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Approaches to “Acting Out” Behavior in Individuals with Schizophrenia

By Aaron T. Beck, MD and Ellen Inverso, PsyD

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, and so on. This category of behaviors shares commonality in that the 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 now to control my negative feelings.” Individuals vary in the degree to which they recognize their beliefs. They are much more likely to recognize their emotions and urges. The affect they experience ranges from nervousness, anxiety, dysphoria, or disappointment to irritation and anger. The motivational system is expressed in terms of needs, desires, urges, impulses, etc., and culminates in the maladaptive behavior. This maladaptive coping represents a “safety behavior” to quell negative emotion--but the negative affect is likely to recur because the system to extinguish it is still in place. Once a belief recurs, the motivational system becomes activated, once again starting the sequence to the maladaptive behavior.

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 presumed alleviation of negative affect. 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 analysis.

Each link on the chain is a potential point for intervention. In terms of the initial provocative stimulus, therapists should determine whether the primary affective reaction occurs in response to a negative interpretation (usually a misinterpretation) of a problem, event, or situation. Or the negative stimulus may be internally generated by a thought such as: “I am a total failure” or “I can’t control myself.” These thoughts can be evaluated by the clinician and the individual. Then they can generate resiliency responses such as, “I can do things to get over this problem and then I won’t need to feel bad anymore.” When applicable, problem-solving can also be implemented by the clinician if the individual encounters challenges.

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, away from the negative feeling. Doing so also allows individuals to demonstrate to themselves that they have more control over their emotions than they had previously thought. A thought such as “I must get rid of this feeling right away or it will go completely out of control, ” is a permission giving cognition which can be empirically tested. For example, a person may “tough it out” by learning to accept these negative feelings and refraining from acting on them. With these adaptive strategies in mind, they also may find that in due course the negative feelings go away without resorting to destructive behavior.

The final step in the linear approach is to have a rehearsal (roleplay). 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—for example, the clinician can propose that the individual vocalize negative beliefs such as “I am helpless” or “Other people don’t care about me.” Once the negative affect is aroused and dysfunctional behaviors are activated, the individual then refocuses.  The individual, consequently, will have a number of successful experiences. The clinician then tries to draw out conclusions such as: “If I wait it out, the bad feelings will decrease;” “I  can take 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’ interpretations. In a chain-analysis, we often find that the individual has interpreted another person’s behavior towards him or her as an offense that needs to be punished. Moreover, the individual anticipates that his or her 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 include: “to set an example for my children” or “It’s not worth the trouble I might get in if I act on these thoughts.”

In contrast to the linear approach, the holistic model is based on the assumption that continuous acting out is counterproductive. It not only inflicts damage but it also 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 entails having the individual set up a satisfying goal, thereby shifting his or her 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 temporary--of attention toward the future. This shift in itself tends to alleviate the dysphoria.

Case Example:

One individual on the unit, who had been hospitalized for many years, had a history of acting-out behavior. She identified her aspiration to teach pre-kindergarten children. Her initial step in this pathway was taking the necessary measures to further her education. Consequently, she reoriented her focus and mental investment to overcoming obstacles and taking the necessary steps to return to school.  The staff brought in many materials relevant to child development and early learning skills for her to read. As she worked away, it was no longer necessary to have the two medical technicians continue to observe her. She was subsequently discharged to a lesser facility where she kept up her work, eventually received supportive housing, and finally enrolled in a community college course in early education.

The holistic strategies and the linear strategies can complement each other. For example, there can be a challenge in solely using the linear approach if an individual’s aspirations and purpose are not identified. Moreover, there have been numerous individuals across several states we have worked with who have told us that it was worth doing the chain analysis and testing new behaviors only because they would help them on their path toward their unique aspirations.  Without the inclusion of their aspirations, there was little motivation in understanding and testing alternative responses. In fact, doing a chain analysis without a meaningful, driving purpose could even increase shame in some cases (for example,  if a person understands the chain but acts out anyway in response to distressing stimuli).

It is important to note that because most of these individuals have a desperate need to belong, it is important for the staff to encourage individuals’ participation in group activities as much as possible. This participation may depend a bit on whether individuals are beginning to show some control over their impulses, but it should be a goal in itself for the staff. We have found that the individuals who are relieved of close surveillance and are introduced to group activities may go for long periods of time without acting out. It seems that the close restraints, which keep these individuals from participating in group activities, are counterproductive. They deny the individuals of closeness to others, opportunities to control themselves, and a sense of achievement when they refrain from exhibiting destructive behavior.

Additionally, to create and maintain a pathway towards achievement of the aspiration or some other objective that has a similar meaning to the individual, staff should provide opportunities for fulfillment of basic needs--as well as solving the problems associated with reaching the goal. The staff thus helps to facilitate the type of actions that lead to satisfaction and improve the self-image of the individual as belonging, competent and having control. Finally, it is absolutely necessary to keep in mind that these interventions and individuals’ pathways to recovery are distinctive. Thus, we aim to meet people where they are. For some individuals with whom we work lots of talking and behavioral testing is ineffective. For those individuals, change may stem from a focus on their meaningful aspirations and positive action steps toward this aspiration--instead of directly addressing and working to change the harmful and dysfunctional behaviors. In these cases, we often find that by shifting focus to their aspirations, the destructive behavior diminishes significantly. For other individuals, it will be necessary to address both the aspirations and their destructive behaviors head-on.