Cool Intervention #5: Head-On Collision

A client has pent-up emotion buried under denial, rationalization and minimizing. "Hey, no one had a perfect childhood, it's no big deal," he says, "it is what it is." What happens next? If his therapist was trained in ISTDP, the client better make sure his seatbelt is fastened. Stand back on the sidewalk and witness another one of the Ten Coolest Therapy Interventions.

Intensive Short-Term Dynamic Psychotherapy (ISTDP) was developed in the 1960's by Dr. Habib Davanloo, a psychiatrist who agreed with the basic tenets of psychoanalysis but became frustrated with the length of time it required. He developed a modality where the therapist becomes a much more active agent of change and where resistance is handled directly and firmly. He believed that when people push through the resistance and experience true, intense emotion about the past and present, psychological symptoms diminish and interpersonal relationships improve.

I once wrote a blog comparing psychological theories to music genres. Due to their shared love of brevity, intense emotion and in-your-face technique, I said ISTDP was analogous to punk rock. If that's the case, then the head-on collision is a stage dive. The therapist, who knows how to spot a defense when she sees one, jumps in and confronts the client with his resistance, points out consequences of remaining defended (which may include lost time, money and relationships) and presents him with a choice. Here's an example of a Head-On Collision, one that could be applied to the client at the beginning of the article:

Let's take a look at what's happening here. You have come on your own free will, because you are experiencing a problem which causes you pain. We have set out to get to the root of your difficulties, but every time we attempt to move toward it, you put up this massive wall. The wall keeps me out, and it keeps you from knowing your own true feelings. If you keep me out, you keep me useless. Is that what you want? Because, as you see, you are certainly capable of keeping me useless to you. My first question is, why would you want me to be useless? You see, the consequences of this would be that I would be unable to help you. I'd like to, but the nature of this work is that I can't help everyone. Sometimes I fail. However, can you afford to fail? How much longer do you want to carry this burden?

It's strong, elaborate and not for everyone. I'm no ISTDP expert, so I'm thrilled to present the wisdom of Allan Abbass, MD, Professor and Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Canada. He is a leading researcher in Davanloo's ISTDP (www.istdp.ca) and STDP in general. He has been the recipient of a number of teaching awards and provides videotape based workshops and immersion courses around the world. He was recently conferred a Visiting Professorship and University of Derby in the UK. He kindly agreed to take the wheel and share his thoughts on this intense and cool intervention.

1. When would a clinician use the Head-On Collision?

The "Head on collision" with resistance is considered the most powerful intervention in Davanloo's method of ISTDP. This intervention is used with highly resistant clients when the patient is face to face with his or her most self defeating defence mechanisms as they are operating in the therapeutic relationship at that moment.

2. What does it look like?

The therapist at that moment highlights the nature of the defences, the destructive effects of the defences, how the defences have killed prior efforts to be close, the potential they could overcome the defences, the good outcome that would follow. The therapist also highlights the decision is up to the client, that victory over the defences is the client's and couples this with encouragement for the client to do the best thing for his or herself, family and future.

3. How does it help the client?

This renders the defences "dystonic" or optimally hated by the client. He or she sees that the defences have caused much pain, loss and suffering for the client. He or she becomes mobilized against these behavioral systems. It inevitably brings some breakthrough of grief over this self defeating adaptation and, depending on certain variable such a timing, can bring to consciousness stronger early emotions about attachment trauma.

4. In your opinion, what makes the Head-On Collision a cool intervention?

The coolest part of it is when you watch the teaching tapes to illustrate this and other emotion-focused maneuvers, it usually brings empathy for the client who had previously been walled off and defeating therapy: Now the viewer and therapist feel admiration for the client who has broken through a longstanding relationship defeating pattern. It also often brings grief in the viewer as he or she recognizes their own or family members' own patterns and the losses and pain the patterns have caused.