by Ben Diamond, Psy.D., Managing Editor

There are different theories and ideas to explain the phenomena of behavioral dysregulation or “acting out” and to justify different interventions. In working with institutionalized patients with extremely severe mental illness, acutely assaultive, suicidal, and self-injurious behaviors are common, and often come with (or constitute) highly intense expressions of emotion by the patients engaged in those behaviors and those involved in caring for them. These behaviors are profoundly disturbing to witness and challenging to treat, and thinking about them can enrich the work of all therapists, even those whose own patients act out in less overt and disturbed ways. 

Skills-based and behavioral treatments are often criticized by analytic therapists for what they miss—the emotional and relational complexities they reduce to the mechanistic operation of a behavioral “black box.” On the other hand, how many opportunities for relational aliveness have been missed—and how many patients lost to suicide—in the name of preferring words to actions, thinking to doing, understanding to acting out? It is frightening and destabilizing to watch my patients do violence to themselves and others. It is also clarifying, enlivening, and brings opportunities to learn new ways of being and living for all involved. I am grateful to have both analytic and behavioral tools to understand these processes and to keep myself and my patients alive. 

When my hospitalized patients are dysregulated and on the verge of hurting themselves or other people, DBT protocols suggest I coach them through coping skills like dunking their faces in ice water, exercising vigorously, or distracting themselves with media or other activities—bodily and behavioral practices to help them get through the situation without killing or physically hurting themselves or someone else. The magnitude of pain underlying life-threatening and disfiguring self-injury is staggering. How much must someone be hurting inside to try and cope by swallowing their eyeglasses? Faced with such behaviors, I remember, with a sickly smile, my own fury, anxiety, and agitation, running around the hospital unit looking for a bowl of ice. Where the hell is the bowl?! This is the one time I need it! To remain upright and awake and in the room, I needed to struggle to find that bowl, and eventually to find it—a much more manageable and completable task than “sitting with” and “understanding” my patient’s pain, even for one moment longer. The DBT skills are for us, at least when our patients live where we work. What a relief, to have something to know and to do and to offer. 

A relief, but not only that. Responding to acting out with action is sometimes necessary. It is also a way of being and remaining alive to something that cannot be tolerated, but must be survived. Patients in intolerable states need to be met, and to be heard. Our viscerally engaged responding—looking for the bowl of ice—is a critical and embodied form of hearing when acting out is all there is. It doesn’t replace, but reflects our deep understanding of what cannot be spoken.