it will go completely out of control”. These thoughts are in the realm of permission giving beliefs and can be subjected to empirical testing. For example, a person may “tough it out” by learning to accept these negative feelings and refraining from acting on t hem not act on them. With these adaptive strategies in mind they also may find that in due course the implicit feelings go away without resorting to destructive behavior.

The final step in the linear approach is to have a Rehearsal (roleplay). Rather than wait for the above sequence of dysphoria leading to acting out to occur, it is often useful to provoke the chain reaction –after gaining the individual’s permission and explaining the rationale. The rehearsal consists of starting the sequence as the clinician for example proposes that the individual vocalize negative beliefs such as “I am helpless” or “Other people don’t care about me”. Assuming the negative affect and dysfunctional behaviors are aroused, the individual then goes on to refocusing and encountering permission-giving beliefs. The individual, consequently, will have a number of success experiences. The clinician then tries to draw out the conclusions: “If I wait it out, the bad feelings will go away”, “I do have control over my feelings by focusing on other things” and “I do not have to give into the urge to hurt myself. This urge will go away”.

Relatedly, the linear model is also very useful in understanding and diminishing the individuals’ striking out at other individuals. Anger is generally aroused in the context of the individuals’ interpreting. In a chain-analysis we often find that the specific individual has interpreted another person’s behavior towards him or her as an offense or a serious advance thatneeds to be punished. Moreover, the individual anticipates that their anger will be relieved by retaliation.The rehearsal of this chain of events is often very useful in helping the individual to get over this pattern of reaction. The individual may come up with reasons for not expressing the anger. Some of these, communicated by some individuals include:to set an example for my children, it’s not worth the effort.

In contrast to the linear approach, the holistic model is based on the assumption that continuous acting out is counterproductive in that it not only inflicts damage but has only a temporary effect.Here, the approach emphasizes ascertaining the individuals’ aspirations and setting up a pathway to realize these aspirations. We have found, for instance, that as the individual becomes more involved in adaptive behavior, leading to the activation of the adaptive mode, they are less subject to the chain reaction leading to maladaptive behavior. This approach obliges each individual towards setting up a satisfying goal thereby shifting the individuals’ investment away from alleviating the dysphoria towards satisfying basic needs such as connection, control, and competence. However, when the individual images the aspirations, there is a shift even though temporarily, of attention towards the future. This shift in itself tends to alleviate the dysphoria.