THE IMPACT OF ASSERTIVE TRAINING ON THE ANXIETY
AND SYMPTOMIZATION OF WOMEN REFERRED BY PHYSICIANS
Gertrude Gies Little
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF THE
UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
Digitized by the Internet Archive
T92r21 RtN]fcling from
University of Florida, George A. Smathers Libraries with support from LYRASIS and the Sloan Foundation
There have been many wonderful
and supportive people who have
helped me during my years
as a doctor
thank all of
them for their encouragement, guidance and friendship during some
of the most
important years of my
I wish to express particular appreciation to those individual
who helped me make my di
station a reality.
Thank you to:
chairman of my supervisory committee, whose
help and emotional
support helped me both develop and
complete this study
He was always responsive and involved.
special ability to help me organize was invaluable.
Mr. and Mrs.
es, my parents, who have continued their
ove and support even when I
seemed to waver off course.
spired me to be whatever
I wanted and had an enduring belief in my
ability to do so.
my husband, who has never known me without
love and patience have been very
and his support is what made thi
particular study possible.
David Lane for his continued encouragement, guidance and
friendship during my entire doctor
He will always be a
Ms. Sue Rimmer for her invaluable assistance with the statistical
and for her encouragement.
Ms. Jennifer Lane for her knowledgeable editing and her willing-
ness to do it when I needed it
Ms. Nanci Clyatt for her expert typing and her calming manner.
TABLE OF CONTENTS
LIST OF TABLES
Need for the Study
of this Study
Plan of the Study
Definition of Terms
- REVIEW OF THE LITERATURE
a Problem for Women
Treatment of Anxiety
Historical Antecedents of Assertive Training
Research on Treatment Procedures and Behaviors
Important to Assertiveness
Applications of Assertive Training
Case Studies on the Applications of Assertive
Research Studies on the Application of Assertive
Training for Women
CHAPTER III METHODS AND PROCEDURES
Selection of Subjects
The Adult Self-Expression Scale (ASES)
Symptom Checklist (HSCL)
The State-Trait Anxiety Inventory (STAI) Form X
CHAPTER V -
of the Data
Description of Subjects
Analysis of the Data
Evaluation of Training
- SUMMARY, LIMITATIONS, DISCUSSION AND IMPLICATIONS
- Doctor's Letter
- Personal and Professional Data
- Personal Data Sheet
- Evaluation Form
- Treatment Procedures
- Consent Form
- Second Doctor's Letter
- Experimental Group Members' Comments
LIST OF TABLES
Age of Subjects
Years in Present Marriag
' Numbers of Children
Highest Grade Completed
' Employment Status
Chi Square Analyses of Demographic Data
Number of Members in Each Group
of Covariance on the Adult
for the Adult Self-Expression
Analysis of Covariance on the A-State
Adjusted Mean Scores for the A-State
Analysis of Covariance on
the A-Trait Scale
Adjusted Mean Scores for the A-Trait
of Covariance on the Hopkins Symptom
ores for the Hopkins Symptom
of Covariance on
the Hopkins Symptom
Checklist Somatization Dimension
Analysis of Covariance on the Hopkins Symptom
Checklist Obsessive-Compulsive Dimension
ores for the Hopkins Symptom
Checklist Obsessive-Compul siv
on the Hopkins
klist Interpersonal-Sensitivity Dimension
Scores for the Hopkins Symptom
on the Hopkins Symptom
Checklist Anxiety Dimension
Adjusted Mean Scores
for the Hopkins Symptom
Checklist Anxiety Dimension
on the Hopkins Symptom
Checklist Depression Dimension
Adjusted Mean Scores for the Hopkins Symptom
Checklist Depression Dimension
Means and Standard Deviations for the
Evaluation Form 114
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements
for the Degree of Doctor of Philosophy
THE IMPACT OF ASSERTIVE TRAINING ON THE ANXIETY
AND SYMPTOMIZATION OF WOMEN REFERRED BY PHYSICIANS
The purpose of thi
study was to investigate whether assertion
training could effectively modify anxiety and symptomization in a
population of women referred by their physicians.
The women all
reported anxiety of an interpersonal nature which they experienced
The sample for this study was composed of
between the ages of 20 and 65 whose primary-care physician had sug-
gested that they might benefit from participation in an assertion
They were women who
, in the physician's estimation,
were experiencing one or more of the following symptoms as a con-
sequence of anxiety:
somatic complaints such as headaches, gastro-
inferiority and of being critical of others; indications of depression
such as loss of sexual interest or pleasure, poor appetite, crying
easily or worrying and stewing about things
such as feeling fearful
indications of anxiety
nervousness or shakiness inside, heart
pounding or racing or feeling tense or keyed up.
These women were assigned to one of six treatment or six control
Members of the experimental groups were tested, received
assertion training and were posttested.
groups were tested
Members of the control
waited seven weeks and were posttested.
training and testing was done by the researcher.
82 women provided all the data requested.
of scores on nine criterion variable
the Adult Self-Expression
Scale, a measure of assertiveness; the A-State and A-Trait Anxiety
and the Hopkins Symptom Checklist, a clinical rating scale
which reflects the psychological symptom configurations commonly
observed among medical outpatients.
The Hopkins Symptom Checklist
yielded a total score and a score on five subscales
Interpersonal-Sensitivity, Obsessive-Compulsive, Anxiety and Depres-
Pre- and postscores on all of the instruments were totaled
for all subjects.
The members of the
The women also completed a Personal Data Form.
experimental group filled out a form evaluating
the training during the posttesting period.
Chi square anal
were used to evaluate the differences between
of covariance, using pretest scores as covariates,
were used to evaluate each of the nine
produced results significant at the .05 level for all variables
except the Depression subscale of the Hopkins Symptom Checklist.
Means and standard deviations were computed for the evaluation form
Based upon these statistical findings the assertive training
group was better than the control group in developing assertive
behavior, in lessening general and situation-specific anxiety and
in lessening the women
interpersonal sensitivity, anxiety and total symptomization.
There are several clear indications that managing or coping with
anxiety and stress i
a problem for a large segment of the population
From the volume of anxiolytic drugs prescribed,it is clear
are aware of anxiety in their patients.
Greenblatt & Shader, 1974) have
shown that approximately 15%
of adult Americans regularly take antianxiety agents on an outpatient
This suggests that anxiety i
prevalent and that physicians
commonly resort to pharmocotherapy to provide relief for these
A second major indicator of the prevalence of anxiety as a problem
in our society i
s that professional
counselors, "self-help" techniques
and a number of popular psychology books aimed at adjustment problems
are widely accepted and utilized.
A recent analysis of the new
help" phenomenon identified self-awareness as a new panacea:
are frantically trying to 'get in touch
to learn how to 'relate' better, and to stave off outer
tie~~~~~~ rrnni Ill, ~ri inna 4nn nan1 ~rir Q7
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methodologies to help individual
deal with the anxiety and turmoil
such searches can precipitate.
Anxiety is difficult to define precisely.
situations vary, anxiety is usually episode
Since stresses change
as opposed to static.
Often related to environmental
stresses or specific
individual considers threatening
anxiety may trouble a person for
a while and then dissipate until
pielberger (1966) distinguishes between two
types of anxiety.
Trait anxiety refers to anxiety
ness that are relatively stable.
High trait anxious persons are pre-
disposed to respond anxiously to a wide
that they perceive as threatening or dangerous.
Because it is relatively
this type of anxiety has a pervasive effect on individual
Time-consuming and often costly treatments are generally
required to achieve
lasting solutions to the problems trait anxiety
study addresses the issue of trait anxi
ty and Spielberger
other type of anxiety
- state anxiety.
State anxiety refers to a
temporary condition or state that may vary in intensity and fluctuate
over time in response to circumstances that an individual perceives
In contrast to the trait anxious
person who characteristically respond
even when unprovoked), an individual
in an anxious manner (often
s experience of state anxiety
can frequently be connected to identifiable
- 2 t. .. -- -
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Need for the Study
Although common to both
, available data support the view
that anxiety is particularly a problem for women.
report more symptoms of anxi
ety and emotional
distress than men
(1976) confirms that women exceed men
in their consumption of psychotropi
drugs in a consistent ratio of
two to one.
Many women fail
to make a connection between the
problems in their environment and their vague, often subjective impres-
sions of anxiety (Williams,
It is very often this failure to
why they are anxious that makes it difficult for women to
cope with anxiety.
factors seem to be especially significant
why women are anxious.
Contemporary thought hold
that changes in
their role in society have resulted in increased stress and anxiety
for women in particular
tresses arising from
potentially conflicting social
(for example, wife, mother
worker) and pressures from multipi
creating problems for
lead to more anxiety.
Women today are caught between con-
forming to existing standards or role definitions and exploring the
promise of new alternatives.
Women today also are confronted with an
increasing awareness and
concern about personal
limitations and the des
ire to overcome them
(Lange & Jakubowski
They feel anxious
, for example,
-. .a.a a-
I II I
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out that as women
potentials for self-growth,
they often notice
in their abilities to assert their
, anxiety about interpersonal
often inhibits their trying out new rol
and seeking new relation-
Thus, many women are caught
in the paradoxical
of experiencing anxiety within their existing situations or rol
(trait anxiety) and at the same time experiencing anxiety (state
anxiety) as they try out new behaviors which might alleviate those
can be treated.
Although it i
sidered a psychological
phenomenon, many individual
, varying from somatic complaints such as head-
aches or insomnia to direct
fearful or nervous. Since
individuals actually feel,
These complaints may be the only distr
the primary-care physician is often the
they approach for treatment.
Because of the physi-
the treatment often takes the form of
This can be expensive and
Frequently a drug which eliminates a person
ide effects such as drowsiness or impairment
anxiety also causes
of psychomotor functions,
thereby reducing the patient'
functioning (Greenblatt &
, treating the symptom or somatic manifestation
of the anxiety without helping the patient
identify and learn to cope
with the anxiety-provoking situation generally does not result in
Historically the psychological treatment of anxiety has involved
extended and intensive psychotherapeutic relationships.
are expensive and time-consuming and therefore generally unavailable
to the vast majority of people. Chesler (1971) has suggested that
for many women the psychotherapeutic encounter is just one more power
relationship in which they are rewarded for expressing distress and
are helped by submitting to a dominant authority figure, thereby
creating more anxiety.
Self-help methods, on the other hand, are popular and inexpensive
but at the same time unguided.
that the use of
Thus,there exists a strong possibility
uch methods may in fact produce even more anxiety
Indeed this possibility seems likely, since by definition state-
anxious individuals are ineffectively using
Some of the more recent professional counseling methods have
potential applicability to the treatment of anxiety.
They are generally
expensive, threatening and time-consuming and more socially
Some of these, such as encounter and sensitivity groups,
Transactional Analysis and communication skill
have enjoyed immense
However, most of these methodology
are based upon
the principle of increasing self-awareness and not specific adaptive
Therefore, there i
a need for methods which emphasize
situational applications and help individuals focus emotional energy
toward alleviating specific difficulties
One of these methodologies, assertion training, is especially
professionals and the
lay public become
interested in it.
current interest to two important
cultural changes which seem to have taken place in the
as it became more difficult to achieve a feeling of
value their personal
, such as work and marriage, people began to
as a major source of life satis-
necessary to better their personal
relationships and to overcome the
anxious feelings inhibiting the expression of needs
behaviors widened and alternative
became more acceptable, many people found themsel
and anxious about either making choi
about how to behave or defending
when criticized or challenged by other people.
Assertion training has thus become a means for helping people
deal more effectively with many problematic aspects of
Since many of
aspects of people
es' lives are anxiety
producing, assertion training ha
to alleviate or pre-
vent some instances of
tate anxiety experienced when trying out new
behaviors and trait anxiety with its more pervasive
would follow then that assertive training might also alleviate some
symptomatic manifestations of this anxiety
Assertive behavior has been defined
involving the direct,
as any interpersonal
honest and appropriate verbal
expression of one's feelings
Assertion training, then,
is any procedure which incorporates the goal
of increasing an individual's ability to engage in such behaviors in
a socially appropriate manner (Jakubowski
thepresent time there is a lack of general agreement about which
specific procedures actually constitute assertion training, the pro-
generally incorporates four basic procedures:
the difference between assertion and aggression and between
nonassertion and politeness; (2) helping peopi
identify and accept
both their own personal rights and the rights of others; (3) reducing
existing cognitive and affective obstacle
to acting assertively,
. irrational thinking
guilt and anger
(4) developing assertive
kills through active-practice methods
A number of variables appeal
related to assertion. These inc
personal adjustment and anxiety.
Ir to be theoretically or conceptually
:lude locus of control, self-confidence,
Research has been carried out
become more assertive
e, manifest anxiety
Berwick & Beigel
, 1974), while self-confidence
(Gay, Hollandsworth & Galassi, 1975) and personal adjustment (Galassi
, 1974) increase.
The assumption here is that assertion
training also should be effective
in reducing the levels of state and
trait anxiety in women, and that if such a reduction occurs the level
and intensity of symptomatization will also be reduced.
Purpose of this Study
The purpose of this study was to determine whether assertion
training, using well-defined and researched procedures, can effectively
reduce anxiety in a unique population of women who experience symptoms
of that anxiety.
The Percell et al.
showed that assertion
training with a small (12 treatment and 12 controls) mixed-sex group
of psychiatric outpatients did successfully reduce anxiety as measured
by the Taylor Manifest Anxiety Scale.
The present study examined the
relationship between assertion training and general feelings of
It also looked at the relationship between assertion training
and those feelings of anxiety specific
Two unique features of this study
to the time of the assertion.
are: (1) its population of
normal women (not a student group and not a psychiatric inpatient
or outpatient population) referred by their physicians
and (2) its
examination of the relationship between assertion training and
If it can be shown that this particular technique does in fact
significantly increase assertion and decrease anxiety and symptomi-
zation, then we have an effective methodology that is (1) socially
acceptable, (2) easily taught and (
relatively easy for participants
to understand and learn.
Plan of the Study
Subjects for this study were women between the ages of 20 and
65 whose primary-care physician suggested they might benefit from
reported situational anxiety of an interpersonal nature which they
The physicians were briefed on the
nature of the treatment and suggested participation on the basis
of the above criteria.
The following null hypotheses were tested:
There is no difference in women
assertion as a result of participation in
an assertion training group.
There is no difference in women
s level of
as a result of participation
in an assertion training group.
There is no difference in women's level of trait
as a result of participation in an
assertion training group.
no difference in number and inten-
sity of symptoms expressed by women as a
result of participation in an assertion
Definition of Terms
Terms relative to this study are defined below:
Assertive behavior is interpersonal behavior involving the honest
assertive behavior may be divided into four separate and specific
the abil ity to say "no"
, the ability to ask for
favors or make requests
the ability to express positive and negative
feelings; and the ability to initiate, continue and terminate general
conversations (Lazarus, 1973).
Assertive training is a therapy technique used with individual
who are inhibited,
hy and therefore unable to express themselves
situations where assertion is called for.
For example, they are
unable to speak up for themselves when they feel they are being taken
advantage of and are also unable to express positive feelings such as
pleasure or affection when this is appropriate.
The purpose of
assertive training i
to increase the individual
s ability to express
The assertiveness trainer makes behavioral assignments which call
lient to involve herself in interpersonal encounters in the
environment outside the group sessions.
The client attempts to use
assertive behaviors in these encounters.
Behavioral rehearsal is rol
playing the desired assertive be-
haviors the client must use in interpersonal encounters in her life.
Psychotherapeutic drugs are those mood-changing drugs generally
used for the treatment of mental disorders or for the alleviation of
symptoms of psychic distress, and are typically acquired through
(Parry, Baiter, Mellinger
REVIEW OF THE LITERATURE
as a Problem
society is plagued by numerous stresses which serve to
induce feelings of helplessness and impotence.
Social and cultural
factors, such as the persistent threat of total destruction in an
atomic age, the social change which occurs in the wake of rapid
scientific and technological advances, and the social estrangement
and alienation of individuals in a competitive society, combine to
undermine feelings of personal security and contribute to increased
feelings of anxiety
There are several clear indications that anxiety is a pervasive
psychological phenomenon in modern society.
cut of these indicators i
One of the most clear-
the widespread use of anti-anxiety agents.
Such usage is increasing at an alarming rate, with one in ten Americans
taking these drugs during any three month period.
This puts the
yearly cost at greater than two hundred million dollars (Greenblatt
A long-term research program on the extent and
character of psychotherapeutic drug use in the United States (spon-
. J L- = j t ^- -- -_ I 1 . i i _--- .. I I^ h I- i t
prescriptions for psychotherapeutic drugs were filled in United States
This was 16% of the 1,400,000,000 prescriptions filled
Approximately 44% of these prescriptions for psychothera-
peutic drugs was accounted for by a single cl
- the anti-
anxiety agents (BaIter, 1973
Audit results indicated that Valium
e recently, National Prescription
, a minor tranquilizer, was the
most prescribed drug in 1976 (
that 75 to 80 percent of all psychoactive drugs prescribed by physicians
in private practi
were prescribed for the purposes of sedation,
sleep (Balter, 1974) would indicate that many indi-
come to physicians with problems that require calming down.
Another manifestation of anxiety in contemporary life i
widespread public pursuit of psychological happiness and fulfillment.
clearly evidenced by the current proliferation of mass-
distributed personal guidance books.
challenge people to grow emotionally
Books which provide insight,
and profess to actually teach
necessary for happiness and fulfillment have received
Passages, which elucidates predictable
crises faced by men and women as they move through adulthood, was
on the New York Times Review hardback best-seller list for 49
consecutive weeks (Publishers Weekly
Erroneous Zones, described by the New York Times Book Review
as a "ePlf-hpln npn talk" ha c hon nn t+h ha2vrhae h-rU+ kn lnrv
This quest i
philosophy of self-interest, joined the best-seller list just two
weeks after its publication (Publishers Weekly, June
1977, p. 118).
This phenomenon, along with the increasing number of centers and organi-
zations offering workshops on every topic from sexuality to separation
and divorce, points to peoples' need to resolve the turmoil in their
Types of Anxiety
Anxiety has been defined
as "a fearful and apprehensive emotional
state, usually in response to unreal or imagined dangers, that inter-
feres with favorable and effective solutions to real problems.
is typically accompanied by somatic symptoms that leave one in a
continuous and physically
(Psychology Today: An In
exhausting state of tension and alertness"
production, 1972, p. 720).
Anxiety usually exp
itself in one of two ways
may be considered to be either (1) generally anxious or (
because of particular circumstances,
The two conditions reflect
entirely different interpretations of the construct,anxiety.
mer refers to a relatively constant condition without time limitation,
whereas the latter impli
likely temporary. Usual
that the anxiety is immediate and most
ly these two types of anxiety are referred to
as chronic and acute.
Acute as a descriptive term is used most often when describing a
flfl~~hnlnnrzA nnnt~ cna c nn v\ 1 1 )C 46 n v-a~ -. n.. nh ...
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The term chronic anxiety also needs explanation.
Usual ly when
the word chronic
is used to described a state or condition it i
preted to mean a condition of relatively
low intensity or indefinite
When applied to an emotional condition
1 ike anxiety,
is actually meant by
position to experience
Individuals who are considered
chronically anxious are identified not by the intensity or degree of
their anxiety but by the number of occurrences and objects which
evoke a detectable
degree of anxiety in them
It follows that anxiety-
individuals are predisposed to respond anxiously more frequently
and in a wider variety of situations than their peers
The distinction between acute or situational
anxiety and anxiety-
proneness or predisposition has been delineated by Spielberger (1966).
response to a
nxiety is defined
as a transitory state that occurs in
generally circumstances that are received
as threatening) and is
likely to vary in intensity and fluctuate
is conceptualized a
Trait anxiety refers to relatively stable individual
ferences in anxiety
The high trait anxious
predisposed to respond with an anxiety state reaction to a wide range
of stimulus situations that are perceived as threatening or dangerous
Spi el berger,
This study concerns
itself with both state and
Anxiety as a Problem for Women
Although common to both
that anxiety i
available data support the view
particularly a problem for women.
for the use of medically prescribed therapeutic drugs are
tially higher for women than for men (29% compared to
1973). Current patterns of use suggest strongly that most of the
difference in rates between men and women can be accounted for by
a single broad
class of psychotherapeutic prescription drugs
minor tranquilizer/sedative group.
Parry et al.
) discuss certain tentative
therapeutic drug u
which were uncovered by the NIMH
se in the United States: (1) A
tudy of psycho-
visit to a physi
is generally the first step in acquiring psychotherapeutic presc
In this sample women were
likely than men
to report visiting a physician in the year preceding the
of the women compared to 46% of
prevalence rates for drugs such as alcohol
stantially higher than female rates, indic
tropic substances may serve a
and marihuana were
eatingg that these psycho-
substitutes for the prescription
(3) Women in our society, particularly
middle-aged and older women
are permitted and often encouraged to
have mild symptoms of p
hic distress and to
see a doctor for them.
Women are more
likely to report higher
They are also more
ly to report having undergone specific
In addition to the societal and psychological factors, Parry et
mention some definite physical factors which might explain
why women take more psychotherapeutic drugs than men.
do not go through the oestrous cycle
childbirth and meno-
pause) which could increase a woman's chance of receiving psychothera-
peutic drugs. Secondly, normal actuarial patterns indicate a wife will
survive her husband. Since culture dictates that women mourn more
openly than men, prescribing of a minor tranquilizer, sedative or
hypnotic for thi
situation is commonplace (Parry et al., 1973)
The literature suggests several other factors which seem to be
significant in discussing why women are anxious.
Tudor (1973) maintain that role expectations confronting women are
generally unclear and diffuse.
In this culture the notion of what it
means to be female inevitably suggests some type of submissive role
Osborn and Harris, 1975), yet women can clearly
see that what society
values are the norm
of the mal
- being assertive, autonomous,
competitive and achieving (Walstedt, 1974).
that women are marginal
Walstedt (1974) maintains
in our society, living on the margin of two
cultures, never socially or psychologically a part of either.
are schooled from birth into the more highly valued norms of the male
but they are also taught to be helpful, unassertive, de-
are drawn to the more powerful and rewarding masculine
world even a
they are also learning to accept as natural that they
Another significant factor to be considered when discussing why
many women experience anxiety is that most adult women are employed
outside of the home:
they constitute 40% of the paid labor force
they hold lower
than do men, which often poses psychological
problems for them.
Another source of anxiety
fact that more women are working,
losely tied to the
or very real conflict between the demand of occupational
Contemporary American society relies primarily on
mothers alone for child care, expecting
little participation by older
, husbands or other relatives
(Gove & Tudor,
, without challenge.
example, Cooperstock (1976) disagrees with the speculation that having
a number of social
as wife, mother and worker creates
stresses for women that
lead to more problems and perhaps even to an
increase in the use of psychotropic drugs.
that contemporary women filling numerous roles have somewhat
and take fewer tranquilizers and
than women filling the traditional
female role of housewife"
. Nathanson (1975) concluded that
has perhaps the most positive effec
t on women'
health of any variable
investigated to date"
he cited studies
showing that working women present fewer symptoms than nonworking
women of the same age, and report fewer days of disability and less
The woman who chooses not to work outside the home is faced
with a unique set of stresses.
frequently have no alter-
native sources of gratification outside the family
Gove & Tudor,
1973) and are frequently isolated from other adults (Seiden, 1976).
Housework is unskilled *and low in prestige, and the housewife role
is relatively unstructured, leaving much time available for women
to worry about their problems (Gove & Tudor, 1973).
The current "women's movement" has focused attention on most
of these factors which potentially contribute to women's anxiety.
In doing so it has helped women in their personal struggles for
But, for others,the challenge to change and grow has
created new feelings of frustrations and anxiety.
They feel anxious,
for example, when the "women's movement" stimulates them to grow
while at the same time they feel unprepared for change.
anxiety about interpersonal conflicts often inhibits their trying
out new roles and seeking new relationships.
Thus, many women are
caught in the paradoxical situation of being anxious about their
existing situations or roles (experiencing trait anxiety) and at the
same time being anxious (experiencing state anxiety) as they try
out new behaviors which might alleviate those anxieties.
Treatment of Anxiety
somatic complaint which may in fact be the only distress they feel
Many, however, hope such a complaint will be more acceptable, or
taken more seriously, than the actual reason for their visit which
may be an unstated constellation of their fears and anxieties (Geyman,
Because of the physician
s medical orientation, treatment
of anxiety frequently involves the prescription of -psychotherapeutic
These drugs are often prescribed in
where a physical
condition may have been caused by, be further aggravated by
perhaps result in anxiety (Parry et al
Caster (1977) differentiates anxiety into four distinct cate-
(1) anxiety neurosi
) situational anxiety, (3) anxiety
as an aspect of disease,and (4) psychophysiologic disorders.
defines anxiety neurosis as a recurring emotional state without
recognizable etiology which i
ness or a sense of impending doom and i
nervous system discomfort. Situat
that of an individual of relatively
manifested by apprehension, fearful-
associated with autonomic
:ional anxiety is identified as
y normal emotional background
whose anxiety is provoked by identifiable stressful life events.
Anxiety as an aspect of di
is a specific example of situational
anxiety where anxious feeling is related to consequences of the
. Psychophysiologic disorders are considered to be conditions
in which emotional factors, particularly stress, play either an
etiologic or perpetuating role.
An example of a psychophysiologic
disorder is a peptic ulcer.
The use of antianxiety agents in these four different groups of
disorders will vary depending upon the specific conditions a
other external events such as the availability of alternate treatment
Lader (1976) suggests that when a patient complains of
anxiety the physician should first try to establish its cause.
there will have been a change in the life circumstances of the patient
which has precipitated the anxiety symptoms.
If the underlying cause
can be readily identified, treatment is directed towards modifying
these factors so as to lessen the pressures on the patient.
If it is
not possible to identify a cause, the physician frequently resorts
to symptomatic relief with drugs.
It is important to ascertain whether the patient has suffered
from life long "personality" anxiety or whether the present episode
has occurred in a previously calm individual
former patients may need long-term treatment and psychological sup-
Since many of these disorders tend to be chronic, reliance
on drug therapy could prevent patients from dealing realistically
with their living situations.
the treatment of choi
The use of antianxiety agents is not
for those who could benefit from therapy
leading to behavioral change (Caster, 1977).
These latter patients experience the equivalent of Spielberger's
Their symptoms will probably subside of their own
~Pr yr nrr4 2 kn, I4-kilh n Cn nflr~ nCjn~ In tH nn fn~lIYn n.I4-n4 nnn n nnn..nJhn -C
these patients is to tide them over a bad time (Lader, 1976).
Greenblatt and Shader (1974) make the point that since anxiety in
these cases is most often an episodic disorder, drug therapy is most
reasonable when it coincides with the exacerbation of symptoms.
can be increased when discomfort is most severe and reduced
or eliminated during remission.
make these adjustments themselv
Patients are often encouraged to
Patients experiencing state anxiety can be further differentiated.
For instance, a patient receiving medication to deal with a single
short duration (e.g.,an accident, death,
grief, divorce) i
different from a patient receiving periodic doses
of medication to improve functioning or living in recurrent situ-
nations (e.g.,meeting deadlines, coping with emergencies, or
in the case of women
, dealing with the effects of unresolved anger)
Both of these
are quite different
from the patient who uses
(e.g., fear of the dentist
medication to offset anxiety or discomfort
, fear of confronting other people)
seems important to make the distinction that where medication might,
in fact, be all that i
necessary in the first case, the others might
yield greater benefit from therapy aimed at bettering their coping
A large proportion of psychotropic drug prescriptions are written
by family Dractitioners.
Fvpn thninnh n vrhiM-tric-c and noirnilnn iee
physician group accounts for 50% of the total
prescribed (Balter & Levine,
It must be remembered that while
family practitioners represent only 31
The family physician and other primary-care physician
involvement with emotional
s experience, which frequently involves the manage-
ment of severe psychiatric disorder
in a hospital or crisis inter-
severe and often situational
see a wide range of 1
in their everyday
including anxiety reactions, p
Patients with these type
of problems are frequently troubled in a
more general and nonspecific
on the doctor to produce a quick cure.
Faced with a busy
is often just easier to write out a prescription for a
listen to the patient'
The potential ne
anxiety are numerous.
Greenblatt & Shader,
!gative aspects of such a
The presence of side effects
tem of dealing with
such as drowsiness, could reduce the
evel of functioning.
symptom without helping the patient identify and learn
the anxietv-Drovokina stimuli donp
to cope with
ittl to nrnmntp pffprtivua hohanvinr
problems that is markedly different from
interprets a physician's involvement
in these problem areas
as an expansion of the bound
She eyes such expan-
obedience of children are common problems presented to physicians,
then it i
sing that psychotropic drug consumption ha
o much during the past decade"
The medical model
has expanded to encompass
more aspects of our
change claim that physi
rather than medical
cians are trying to treat
illnesses when they prescribe
psychotherapeutic drugs" and they assert
"the more common personal,
social, and family problems of everyday
life are being
illnesses and treated by drugs"
, 1973, p.
Reflecting our country
emphasis on individualism,
self-help books emphasis
might be called psychological
maintains that though these self-help method
differ in catch phrases
they seem to share
erta i n values.
The most important
the happiness and fulfillment of the
reading the book.
(2) Other peoples'
wishes and needs are
important only to the extent that they
contribute to the well-being
of the reader.
3) Guilt i
considered an inappropriate response
which the person must work to di
is considered bad unl
individuals completely responsible for their
lives and tend to
overlook the person's
interaction with the social
Self-help methods are popular but at the same time unguided.
All too often they are simplistic approaches to human behavior.
They give people the idea they can easily do things they often
Farson (1977) claims that by offering fulfillment, communi-
, these methodologies
et up standards that individuals will
never be abl
a discrepancy between what per-
they might have and what they do have.
can frequently be a source of anxiety rather than an effective
There is disagreement among therapists
ch therapeutic approach or technique
is best for treating
Therapists choose those therapeutic techniques which best
reflect their theories and philosophies.
Anxiety plays a central
role in psychoanalytic theory.
it is thought of as a product of guilt produced by repressed early
likely to occur when the ego
(according to Freudian theory,
transactions with the
that part of the psyche that handles
environment) receives threats from
and most primitive part of
thP ncvrhc rcnmnrcinn drixoc
Ah. -I -^ A
*11JJI S. '* I Ir'l **SI .. *I *l*lZL L *r IIIII ~O ~ I
of anxiety is to warn persons of impending dangers so that they may
do something to avoid them.
Frequently the ego responds to the
pressure of anxiety with defense mechanisms which operate uncon-
sciously and deny, falsify or distort reality.
of the anal
t would most likely involve helping the
insight by conjuring up painful past experiences.
aware of the interplay of unconscious forces and the way in which
they affect the
The crux of therapy is to
share with the client full insight into hi
therapy operates on the assumption that emotions
are largely controlled by cognitive, ideational processes.
that an individual '
and motivations represent learned re-
These can potentially be reviewed, modified and recon-
structed by the individual.
likely view anxiety as a re
were telling themselves were true.
The rational-emotive therapist would
Ssult of irrational thoughts clients
Therapeutic techniques would
involve actively pointing out the client's irrational thoughts
and challenging their soundness as well as getting the client to
try out alternate ways of thinking (Blocher
The client-centered therapist holds that all behavior i
function of an individual
perceptions at the moment.
nnrrni t1 a iiha +- 1c &nnrnnro nfvn'h navcnnc with t- hoiry
When an individual's self-concept is threatened, his
field of perception is narrowed and distorted.
therapist seeks to reduce threat and remove it as an obstacle to
clearer perceptions and more effective behaviors.
of a relationship in which the counselor experiences feelings of
unconditional positive regard and is genuinely empathic and under-
standing of the client's internal frame of reference is the prime
goal of the therapist.
Having established a warm, accepting and
permissive counseling environment, the counselor seeks to facilitate
own self-exploration by reflecting and clarifying hi
self-referent feelings and statements (Blocher, 1966; Steffire
The theories described above are representative of traditional
psychological approaches to anxiety. The
the psychological treatment of anxiety ha
*y reflect the fact that
extended and intensive psychotherapeutic relationships.
methods are often
expensive and time-consuming and, though generally
required to achieve lasting solutions to the problems trait anxiety
they are not usually necessary when dealing with
Equally important here, however
, is the fact that conventional
forms of psychotherapy have been criticized in terms of their appli-
ability to women.
Most significant seems to be the criticism that
nrc \/rkn haj r f rn\ rnrc ...l r+n +,^1 I, rn +kn n +-k3n 2t 4- T 4-
Th; ~ c~tl; nrr
psychotherapeutic encounter is just one more power relationship in
which they are rewarded for expressing distress and are helped by
submitting to a dominant authority figure,
thereby creating even
Some recently developed counseling
applicability to the treatment of anxiety.
threatening and time-consuming,
and in many
more well-known than traditional
Some of these,
encounter and sensitivity groups,
Transactional Analysis and communication skills training have en-
are based upon the principle of
specific adaptive behaviors.
, however, alternatives to
these theories and techniques in the field of learning theory and
language of S-R reinforcement theory,
"fear or anxiety
learned or acquired emotional
reaction to originally neutral
timuli which were presented a number of times together with a noxious
, 1965, p.
who advocate a direct approach to the elimination of anxiety generally
either in the therapist's
office or in the outside world,
to produce anxiety reduction.
procedure such as systematic desensitization
is representative of
this direct approach to anxiety relief
The more direct or behavioral
training approaches to psycho-
therapy are based on a
response acquisition model
"Within this model
, maladaptive behaviors are construed in terms
of the absence of specific response skill
The therapeutic objec-
to provide clients with direct training in precise
lacking in their response repertoires.
given to eliminating existing maladaptive behaviors,
assumed that a
, adaptive responses are acquired
hearsed and reinforced
, the previous
displaced and will disappear"
A therapeutic procedure which exemplifies this indirect behavioral
approach to anxiety is assertive training
extinction of anxiety as a by-product of teaching
clients how to behave in an assertive manner within the nonpunitive
atmosphere of a counseling relationship.
Assertive behavior is
behavior involving the
honest and straightforward expressing of feelings.
ponents of assertive behavior may be divided into
The main com-
and specific response patterns:
the ability to say "no";
to ask for favors or make request
ability to express positive
and negative feelings; and the ability to
Assertive training is a therapy technique which is used with
individuals who are inhibited,
shy and therefore unable
is called for.
they are unable to speak up for themselves when they feel
being taken advantage of and are also unable to express positive
feelings such as pleasure or affection when this is appropriate
The purpose of assertive training is to
ability to express these
Historical Antecedents of Assertive
The work of Andrew Salter played an important role in the develop-
ment of the current conceptualization of assertive training.
(1961) applied the conditioning principles
of Pavlov to the
spectrum of neurotic behaviors
alter & Reyna
People, according to Salter
, are born "excitatory."
many of their excitatory responses
ment and they become inhibited.
are paired with punish-
inhibited response patterns
which are conditioned during childhood may remain in a person
For Salter the goal
in therapy i
"unlearning" of these
inhibited responses through the reconditioning of faulty inhibitory
He equates mental
health with the attain-
ment of emotional
freedom and advocates excitatory procedures for
virtually every conceivable psychological disorder and for all
clients seen as suffering from inhibition.
"The happy person does
not waste time thinking.
comes from no control
Salter's therapeutic technique
excitation through verbalization.
implemented to increase
Pauses and silences are not valued
desired, not insight.
The first technique is
called feeling talk.
Using feeling talk means spontaneously expressing
felt emotions, being truthful and emotionally outspoken.
rule of conduct
talk, refers to the congruence between one's
emotions and facial
The third technique is to contra-
dict and attack.
differ with someone they
freely express their true feelings and not pretend to agree.
fourth technique requires
the deliberate use of the word I as much
The fifth tec
hnique is to express agreement when praised
and to volunteer praise of
the sixth and last
rule of conduct, refers to being completely spontaneous
Salter is not concerned by what his patients tell
him they think.
He is more interested in what they say they did because that
they got to the state they are in and how they are also going to get
"To change the way a person feel
change the way he acts toward others; and by constantly
treating inhibition, we will
be constantly getting at the roots of
excitation bears great similarity to the
modern concept of assertiveness
There are three basic differences
First, Salter advocates excitatory procedures for
virtually every conceivable psychological disorder.
current assertive training techniques would not assume that every
client is primarily in need of assertive training.
Salter views assertiveness as a generalized trait, the present con-
ceptualization of assertiveness is that of a situation-specific
the questions "to what
degree?" and "in what situations?" (Mize, 1975
showed little concern for the interpersonal consequences
especially negative, of excitatory behavior.
Being assertive, by
present definition, involves being socially appropriate.
persons take into account the consequences of their behavior and
the impact it may hav
Assertive training as it is presently conceptualized originated
with the work of Joseph Wolpe
Wolpe interprets assertive responses
in terms of his theory of reciprocal inhibition as a therapeutic
"If a response antagonistic to anxiety can be made to
occur in the presence of anxiety-evoking stimuli so that it is
accompanied by a complete or partial suppression of the anxiety
responses, the bond between these stimuli and the anxiety responses
will be weakened" (Wolpe, 1958, p
that assertive responses or behaviors are incompatible with anxiety.
In other words, when individual
express themselves assertively,
anxiety is reduced and assertive responses are strenghtened.
Wolpe appl i
assertive "to any overt expression of
to other people" (Wolpe, 1976, p. 20).
To Wolpe (1958) assertive
behavior refers not only to anger expressing behavior, or standing
up for one's rights
but also to the outward expression of friendly
affectionate and other typically nonanxious feelings.
in which assertive behavior is an appropriate therapeutic instrument
In almost all of them we find the patient inhibited
from the performance of 'normal' behavior because of neurotic fear.
He is inhibited from saying or doing things that seem reasonable
and right to an observer.
He may be unable to complain about poor
services in a restaurant because he is afraid of hurting the feelings
of the waiter; unable to express differences of opinions with his
friends because he fears they will not
... and unable to
express affection, admiration or praise because he finds such expres-
Wolpe, 1973, p. 81).
Wolpe also points out that
"besides the thing
he cannot stop doing
he cannot do because of fear, there may be others
For example, he may compulsively reach for
the lunch check again and again to ward off a fear of incurring an
obligation"(Wolpe, 1973, p. 81).
Whereas Salter describes nonassertion as a generalized trait,
Wolpe defines it as a conditioned response to a specific circumstance
He applies assertive training only in specific contexts
which evidenced a need for it.
He acknowledges that there are some
patients who are nonassertive in a very wide ranan of interactinnS
The kind of assertive behavior that
is most used in therapy is
aggressive or anger-expressing behavior (Wolpe,
assumes that some measure of resentment
is present with
of anxiety and helplessness at most times.
The anxiety inhibits the
expression of the resentment.
He further suggests that,
the expression of resentment,
it might be expected that
augmenting the resentment to force its outward expression would
reciprocally inhibit the anxiety and thus suppress
it to some extent
"Each time th
he weakens in some measure the anxiety habit"
The role of the therapist is to
motivation to express
can be accomplished by means of various exhortations,
pointing out to clients
the emptiness of their fears and showing
them how their fearful modes
of behavior have
put them at the mercy of others (Wolpe,
incapacitated them and
Wolpe advises that the therapist
behavior on the part of the client only
should encourage assertive
when "the anxiety evoked
by the other person concerned
By this statement he means that the client feel
anxiety in a
situation even when there is no valid reason to do so,
repercussions can reasonably be expected.
that call for some action,
but in which direct assertion would be
inappropriate, Wolpe advocates the use of
Wolpe utilizes a form of behavior rehearsal
people in real
in his assertive
an attempt to prepare the patient to deal with real
relationships, the therapist and the patient act out
from the patient
the therapist assumes the role of
towards whom the patient feel
unadaptively anxious and inhibited.
, a certain amount of deconditioning of anxiety can
occur during the behavior rehearsal
There are two other theorists who have contributed directly
or indirectly to
the contemporary as
sertive training process.
, the founder of psychodrama
a method of psychotherapy
the use of role playing in order to achieve insight.
Assertion training draws from psyc
employment of staged
dramatizations of the real
life attitudes and conflicts of those
Psychodrama also strongly emphasis
neity and improvisation
both of whi
h Salter stressed.
is similar to one of Wolpe
is used in assertive
for the client
to achieve in-
sight through the acting out of
goal of behavior rehearsal in a
expand the client
to enhance and
repertoire of assertive behaviors (Mize,
A second theorist whose contributions are
indirectly related to
-~~. S S -- S
.1 ~ .I
is based upon Kelly
construct" theory of personality
According to Kelly,
look at the world and the events
happen to them in terms of constructs they have developed from their
own individual experiences.
Fixed-role therapy involves
particular constructs as well as determining the con-
structs the client must have in order to resolve problems.
deriving a personality sketch of a fi
individual who is free of the anxieti
which plague the client.
lient is then asked to assume the
role of the
person who possesses the desirable
in a manner consistent with the
role as wel
as adopting the fictitious person's way of looking
at or perceiving the world
until clients no
The role-playing features are quite
similar to the behavior rehearsal
Even though training is not specifically aimed at modi-
flying a client's cognitions
Rimm and Masters (1974) report that
histories suggest that
do undergo certain attitu-
as a result of treatment, especially in relation to
Treatment Procedures and Behaviors Important to Assertive-
In the therapeuti
setting the a
tive training procedure
traditionally one of therapist modeling with role-playing inter-
modeling by the therapist of appropriate assertive
on the part of the client,
to the client from the therapist and reinforcement of the client's
(generally by the therapist's verbal
The approach taken by many researchers, particularly
in the early studies of assertive training, was to compare various
treatment procedures as to their effectiveness
in increasing assertive
to be the primary
methodology of assertive training.
1966 he reported what he
claimed to be the first
study of behavior re-
He compared it with direct advice and nondirective therapies
in training patients to be more assertive.
Behavior rehearsal was
shown to be effective
in which it wa
whereas the other approaches were only 44% and
clients who are very non-
e, Lazarus advocates the use of behavioral
similar to that used in
This methodology, called rehearsal
desensitization (Piaget & Lazarus,
, involves gradual
presentation of anxiety-arousing
starting from the
least anxiety-provoking and moving to the most
McFall and Marsto
on behavior rehearsal
(1970) cited the
and pointed out several
: of systematic research
factors which needed to
therapy in assertive training.
ment procedure had never been
the behavior rehearsal
technique was typically applied to poorly defined and un-
pecified behavior classes.
, there were no satisfactory, reli-
real life measures available to
the behaviors typically treated with behavior rehearsal
What followed was a sern
and development of behavior re
experiments aimed at the evaluation
In the first study of
and Marston (1970)
developed a standardized
semiautomated behavior rehearsal
ment procedure and used it in examining two experimental
, sufficient to produce
in the problem behavior and
(2) what i
importance of response feedback -- specifically
playback of tape recorded rehearsal responses?
Results of behavioral,
self-report and psychophysiological
an unobtrusive in-vivo assertive test,
receiving response practice improved s
revealed that individual
significantly more than those
in placebotherapy and untreated control
, and that response
tended to augment these effects although not to a significant degree.
In a subsequent study McFall and Lillesand
(1971) added two new
symbolic modeling and therapist coaching,
the rehearsal with feedback procedure.
They focused on
limited and homogeneous response
I S .. a -e -
therapist coaching made significant contributions to the assertive
The rehearsal-modeling group was divided
half of the
engaged in overt response rehearsal while the
in covert rehearsal
Overt response rehearsal occurs
externally and allows the therapist to monitor the subject'
Covert procedures, on the other hand, occur within
They are more difficult to monitor,
but they do offer the advantages
of being more flexible
arrange and often
results of this study indicated that covert rehearsal
as overt rehearsal,
if not more so.
McFal and Twentyman
further assessed the contributions
of rehearsal, modeling and coaching to an experimental
training program in four
rehearsal and coaching both contributed significantly to the
improved performance on self-report and behavioral measures of assertion.
They found that the modeling component used in the studies added little
or nothing to the training effects of either rehearsal
alone or re-
This was true regard
of the particular
type of model
versus abrupt) or the means of
No differences were found
the three modes of rehearsal
or a combination or covert and overt rehearsal
-II_ L~ i I P
situations, and in the final
experiment there was some evidence that
treatment effects generalized from
laboratory to real
An even broader study of a
(1971) who investigated the
assertive behavior was that of Friedman
effectiveness of modeling, role playing
and modeling plus role playing.
One hundred five
and female college students
ssertive refers to the
a person to engage in behavior which indicated he feel
exercise certain rights) were
signed to one of
observed assertive models)
enacted the rol
of assertive model,
a script); improvised role playing
script as those in the directed rol
(students were given the same
playing condition except that
their responses were de
modeling plus directed role playing;
assertive script employed
in the other treatment conditions
nonassertive script which wa
designed as a control
primary behavioral measure involved taping the students'
live confederate who became increasingly annoying to them.
were rated by blind judges on five
request to stop).
number of responses in all
ries gave a Sum Assertion score.
Subjects also filled out a
of personality tests
including an Assertiveness test constructed
effectiveness of these treatment procedures
assertive behavior was substantial.
treatment elicited between 44% and
havior at posttesting.
81% of low assertive mal
The most promising result was that 69
in the modeling-plus-directed-
howed assertive behavior at posttreatment
testing which was equivalent to members of an independently assessed
Friedman also found that the
playing condition eli
levels of assertive behavior at
posttesting for 50% of male
He makes an interesting
point when he
claims that his results indicate that students who could
improvise responses during a role playing procedure could later
transfer these responses to another behavioral
situation, and that
socially inhibited students who were
thinking up and
assertive responses during role playing were unable to
profit a great deal
goes even further and
playing was as
effective as the directed role playing condition.
explicit cues to guide training part
behavior would not
seem to be necessary for those individual
who can construct their
own assertive responses during a role playing procedure.
Perhaps the most
implication of this study
importance of matching the treatment program to the needs of
the particular clients.
For nonassertive persons who have no rep-
consisting of modeling plus directed role playing or behavior re-
hearsal would be much better than modeling alone.
have assertive responses in their repertoires
but fail to employ them frequently or appropriately
e-playing technique might be appropriate.
modeling would probably be extraneous.
Although the above studies contributed significantly to the
understanding of assertive training, they failed to specifically
behaviors which are considered important in assert-
While a variety of techniques had been used to increase
., behavior rehearsal, audio and/or videotape
feedback and modeling) there was little attention directed toward
specifying what actual behaviors are altered a
a consequence of
To examine this question Eisler, Miller and
videotaped psychiatric patients interacting in a
series of role-played
situations with a live stimulus model
were then rated on nine behavioral components of assertiveness
which had been compiled by researchers.
Several experienced clinicians
had listed specific behaviors that they felt might be related to
acting assertively in negative contexts.
They identified nine be-
and five specific factors capable of differentiating indi-
high in assertiveness from those low in assertiveness.
Thornc \ava ti-sn imvh^1 i nniroC
rnmni t3nrn rnnant" (who thov, ny nnt
In a later study Hersen
Eisler, Miller, Johnson and Pinkston
(1973) demonstrated that different assertive training procedures
changes in these specific factors.
instance, they found that in modifying a subject's loudness
him verbal instructions about what he
should do was more effective
than modeling alone, whereas in modifying his compliance content
modeling was a much more helpful training procedure.
also confirmed earlier findings by Eisler
Hersen and Miller (1973)
that just practicing behaviors without the addition of techniques
, modeling, or a combination of the two will not
lead to behavioral change in terms of the components of assertive-
Underlying this finding is the assumption that "an individual
evidencing a behavioral deficit must be taught a new way of responding
as appropriate responses are
imply unavailable in his current
repertoire" (Hersen, Eisler, Miller, Johnson & Pinkston, 1973).
These results are in conflict with earlier findings that rehearsal
by itself may result in noticeable improvement on a subsequent be-
havioral assessment of assertiveness.
Rimm, Snyder, Depue, Haanstad
and Armstrong (1976) later conducted an investigation which further
reinforced the theory that the results of practice alone are neg-
A more recent study by Eis
(1975) examined the effects of
Hersen, Miller and Blanchard
social context on interpersonal
scenes with nonpatient males and female
who took the parts of persons
either familiar to the subject or unfamiliar to him.
It was presumed
that a patient's responses to a person he interacted with on a day-to-
day basis would differ from hi
ess familiar persons.
At the same time the
to identify some of the
of positive assertion by using some
that typically elicit positive
significant differences between how patients
requiring positive or negative assertions.
responded in situations
The results also supported
s-specific theory of
able to be assertive in one
(that is, an individual
onal context may not be
in a different situation)
hypothesized that college women who observed video-
specific assertive respon
more assertive behavior and be rated more assertive by judges than
women in two control
met for one hour
once a week for seven weeks
The assertive training group viewed a
videotape each week in which assertive model
and discussing their assertive experiences.
were observed interacting
The models demonstrated
nine types of assertive responses:
, feeling talk,
disagreeing passively and actively,
talking about oneself
agreeing with compliments, avoiding trying to
justify opinions and looking people
in the eye.
In addition to
viewing the tapes,
the assertive training group members practiced
.Ein -,--- -
Results indicated that the training method was signifi-
cantly effective in inducing assertive behavior.
There was also a
consistent trend for women receiving this assertive treatment to
report lower general fear and fear of social conflicts than did those
who received a placebo treatment or no treatment.
investigated the problem of
developing assertive behavior with covert modeling from several
In one of his initial studi
(1974) he examined the
effectiveness of covert modeling and the influence of favorable
consequences following model behavior in increasing an
assertive skills. Participants were assigned to one of three
treatment conditions: covert modeling (imagined scenes in which a
model performed assertively); covert modeling plus reinforcement
(imagined scenes in which a model performed assertively and favorable
consequence followed model performance), no modeling (imagined scenes
with neither an assertive model nor favorable consequences)
subjects received delayed treatment.
Participants in all of the
including the no-model condition
ment in self-perceived assertive ability.
Only individuals in the
model and model-reinforcement treatment groups improved significantly
on a role-playing test of assertiveness.
Kazdin (1975) extended this investigation and evaluated the
rnn y+n iA rn -4 n iC i n rl F 4- r 4" rr ^ mi a 1+ i r1 I f- mn ,- ,mn nl ntntnl < Y rl nl I
they imagined scenes in the treatment sessions.
were assigned to one of three treatment groups:
and of the
subjects imagined a person similar to themselves in age
same sex and favorable consequences followed model per-
model/no reinforcement; multiple models/reinforce-
ment (subjects imagined a different model/no reinforcement). As
they imagined the scene they were instructed to verbalize or narrate
The scenes were then rated according to whether (1) the
scene was complete, (2) the scene had been elaborated upon and (3)
the participant had completed the scene in the allowed time.
indicated that imagining multiple model
especially with model rein-
forcement significantly enhanced the behavioral role playing test.
Subjects did adhere to the imagery conditions to which they were as-
signed, but they tended to elaborate on the scenes periodically.
, the actual imagery on the part of the participants may con-
found the experimental conditions when researching covert modeling.
More recently Kazdin (1976) studied the effects of using a
multiplicity of models (imagining a
single model versus
tively) and model reinforcement.
study were unclear.
Covert modeling did lead to
increases in assertive behavior and imagining several model
in assertive behavior with favorable consequences did enhance the
f raza mont nfCfrb
MI-tlt.Ilhrl 4~ .-,nnnI
t. IEL tLAI t-**k-* t. II~V' Il Ucrt-*- n%-IIe~rIr I t-~ f
iha mlrltinriri~\r nf mnrl~lr
studies demonstrate that imagining a person modeling
assertion in different situations and
following the model
assertion are effective way
Martorano and Melnick
that given the typically fragile nature of early assertive attempts,
should also be trained to deal with the noncompliance or
negative consequences which
their assertions will
They designed a covert modeling
plus reply training,
procedure which involved two elements:
the visualization of a non-
assertion by the model and then
visualization of a second
assertive counterreply by the model
reply training condition resulted in
significantly greater changes
assertion than the modeling alone.
When Young, Rimm and Kennedy (197
) assessed the value of ver-
bally reinforcing female
' repetition of responses
which had been modeled for them,
they found that although modeling
as an individual component of behavior rehearsal was effective in
improving assertive performance the addition of verbal reinforce-
ment did not significantly augment the treatment effect.
It can be concluded from these studies
that assertiveness i
that can be
learned through the
systematic application of a
variety of behavioral
see if the acqui
Winship and Kelley (1976) designed
sition of assertive behavior might be
facilitated by yet another
-- the use of a
components that were taught systematically:
(1) an empathy statement
(the ability to
situation through the other person's eyes),
(2) a conflict statement (the individual
for action) and (3) an action statement (what it is the individual
wants to have happen).
Twenty-five undergraduate nursing students
were randomly assigned to either an assertive training group, an
attention control group and a no-treatment control group.
assertive training group spent four 2-hour group sessions learning
and practicing the verbal response model through the use of modeling,
, videotape feedback and positive reinforcement.
All groups were posttested on a self-report
scale, on responses to
written situations and on a videotaped role playing situation.
differences were found between the assertive training group
and the other two groups but not between the two control groups
themselves. This indicates that training people to use a specific
verbal response model can be an effective method for helping them
learn how to be more assertive.
As practiced in a clinical setting
assertive training may in-
clude a combination of the techniques mentioned above as well as
procedures such as bibliotherapy, therapist exhortation and/or re-
enforcement, group support and didactic exercises.
and Litz (1974) designed a methodology to investigate the effective-
ness of a total assertive training package.
Their study was unique
number of assertive behaviors which included expressing affection,
refusing requests and initiating requests, and they were given video-
tape feedback on their performance in role-playing situations.
mental subjects received eight training sessions consisting of video-
behavior rehearsal; video
peer and trainer feedback;
homework assignments; trainer exhortation and peer
The sessions were held twice a week for an hour and
a half in three 30-minute segments.
During the first part of each
ion group members discussed the rationale behind self-assertion,
readings related to the training and outcomes of their in-vivo
behavior practice sessions.
Next, the groups looked at videotapes
of models involved in
and practiced the modeling scenes.
They then divided
Group members who
were practicing received feedback from their peers and/or the trainer.
The assertive group's performance on self-report and behavioral
was significantly better than that of the control group.
Included were significant differences in three behaviors considered
important in assertiveness, namely percentage of eye contact, length
of scene and assertive content.
A follow-up study a year later
Kostka & Galassi,
showed that differences between
treatment and control groups were maintained on the self-reports
and in eye contact and scene length.
Thpee studies were the first to niipetinn the valup nf aisinn
latency .between the experimental
and control groups as were present
in the finding
of other investigators
Hersen & Miller,
McFall & Lillesand
the point that response latency is determined by many factors other
than anxiety aroused by being assertive,
such as cultural and geo-
the authors (Galassi
Galassi & Litz
say that in their
study it was necessary to
train some individual
increase rather than decrease response latency.
were taught not to blurt out ineffectual
by another individual
responses when confronted
but rather to concentrate on producing appro-
privately assertive statements.
The contribution of videotaped feedback to assertive training
was not really assessed by this study.
one and four in importance among the ten components
of the assertive training program as far as helping modify behavior
but there were no tests of
McFall and Twentyman (1973)
found that audiovisual modeling added little to training in a
ness, and a number of other researchers have found, contrary to
that videotaped feedback did not contribute to the
therapeutic impact of behavior rehearsal
(Aiduk & Karoly,
Melnick & Stocker,
, Otis and Rainey (1975)
evaluating a microtraining approach for training situationally non-
assertive clients in assertive expression,
tape feedback had little effect.
found the use of video-
Their results indicated that
dealing with why the person is not able to be more assertive.
feedback itself seems to be what is important, rather than how the
feedback is given.
They make the point that using video-tape feed-
back during the initial stages of training may give the trainee more
data than he can use (Gormally et al., 1975)
1970), on the other hand, have
McFall and Marston
shown that audio-tape feedback was
an important component in assertive training.
In contrast to earlier studies (McFall & Marston, 1970
McFall & Twentyman, 1973) the Galassi, Kostka
and Galassi (1974) follow-up study strongly indicates the long-
term effects of assertive training.
for the discrepancy in these results.
There are two possible reasons
The first is that Galassi,
Galassi and Litz (1974) used a longer
more intensive and
Particularly significant here is that their
treatment program lasted a total of 12 hours (sessions were approxi-
mately one and one-half hours and were held twice a week for four
Treatment time in the McFall studies varied from 40 minutes
(McFall & Lillesand
, 1971) to four hours (McFall & Marston, 1970).
The second explanation for the discrepant results might be the
The follow-up in the Galassi study was con-
ducted in the laboratory whereas the McFall studies relied primarily
on in-vivo follow-up (
or phone calls).
in-vivo follow-up has the potential of providing a stronger test of
assertion training than laboratory assessment, the procedures used
in the McFall studies might have been confounded by other variables
that make results difficult to interpret
, Kostka & Galassi,
Another issue relevant to treatment procedures in assertiveness
the question of whether the training should be carried out
individually or in a group.
exception of a few studies
(Rathus, 1973; Galassi, Kostka & Gal
assi, 1974) all of the above
research involved treatment on an individual basis.
, a growing
number of clinicians have come to recognize that the various procedures
of assertive training can be applied to the treatment of groups as
well as individuals.
Fensterheim describes the use of assertive
training in the context of a group and specifically notes how "the
social nature of assertive training suggests that it would be partic-
ularly effective in the treatment of groups" (1
one of only a few authors who have published a clinical description
of such a gr
Group treatment also has the advantage of being
Assertive training in groups has been suggested to be
an effective vehicle for working with women (Osborn & Harris, 1975),
a speculation grounded in research with group
of women (Gambrill & Richey, 1975; Winship & Kelley
But there is also evidence pointing to its effectiveness as
a treatment procedure in assertive training for men (Rimm, Hill,
Brown & Stuart, 1974) and for mixed groups (Galassi, Galassi &
This review of the research
literature indicates that assertive
an effective procedure for use with individual
the social and interpersonal
skills to ensure successful
Assertive training is specifically directed toward teaching them more
evidence also indicates
of assertion i
rarely a generalizable trait.
limited to specific types of situations.
For instance, a
person who is quite assertive in impersonal
situations might be quite
, and the person who voices
negative emotions freely may be unable to express positive ones.
The specific treatment procedures used
have been examined and som
understanding of the elements necessary
for change has been reached.
training procedure can
be conceptualized as an active process taking place between the
therapist and the patient or the
leader and the participant.
similar to that between teacher and
therapist instructs, models, coaches and reinforces appropriate verbal
the client practices newly acquired skills
first in a protected environment and then in real
Eisler & Miller,
Applications of Assertive
Case Studies on
the Applications of Assertive
There have been widespread
clinical applications of assertion
Tho fnllnwinn rnca cf-iirli1c -llnct-vran- hnw a cc-rtiVi trnai nn nn
has been used either alone or with other treatment strategies for
1961) reported a ca
ch assertive training was
used in treating violent somnambulistic behavior of a 35-year-old
male against hi
The patient related hi
behavior to his poor
relationship with hi
mother, whom he
found domineering and authori-
The therapist hypothesized that during wakefulness the
intense anxiety prevented hi
solving this problem.
learned fear responses were reduced
Treatment consisted of only one interview and
involved the develop-
ment of more assertive behavior by the patient toward his mother.
The somnambulistic behavior decreased after two weeks and had been
ssipated by the time of follow-up two months
There was neither recurrence nor evidence of symptom substitution
, (2) relaxation
(4) assertive training to treat three individual
nation and reassurance
He used desensiti-
inhibit their anxiety and a
and relaxation to help them realize they could control
The first case was that of a 23-year-old
ingle female school
teacher who wa
of other people that her
job was in jeop-
3 hours of behavior therapy she had almost a complete
remission of symptoms.
The second case was that of
female doctoral student and teacher who reported extreme tension.
This client revealed that she was an only child who was completely
dominated by her mother who
values were very different from her
When she disagreed with her mother
the mother would scream
resulting in a panic reaction in the patient.
A number of stimuli
induced her fear and anxiety:
sex, religion and being
criticism and teasing and any parental disapproval.
ions she was able to control her fear and anxiety in all real-
The third case concerned a 45-year-old draftsman
who came for therapy for hi
feel ings of anxiety.
The patient had
recently been hospitalized for a bleeding ulcer.
While he was
hospitalized his wife began working and became quite successful and
she became more independent and dominant the client
became more passive, dependent and anxious.
This client was desen-
sitized to criticism and began to achieve some success in being asser-
, however, a really
significant decrease in anxiety
was noted only after desensitization about sexual activity with his
Seitz (1971) described the treatment of a neurotically depressed
36-year-old widowed ma
patient who was hospitalized following a
Here assertive training wa
used in combination
with three other behavior modification techniques.
was initiated in order to increase annronrilate ncial intpractinn
by the patient.
This patient showed
improvement after eight weeks
Lambley (1976) treated a 38-year-old woman suffering from migraine
headaches with a combination of assertive training and psychodynamic
Lambley makes the point that since migraine i
a psychosomatic condition, and as such,
involves the functioning of
both somatic and p
treatment methods must be
including both behavioral and psychodynamic
woman's case hi
story data revealed several areas of possible
such as her husband and
her mother and behavioral anal
he was unable to
in day-to-day interactions and tended to avoid any
situations which might cause friction.
Assertive training was employed
to teach the woman what to do if conflict occurred and psychodynamic
insight into the reasons for the conflict to perhaps keep it from
ler and Pinkston (1975) reported the
of a 56-year-
who was successfully trained to control
chronic abusive and
assaultive behavior by use of modeling alone and modeling combined
with instructions focused on desirable
features of the modeled be-
six month follow-up showed that changes
in behavior had
been maintained and had generalized to the natural
, Hersen and Miller (1974) reported the modification of periodic
The main emphasis in these
consequences of a
lack of appropriate
has been on the
tive behavior or on the
somatic symptoms that have been considered
ide effects associated
with unexpressed impul
(1967) examined another response
which sometimes occurs in response to the inhibition of anger-crying.
he worked with
8-year-old man who cried
ively in response to
situations which made him angry
the point that
ive crying is
inappropriate behavior for males.
this concept of crying as dysfunctional
behavior in handling
anger can also be extended to women.
To break the cycle involving
anger and crying, assertive training was
To teach the
patient to be assertive rather than fearful
in the face of anger-
timuli, a shock escape technique was employed, an unusual
procedure in the assertiv
noted after two months of therapy.
These case studies illustrate the versatility of assertive
training as a therapeutic tool. Although treatment methods are pre-
, the precise evaluation of particular techniques is unavailable
in most cases
Except for Foy et al.
(1975) and Eisler et al
the case studies mentioned above offer only global
Research Studies on the Applications of Assertive
Behavior therapy research has generally focused on demonstrating
that behavior can be changed. The widespread attention of researchers
Changing an individual
would seem to be of
sequence if the person still
and attitudinal c
It seems necessary to also as
changess which accompany changes
The following studies attend to
this need and can be divided into two category
late assertiveness with other variables and those which have a
training component to
show whether becoming more assertive can
fact, change other variables.
indicated that the assertive individual
confident and able to influence and lead
others while the nonassertive person more often feel
, has a marked tendency to be oversolicitous of
support from others and exhibits
, De Lo, Gal
assi & Bastien,
It would seem,
is an association between
assertiveness and such variables
locus of control
ment and anxiety.
is some research available which supports
The concept of locus of control
the extent to which
individuals view rewards as contingent on their own behavior.
a reinforcement i
perceived by individual
as contingent on their
, Rotter (1966) terms thi
a belief in internal
see events as
independent of their own actions,
Bates and Zimmerman (1971) have directly investigated the
relationship between assertiveness and locus of control
cant results were obtained from individual
taking the Rotter I-E
e, a measure of generalized expectancy for internal versus
external locus of control
to test the notion that nonassertive
subjects are more likely than assertive
subjects to perceive rein-
as externally controlled.
It follows that nonassertive
individuals can be considered more compliant to external demand
than their more assertive peers.
substantiated that internal
Appelbaum, Tuma and Johnson (1975)
are significantly more assertive than
Rimm et al. (1974) tested a small group of subjects
participating in assertion training to modify antisocial aggression
if they became more assertive or changed their locus of
The found no significant differences between treatment and
control groups on either assertiveness or locus of control, findings
which conflict with those of other researchers.
The findings are in
, however, with Gay
Hollandsworth and Galassi'
that locus of control did not discriminate between low- and high-
A number of theoreticians in the area of assertiveness have
speculated that there is a relationship between peoples' level of
assertiveness and their feelings of
self-confidence (Salter, 1961;
Wolpe, 1958; Alberti & Emmons, 1974)
Gay et al
. (1975) found that
described themselves as more self-confident than low scorers.
relational data for the ASES with the Adjective Check List need scal
indicated that high scorers are more achievement oriented, more likely
to seek leadership rol
in groups and individual relationships, more
independent, less likely to express feelings of inferiority through
self-deprecation and less deferential in relationships with others.
These findings are very
similar to the findings of both Bates and
1971) and Galassi, DeLo,
Galassi and Bastien (1974).
Percell et al. (1974) also found a significant positive corre-
lation between assertiveness and self-concept when they administered
a battery of tests including the Lawrence Interpersonal Behavior
assertion) and the Self-Acceptance Scal
of the California
Psychological Inventory to a group of outpatient psychiatric patients.
Later, in an experiment to
the effects of assertive training
on the same population, they found that as individuals became more
assertive they also became more self-accepting
Percell et al., 1974).
Another variable that seems to relate to assertiveness is personal
Galassi and Galassi (1974) found that students who sought
personal adjustment counseling were significantly less assertive than
and students who sought only vocational-educational
Gay et al.
(1975) reinforced this when their study of
inventory for adults revealed that individual
personal adiustment cnunsPl ino
scnred sinnificantlv oIwer on the
on the Adjective Check List Counseling Readiness Scale
are thought to reflect
that constricted males are
tolerant of their own
assertiveness in comparison to constricted females for whom a demure,
sex role alternative is sanctioned by society
The variable which has received the most attention regarding its
relationship to assertive behavior i
peculated about the relationship between social
and lack of assertive behavior
between them has been supported by a number of
1974) administered the Wolpe-Lang Fear Survey Schedul
Assertivenss Schedule to psychology students and found
significant relationship between assertive-
- Bates and
(1971) administered the Constriction Scale
and the Multiple Affect Adjective Check List to 600
students as one
of the validation procedures for the Constriction
significant correlation between scores on the two scales which
affirmed their hypothesis that anxiety is positively correlated with
Galassi, De Lo
students scoring lo
Galassi and Bastien
1974) found that college
w on a measure of assertiveness
hecklist that indicated
Students who scored high, on the other hand, were confident.
Gay et al.
using 464 subjects ranging in age from
60 years, administered the Adult Self-Expression Scale and the
Manifest Anxiety Scale
as one of the validation studies for ASES.
They found that the measure of anxiety
from high assertives a
early differentiated low
identified by the ASES
hypothesized that there would be
ficant negative correlation between measures of assertiveness and
The hypothesis was supported
Orenstein, Orenstein and Carr
(1975) found the same using
450 college students.
Besides these correlational
studies there have been
assessments of the effectiveness of assertiveness
training in elimi-
nating or reducing anxiety.
(1973) administered both an
inventory and a fear survey to groups of female students
receiving either assertive training, a placebo treatment or no treat-
The group receiving the ass
ertive training did not become
significantly more assertive and
, though results
were not significant,
did show greater reduction of fear than did the groups not receiving
Brown and Stuart (1974)
volunteers reporting a history of exp
reported that male student
ing anger in an inappropriate
or antisocial manner reported
significantly greater decreases in feelings
after receiving eight hours of assertive training
than did controls.
Percell et al. (1974) tested the hypothesis
patients would exhibit a decrease in anxiety after receiving
The Lawrence Interpersonal Behavior Test (a test
of assertion) and the Taylor Manifest Anxiety Scale were administered
to a group of seven male and five female outpatient psychiatric patients,
before and after eight sessions of group assertive training, and to
a group of five male and seven female
outpatient psychiatric patients
before and after eight sessions of a relationship-control therapy
Both groups had essentially the same format, discussing the
advantages of being assertive,
exploring the situational determinants
of each subject's nonassertive behavior and giving advice on how to
more effectively and solve some of their problems.
tive training group incorporated behavior rehearsal.
the study supported the hypothesis
The results of
that anxiety would decrease
the patients became more assertive.
Gambrill and Richey (1975) have developed the Assertion Inventory
which permits respondents to note for each item their degree of dis-
comfort as well as their probability of engaging in the behavior.
Normative data from a sample of 19 women participating in assertion
training programs showed a significant reduction in mean discomfort
after assertion training.
There appears to be a definite relationship between assertiveness
and locus of control, self-confidence, self-concept, personal adjust-
ment and anxiety.
Another interesting finding in the research
Galassi, De Lo, Galassi and Bastien (1974) found a
nonsignificant correlation between aggression, as measured by the
Adjective Check List and scores on their College Self-Expression
This is especially important in view of how aggressiveness
is often mistaken for assertiveness.
Results of assertive training
with individuals who tended to exhibit antisocial aggression
opposed to temerity) in certain critical
et al. 1974), although not significant
social situations (Rimm
did suggest that assertive
training may provide an effective means for dealing with anger which
ead to antisocial aggression if
Assertive Training for Women
Recently a number of writers have proposed that nonassertiveness
is a pervasive cultural phenomenon among women
Lange & Jakubowski
, 1976; Osborn & Harris
& Pearlman, 1975) .
They talk about women as "victims" of sociali-
nation, stereotyping and institutional sexism which combine to inhibit
the fulfillment of their interpersonal rights.
Women are conditioned
to be passive and nonassertive, so even when new opportunities and
choices have become available old feminine conditioning often per-
sists and women find themselves unequipped to cope with them.
around them, often hampered by the same stereotypical thinking,
frequently fail to offer much needed support.
The women's move-
ment has been responsive to this disparity facing many women
and has emphasized finding ways to help women learn to express
This emphasis has kindled a burgeoning
assertiveness training for women.
Assertive training is considered a
much as a
Hartsook, Olch and de Wolf
studied the personality characteristics of women who
training and found that these women are
cerned with the approval
of others and moderately inhibited in
pressing their feelings, but in most respects are integrated and
(Hartsook et al
., 1976, p.
to teach women assertive
training procedure ha
been used successfully
1973) and has the potential
to help them become more effective and fulfilled.
Much of the
nation we have about women and the effectiveness of assertive training
is ancillary to research conducted with mal
and females about
in assertive training.
that assertive training results
significantly improved for
both men and women with the addition of behavior rehearsal
modeling and role playing
1974) and coaching (McFall
We also know some
things about treatment results;
for instance Percell
found that both male and female psychiatric patients
self-concept as a result of an assertive training program.
Except for the study by Percell
involved treatment on an individual
conducted in groups (Lange & Jakubowski
Osborn & Harris,
There is some research available which supports the idea
ness training i
effectively carried out in group
with women (Rathus,
Gambrill & Richey,
Winship & Kelley,
1976; Pearlman &
, 1977), but not that it i
necessarily better than assertiveness
is more effective with
all-women groups than mixed
Pearlman and Mayo
s (1977) data
from a follow-up
that 65% of women partic
in group assertiveness training felt
increased moderately or greatly in the six to
eighteen months after their training had finished.
(1976) asked for verbal appraisal
Hartsook et al.
of their training experience from
members of an all-female assertiveness
Remarks suggested that
had generalized beyond the situations
in the group and that group members
significant others had undergone radical
These findings suggest that women who hav
training are able to expand their use of the skill
changes for the better.
participated in assertive
group participation and generalize their assertive behaviors to real-
The preceding review of the research
literature suggests that
assertive training can be an effective treatment procedure for
S .- .. 1 -- -- -..
,.-. I.. -- P -- I
With patients who simply do not evidence the requisite
social and interpersonal
skills to ensure successful
assertive training is specifically directed toward teaching new
modes of responding.
lack of these interpersonal
skills can precipitate
a state of anxiety for an individual.
This anxiety often manifests
patients become more
skilled in routine
, the probability of their receiving rein-
forcement from their
social mileau is
At that point
symptomatic behaviors become nonfunctional and are eliminated from
their repertoires (Hersen,
Eisler & Miller
specific techniques contributing to the overall
assertive training have been examined
the elements producing change ha
not been achieved, some
definite patterns have emerged.
is the extent to which
an active process takes place between the therapist and the patient.
The relationship approximates that of teacher and student.
s, coaches and reinforces appropriate
verbal and nonverbal
the clients first
practice their newly developed repertoires in the consulting room
and then in actual
situations requiring assertive responses
The purpose of the present study wa
to determine whether an
assertive training program using well-defined research procedures
exhibit symptoms of that anxiety.
Although there has been some
research examining the relationship between assertive behavior and
anxiety, it has been carried out with small groups of either psychi-
atric patients or college students and has not considered the element
METHODS AND PROCEDURES
Many women evidence moderate to severe
Frequently the lack of these
a state of anxiety which in turn manifest
Accordingly there is
a need for methods to help women become more
training has been used
successfully to teach women assertive skill
and has the potential
to help them become more interpersonally effective and fulfilled.
study examined the effectiveness of assertive training in re-
during anxiety in a group of women who experience symptomatic mani-
festations of that anxiety.
with the hypotheses, population, sampling
in this study.
treatment proceduresand experimental
It also includes an explanation of how
the data were collected and analyzed.
election of Subjects
is generally considered a psychological
first manifest anxiety in a
symptoms may, in fact, be the only distress the person feels.
the primary-care physician is often the first professional approached
by the anxious patient and is generally the person who initiates
Primary care is defined
as basic or first-contact care.
of primary care is the function of the family practitioner
pediatrician or gynecologist
This particular study dealt with adult
women who approach their primary-care physician with symptoms of
The physician sample was drawn from those primary-care
physicians who have adult women
as patients, namely family practit-
, internists or gynecologists.
This physician group included all residents in the Family Practice
Residency Program at the University of Florida College of Medicine as
, 1977 and those family practitioners, gynecologists and
internists listed in the Gainesville, Florida, telephone directory
who were practicing in Gainesvill
during January, 1978.
generated a list of approximately 20 family practice residents, 20
family practitioners, 21 internists and 14 gynecologists.
the physicians were women.
This sample was
female volunteers between the ages
of 20 and 65 whose primary-care physician had suggested that they might
benefit from participation in an assertion training group.
and muscle soreness; indications of interpersonal sensitivity such as
temper outbursts, feelings of inferiority, and feeling critical of
others; indications of depression such as a
oss of sexual interest
or pleasure, poor appetite, crying easily or worrying and stewing
indications of anxiety such as feeling fearful, nervous-
ness or shakiness inside, heart pounding or racing or feeling tense
or keyed up.
In order to obtain subjects a letter (Appendix A) was mailed to
the Family Practice Residency Program at the University of Florida
College of Medicine and those family practitioners, gynecologists
and internists listed in the Gainesville, Florida, telephone directory
who were practicing in Gainesville at the time of the study.
letter explained the nature of thi
physicians to refer female patient
research project and asked the
who met the criteria
researcher followed this letter with a phone call to each physician
asking if he would like more information about the project.
appointment was made with the doctors who requested it.
The physicians were asked to refer adult women, defined as women
between the ages of 20 and 65, experiencing one or more of the fol-
somatic complaints such a
soreness of muscles,
headaches, gastro-intestinal distress, pain in the heart or chest
trouble getting their breath and faintness or dizziness;
inferiority; indications of depression such as loss of sexual interest
or pleasure, poor appetite, crying easily, feeling blue and worrying
or stewing about things
of anxiety such as feeling
fearful, nervousness or shakiness inside, heart pounding or racing
and feeling tense or keyed up.
The physicians referred women they
considered to be experiencing these symptoms
No patient with evidence of organicity, psyc
or sociopathy was included.
as a consequence of anxiety.
hosis, addictive disorder
The physicians were asked to tell their
patients only that they felt the patient might benefit from
participation in the training program.
Enclosed with this letter to the physician were a copy of the
researcher's vita (Appendix B) and
several copies of a letter from the
researcher to the individual patient (Appendix C).
"patient's letter" was a postage-paid card (Appendi
Attached to thi
D) which provided
space for the women to either express an interest in the training and
list times they would be availabi
or to request further information.
The physicians were asked to give a card to each woman as they discussed
the program with them.
The letter to the patient explained that a program was being offered
to help women feel better about themselves.
It also indicated that
there was no
charge for the program.
better explained that it was
very important to the research part of the project that those women who
began the training complete it.
Women who were interested were asked
to fill out the postage-paid card and return it.
need more information.
want to participate and have indicated at
The time periods
- 12:00 PM
- 3:00 PM
- 5:00 PM and
- 9:00 PM on Monday through Saturday.
ions were held during those time period
All women who returned the card were telephoned by the researcher
immediately upon receipt of the card
The researcher tried to deter-
mine whether a potential
12 to 1
subject would be able to attend all
The names of interested women were held until
6 was attained.
a pool of
The women were then assigned to either a
treatment or control
The treatment group compositions were
established according to times each
subject indicated as convenient.
The subject recruitment process described above wa
a subject pool
women was reached.
in the experimental
groups began to receive the training
as soon as possible
of the control groups were offered the training after the posttesting.
Participants were asked to complete a personal
and three self-report instruments:
the Adult Self-Expression Scale
(ASES), a measure of
the State-Trait Anxiety
(STAI) and the Hopkins Symptom Checklist (HSCL), a clinical
cralo which rofltorc th0 ncvrhninnirm l
cvmnfnm rnnf iniiratinn rnmmnnlv
observed among medical outpatients. Administration of all of the
instruments took approximately one hour. This occurred during the
hour immediately proceeding the first treatment session and the
hour after the
last treatment session.
session the experimental
groups were also asked to fill
questionnaire evaluating their experiences during the training
Descriptions of the assessment measures follows.
elf-Expression Scale (ASES)
The Adult Self-Expression
report measure of
assertiveness designed for general
Its construction was based upon a
is a 48 item
use with adults.
situations in which
assertive behavior might occur
interactions with family,
the public, authority figures and friend
A second dimension
specified assertive behaviors that might occur in these interpersonal
The behaviors included express
ing personal opinions,
refusing unreasonable requests,
taking the initiative in conversations
and in dealing with others, exp
ing positive feel ing
legitimate rights, expressing negative feelings and asking favors
and generalized components of
behavior were taken into account in the design.
A factor anal
procedure resulted in
factors that accounted
Forty-five of the 4
items on the
- a r
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in terms of types of assertive behavior (also mentioned above).
Three types of assertive behavior were represented by two factors
expressing positive feelings,
standing up for one'
and taking the
dealings with others.
The ASES uses a five-point Likert format
are asked to answer the questions by indicating how they generally
n a variety of
"almost always" or "always"
), or "never" or "rarely"
respondents that if a particular
situation does not apply to them
they should answer as they think they would respond
They are told their answers
should not reflect how they feel
ought to act or how they would like to act but rather how they generally
It takes about
15 minutes to complete the ASES.
score for the ASES can range from 0 to
positively worded and
worded items must be reverse
scored prior to calculating the total
The mean ASES total
score obtained from 640 adults ranging
18 to 60 was approximately 11
standard deviation of
This would mean that ASES
scores falling above
are considered high scores while those falling below 95 could be con-
sidered low score
Test-retest reliability for the ASES wa
established by adminis-
tering the instrument to two sampi
r oiiorl f-ho
1-ocf adminict-ratinn at thp
was administered a second time to one sampi
period, to the second sample
at the end of a two-week
at the end of a five-week period.
Pearson-product moment correlation was computed establishing two
and five week reliability coefficients of
and .91, respectively.
Internal consistency was determined by correlating the total odd
scores with the total even scores for 464 subjects using a Pearson-
product moment correlation. The res
ASES possesses moderate homogeneity.
;ults (.79) indicated that the
A Spearman Brown r of
obtained for the full test (Gay, 1974
Gay et al.
Gay (1974) conducted several studies to establish validity data
for the ASES.
Construct validity was established by correlating
taking the ASES with their
on the 24 scales of the Adjective
The ASES was found
to correlate positively at the p
Adjectives Checked and the Self-Confidence
< .001 level with the Number of
, Ability, Achievement,
Aggression and Change
ales of the Adjective Check List.
was found to correlate negatively at the p
< .001 level with the
Succorance, Abasement and Deference scales of the Adjective Check
Concurrent validity for the ASES was established through the
method of contrasted groups.
Thirty-two clients seeking personal
adjustment counseling scored significantly lower (X
the ASES than did noncounseled subjects (2
- 101.81) on
the Taylor Manifest Anxiety Scale),
self-confidence (as measured by the
Self-Confidence Scale of the Adjective Check List) and locus of control
(as measured by Rotter's measure of generalized expectancy for internal
versus external control of reinforcement)
A discriminate analysis
cedure was performed.
It resulted in a
significant F value, F (3,54)
9.56, p <.001.
The univariate tests for the three variables revealed
that anxiety F (1,56)
= 17.86, p
<.001 and self-confidence F
, p <.001 did significantly discriminate between low and high
Locus of control F
- 1.14, p
<.291 did not.
Hopkins Symptom Checklist (HSCL)
The Hopkins Symptom Checklist (initially developed by Parloff,
, 1954) is a multidimensional symptom
items which are representative of
the symptom configurations commonly observed among medical outpatients.
It is scored on five underlying symptom dimensions:
interpersonal sensitivity, anxiety and depression.
symptom constructs underlying the HSCL have been deter-
mined through clinical-rational clustering and factor analytic studies.
In clustering studies (Lipman, Covi, Rickel
Uhlenhuth & Lazar, 1968)
asked highly experienced clinicians to assign the symptoms
of the HSCL to homogeneous clinical
lusters based on their clinical
Symptoms that were assigned with a high level of consis-
tency were returned and provided HSCL cluster definitions.
Will iams and her
iates (Williams, Lipman, Rickel
Uhlenhuth & Mattsson
of a large sampi
, 1968) performed a factor analysis of
of 1,115 anxious neurotic patients.
(1969) factor analyzed psychiatrists' HSCL rating
of 837 of
the same patients.
In both of these studies five
ful dimensions were isolated:
somatization, fear-anxiety, general
neurotic feelings, depression and cognitive performance difficulty.
Another important issue dealt with in the factorial development
of the HSCL i
the question of factorial invariance or dimensional
question has to do with the generalizability of
developed from a specific sample to other sampi
Derogatis, Lipman, Covi and Ricke
(1971) employed five symptom
and depression) in a study of the factorial invariance of the HSCL.
They derived these dimensions by factor-analyzing the HSCL self-ratings
,066 anxious neurotic outpatients and psychiatrists' ratings for
The patients were
assigned to one of
three social cla
of Social Position
groups in terms of Hollingshead Two-Factor Index
The congruency coefficient and the coefficient
of invariance (riv
were used to evaluate the contrasts.
a high level of invariance for the HSCL symptom dimensions both among
patients and between patients and psychiatrists.
On the Somatization
s were above
.95 for all three p
.76 while that among patients was .60.
of General Neurotic Feelings exhibited moderate to high similarity
coefficients across the three patient groups.
.74 between the upper-middle class and lower-cl
.48 for the working cl
versus lower class contrast.
parsons of thi
factor with the psychiatrists' dimensions resulted
in almost equivalent coefficients.
is of the Irascibility factor
.64 and .67 between the upper-middle class and the
working-class groups, respectively, and the psychiatrist's ratings.
Lipman, Covi and Rickels (1972) factor-analyzed the
HSCLself-ratings of two patient sample
251 depressed neuortics
- 641 anxious patients and
symptom dimensions were established
Anxiety and Inter-
They then examined these symptom dimensions
regarding dimensional constancy across the categories of anxiety
states and depressive neuroses.
The Somatization and Obsessive-
Compulsive constructs proved to be highly invariant across diagnostic
They had similarity coefficient
.97 and .96, respectively.
The dimension of Interpersonal Sensitivity also reflected high agree-
ment between the two sample
The Depression dimension
showed considerable invariance (riv
yet at the same time
reflected overtones unique to each of the diagnostic cl
Anxiety dimension was not significant because of a failure to sustain
a distinct dimensional representation of anxiety for the depressed
However, the coefficients were of moderate magnitude and
The symptoms that are fundamental to interpersonal sensitivity
focus on feelings of personal inadequacy and inferiority
in comparison with other individuals.
Self-deprecation, feelings of
uneasiness and marked discomfort during interpersonal interactions
of persons with high scores on thi
Other typical sources of distress are feelings of acute self-conscious-
ness and negative expectancies regarding interpersonal communication.
seven items which make up this dimension.
range from 7 to
The scales subsumed under the dimension of depression reflect a
broad range of the concomitants of the clinical depressive syndrome.
Symptoms of dysphoric affect and mood are represented, as are
of withdrawal of interest in activities, lack of motivation, and loss
This dimension also includes feelings of hopelessness and
Eleven items comprise thi
from 11 to 44.
The anxiety dimension is comprised of a set of symptoms and
behaviors generally associated clinically with high manifest anxiety.
This dimension includes general indicators such as restlessness,
nervousness and tension, as well as additional somatic signs e.g.,
Items touching on free-floating anxiety and panic
attacks are also included
This dimension i
comprised of 6 items.
Possible scores range from 6 to 24.
Fourteen items from the
are not inrcldpdr in anv dimpn;ion
The HSCL is scored on the basis of the five symptom clusters:
somatization, obsessive-compulsive, interpersonal sensitivity,
depression and anxiety.
Patients are instructed to rate themselves
on each symptom using a four-point scale of distress
= "not-at-all ."
= "a little bit," 3
= "quite a bit," 4
Therefore, scores on the rating scale reflect not only the existence
of a symptom, but also the extent of the symptom.
A description of
each of the symptom dimensions follows.
The items comprising the dimension somatization reflect distress
arising from perceptions of bodily dysfunction. They include com-
plaints focused on cardiovascular, gastrointestinal, respiratory
and other systems with strong autonomic mediation. Headaches, back-
aches, pain and discomfort localized in the gross musculature and
other somatic equivalents of anxiety are also represented.
items contribute to this dimension.
scores range from 12
The items that form the dimension obsessive-compulsive reflect
symptoms that are closely identified with the clinical syndrome of
The focus of this measure is on thoughts, impul
actions that are experienced by the individual as irresistable and
They are, at the same time, of an ego-alien or unwanted
Behaviors indicative of a more general cognitive difficulty
(e.g. mind going blank, trouble remembering) also load on this
The HSCL has a flexible time context which means
limits may be used.
Under standard conditions
time context used is seven days.
Respondents are asked to respond
in terms of "How have you felt during the past seven days including
Two of the major normative samples for the HSCL have been developed
around neurotic disorder
with primary symptom manifestations of anxiety
A third normative sample
is composed of individual
who were administered the HSCL as part of a more extensive health sur-
This group represents a complete random sample and contains a
high proportion of normal.
There have been a number of reliability studies
research on the HSCL.
estimates of the
of the HSCL symptom dimensions
are uniformly hiah.
based on an N of 1435 range from
were also calculated for the
to each dimension.
most were at about
items which contributed substantially
All of these coefficients were above .50, and
Test-retest coefficients are also available.
Based on a sample of 42
anxious neurotic outpatients
from .75 for anxiety to .84 for the obsessive-compulsive dimension.
involved were all
trial with antianxiety agents. The
formed one week apart, prior to the
cipants in a psychotropic drug
test-retest evaluations were per-
initiation of treatment with
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L a a
distress levels on the HSCL was identical to the rank ordering suggested
by clinical practitioners and independent external
high internal consistency of the various symptom
contributes to their validity.
Another study indicates even more extensive validity for the HSCL.
Garcia and Fisher (1972) contrasted HSCL distress
observed at initial visit in two groups of gynecological normal
Gynecological patients were classed by their treat-
ment physicians as either emotionally labile, i.e., mildly tense or
anxious, or nonlabile.
Neurotic patients were categorized as unimproved,
mildly improved or markedly improved.
Results of this study were highly
They showed that the rank ordering of the groups on all
five HSCL dimensions proceeded from gynecological nonlabile at the
lowest distress level
to unimproved neurotics at the highest.
Differences between the groups were statistically significant on all
of the HSCL dimensions.
The State-Trait Anxiety Inventory (STAI) Form X
The State-Trait Anxiety Inventory is comprised of separate self-
for measuring two distinct anxiety concepts:
anxiety (A-State) and trait anxiety (A-Trait)
underlying the construction of the STAI
(1966) are as follows:
The theoretical bases
as outlined by Spielberger
"State anxiety (A-State) is conceptualized
as a transitory emotional state or condition of the human organism
Since A-States may fluctuate over time and vary in intensity,
a measure of
state anxiety must be sensitive to stress situations.
Trait anxiety (A-Trait)
on the other hand,
"refers to relatively
stable individual differences in anxiety proneness,
differences between people in the tendency to respond to
perceived as threatening with elevations in A-State intensity"
(Spielberger et al.,
A measure of trait anxiety
should be stable and consistent.
For a given group of respondents
trait scores ought to be
correlated with an increase
in state scores
The STAI A-Trait
Scale consists of 20 statements that ask people
, how they "generally" feel.
The A-State scale also con-
sists of 20 statements
, but the instructions require respondents to
indicate how they feel
"at a particular moment in time.
" The scales
are printed on opposite
sides of a sing
will make use of both scales.
The range of possible scores for Form
of the STAI varie
a minimum of
0 to a maximum of 80 on both the A-State and A-Trait
ects repond to each
item by rating themselves
on a four-point scale:
for the A-Trait
(4) almost always.
The A-State scale is balanced for an acquiescence set,
directly scored and ten reversed
Scale has seven
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The STAI was designed to be self-administering and may be given
either individually or in groups.
instructions for both
are printed on the test form.
inventory has no time
It generally requires
15 minutes to complete both scales, de-
pending upon the educational
level of disturbance of the
The title printed on the test form is SELF-EVALUATION QUESTIONNAIRE.
Although many of the STAI
items do have face validity as measures of
anxiety, directions for administration demand that the examiner not
use this term in administering the
Normative data for the STAI
are available for
of college freshmen
undergraduate college students and high school
Normative data are also reported for male psyc
medical and surgical
and young prisoners.
The A-State Scale i
considered "a sensitive indicator of
level of transitory anxiety experienced by
clients and patients
counseling, psychotherapy, behavior therapy or on a psychiatric ward.
It may also be used to measure change
in A-State intensity which
occur in these
essential qualities evaluated by the
A-State scale involve feelings of tension, nervousness,
(Spielberger et al.,
Validity of the A-State
having a clear understanding of the
upon the respondents
instructions which require
them to report how they feel
hp modified tn pvaliatp t hp
I pvl nf A-Statp
intpnditv fnr any citiatinn
period for which the subjects
A-State responses are desired must
cipants in this study were in-
in the following way:
Please think back during the past week to a
situation which called for you to make an
In other words
called upon to express your feeling
, you were
and openly in a manner which took into account
of the other person
It is not
important whether or not you acted assertively,
only that the incident occurred.
Try to pick a
though you were in that situation.
situation which wa
The following incidents were given as
participants who needed further clari-
Suppose you were in a clothing
clerk tries to
by using flattery
the clerk keeps
look good in it.
you a garment
look right on you,
insisting that you really
A good friend asks to borrow a
this person return
it, you find
writing all over the margins and coffee
, she then asks to borrow another
Your neighbor call
you to do some
work collecting money on your bloc
have done the same job for the
and had not intended to do
Test-retest correlationsfor the A-State
Inventory were relatively
low, as was expected for an instrument designed to be
high degree of
i t ha s
formula K-R 20 as modified by Cronbach (1951) for the normative
These reliability coeffi
... ranged from
(Spielberger et al.,
The STAI manual
(Spielberger et al
, 1970) reports evidence
bearing on the construct validity of the A-State
State scale was administered to a group of college
They were asked
to respond according to how they believed they would feel
fore an important final examination.
testing conditions as well as critical
between these means and point-biserial
Mean scores for the two
ratios for the differences
correlations are reported.
The mean score for A-State was considerably higher in the exam
in the norm condition for both males and females.
validity data for the A-State Scale was obtained in a
study in which the scal
was administered to
dents under four condition
in a single testing
station was at the beginning of the
testing session (normal
condition), the second followed a
training (relax condition)
10-minute period of relaxation
Then the students were asked to work
on an IQ test and were
third time (exam condition)
10 minutes to take the
last administration was
mediately after the students viewed a stressful movie (movie condition).
score for the A-State scale, a
as the scores for
individual A-State items, were
the relax condition and
highest in the movie condition.
The A-Trait Scale reflects differences
to respond to stressful
with varying amount
, it would be expected that those who are high in A-Trait
exhibit A-State elevations more frequently than
they tend to react to a wide range of
as dangerous or threatening.
likely to respond with incre
that involve interpersonal r
High A-Trait persons are also more
hased A-State intensity in situations
Relationships which pose some threat to
(Spielberger et al.
Validity of the A-Trait
cale depends upon the respondents having
a clear understanding of the
ch require them
to report how they "generally" feel
To preserve thi
be administered before the A-State scale.
way the respondents will
not be confused by the special
instructions they will
use for the A-State scale
est reliability data for the A-Trait inventory showed
relatively high correlations, ranging from
shows a high degree of
as evidenced by alpha
coefficients ranging from .86 to
Correlations of the STAI with the
IPAT Anxiety Scale,
Manifest Anxiety Scale (TMAS) and the General
Form of the
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