The impact of assertive training on the anxiety and symptomization of women referred by physicians

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Title:
The impact of assertive training on the anxiety and symptomization of women referred by physicians
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Little, Gertrude Gies, 1947-
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Women -- Psychology   ( lcsh )
Assertiveness (Psychology)   ( lcsh )
Anxiety   ( lcsh )
Counselor Education thesis Ph. D
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bibliography   ( marcgt )
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Thesis--University of Florida.
Bibliography:
Bibliography: leaves 151-159.
Statement of Responsibility:
by Gertrude Gies Little.
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Typescript.
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Vita.

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THE IMPACT OF ASSERTIVE TRAINING ON THE ANXIETY
AND SYMPTOMIZATION OF WOMEN REFERRED BY PHYSICIANS














By

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














ACKNOWLEDGMENT


There have been many wonderful


and supportive people who have


helped me during my years


as a doctor


student.


thank all of


them for their encouragement, guidance and friendship during some


of the most


important years of my


life.


I wish to express particular appreciation to those individual


who helped me make my di


sser


station a reality.


Thank you to:


Larry Loesch,


chairman of my supervisory committee, whose


technical


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.


William Gi


es, my parents, who have continued their


ove and support even when I


seemed to waver off course.


They in-


spired me to be whatever


I wanted and had an enduring belief in my


ability to do so.


George Little


my husband, who has never known me without


my dissertation


love and patience have been very


sustaining


and his support is what made thi


particular study possible.


David Lane for his continued encouragement, guidance and


friendship during my entire doctor


program.


He will always be a


very special


friend.










Ms. Sue Rimmer for her invaluable assistance with the statistical


anal


yses


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


Page


ACKNOWLEDGMENTS


LIST OF TABLES


Viii


ABSTRACT


CHAPTER I


- INTRODUCTION


Need for the Study


Purpos


of this Study


Plan of the Study


Hypotheses

Definition of Terms

Assertive Behavior


Assertive
Behavioral
Behavioral


Training
Assignments
Rehearsal


Primary-Care Physician
Psychotherapeutic Drugs


CHAPTER II


- REVIEW OF THE LITERATURE


Anxiety


Anxiety a


Types


a Problem


of Anxiety


Anxiety a


a Problem for Women


Treatment of Anxiety

Medical Approaches


Psychological


Approaches











Page


Assertive Training

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
Training
Research Studies on the Application of Assertive
Training


Assertive


Training for Women


Summary


CHAPTER III METHODS AND PROCEDURES
Selection of Subjects

Physician Group
Subject Sample
Sampling Procedures

Assessment Measures

The Adult Self-Expression Scale (ASES)


The Hopkin


Symptom Checklist (HSCL)


The State-Trait Anxiety Inventory (STAI) Form X

Hypotheses

Treatment Procedures

Design


Analysis

CHAPTER V -


of the Data


RESULTS


Description of Subjects

Attendance











Page


Analysis of the Data


Hypothesi
Hypothesi
Hypothesi
Hypothesi


Evaluation of Training


CHAPTER V


- SUMMARY, LIMITATIONS, DISCUSSION AND IMPLICATIONS


ummary


Limitations


Discussion

Implications

APPENDICES


APPENDIX A

APPENDIX B


- Doctor's Letter

- Personal and Professional Data


APPENDIX C


- Patient'


Letter


APPENDI


APPENDIX E


APPENDI


APPENDIX G

APPENDIX H


APPENDIX


APPENDIX J


- Postcard

- Personal Data Sheet

- Evaluation Form

- Treatment Procedures

- Consent Form

- Second Doctor's Letter

- Experimental Group Members' Comments


REFERENCES














LIST OF TABLES


TABLE

1

2


Page


Age of Subjects


Marital


Status


Years in Present Marriag


Subj


ects


' Numbers of Children


subjects

subjects


Highest Grade Completed


' Employment Status


Chi Square Analyses of Demographic Data

Number of Members in Each Group


Analysi
Scale


of Covariance on the Adult


Adjusted Mean


Scores


If-Expression


for the Adult Self-Expression


Analysis of Covariance on the A-State


Adjusted Mean Scores for the A-State


Analysis of Covariance on


cale


the A-Trait Scale


Adjusted Mean Scores for the A-Trait


Analysis
Checklist


cale


of Covariance on the Hopkins Symptom


Total


core


Adjusted Mean


ecklist


Analysi


Total


ores for the Hopkins Symptom
Score


of Covariance on


the Hopkins Symptom


Checklist Somatization Dimension









TABLE

19


20


Page


Analysis of Covariance on the Hopkins Symptom
Checklist Obsessive-Compulsive Dimension


Adjusted Mean


ores for the Hopkins Symptom


Checklist Obsessive-Compul siv


Dimension


Analysi


of Covariance


on the Hopkins


Symptom


Chec


klist Interpersonal-Sensitivity Dimension


Adjusted Mean


Checklist


Scores for the Hopkins Symptom


Interpersonal-Sensitivity Dimension


Anal


of Covariance


on the Hopkins Symptom


Checklist Anxiety Dimension


Adjusted Mean Scores


for the Hopkins Symptom


Checklist Anxiety Dimension


Analysis


of Covariance


on the Hopkins Symptom


Checklist Depression Dimension

Adjusted Mean Scores for the Hopkins Symptom
Checklist Depression Dimension


Means and Standard Deviations for the


Treatment


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


Gertrude Gi


Litti


August 1978


Chairman:


Larry C


Major Department


The purpose of thi


. Loesch


Counselor Education


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


symptomaticall


The sample for this study was composed of


female volunteers


between the ages of 20 and 65 whose primary-care physician had sug-

gested that they might benefit from participation in an assertion


training group.


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


groups.


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


Data consisted


the Adult Self-Expression


Scale, a measure of assertiveness; the A-State and A-Trait Anxiety


Scal


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


Somatization,


Interpersonal-Sensitivity, Obsessive-Compulsive, Anxiety and Depres-


sion).


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


yses


were used to evaluate the differences between












Anal


yses


of covariance, using pretest scores as covariates,


were used to evaluate each of the nine


scale scores.


The analyses


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

items.

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


somatization, obsessive-compulsivity,


interpersonal sensitivity, anxiety and total symptomization.



















CHAPTER I

INTRODUCTION


There are several clear indications that managing or coping with


anxiety and stress i


today.


a problem for a large segment of the population


From the volume of anxiolytic drugs prescribed,it is clear


that physicians


(e.g


are aware of anxiety in their patients.


Greenblatt & Shader, 1974) have


Surveys


shown that approximately 15%


of adult Americans regularly take antianxiety agents on an outpatient


basis.


This suggests that anxiety i


prevalent and that physicians


commonly resort to pharmocotherapy to provide relief for these

symptoms.

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:


"Across


the country


American


are frantically trying to 'get in touch


with


themsel


ves,


to learn how to 'relate' better, and to stave off outer


tie~~~~~~ rrnni Ill, ~ri inna 4nn nan1 ~rir Q7


Oulr nllllr tiroi Ar 101








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


situations the


individual considers threatening


anxiety may trouble a person for


a while and then dissipate until


individual


encounters further


stresses.


Accordingly,


pielberger (1966) distinguishes between two


types of anxiety.


Trait anxiety refers to anxiety


level


and prone-


ness that are relatively stable.


High trait anxious persons are pre-


disposed to respond anxiously to a wide


range of


stimuli


situations)


that they perceive as threatening or dangerous.


constant

lives.


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


precipitates.


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


as threatening


(Spielberger


, 1966).


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


tressful


events or


- 2 t. .. -- -


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Need for the Study


Although common to both


sexes


, available data support the view


that anxiety is particularly a problem for women.


Women consistently


report more symptoms of anxi


ety and emotional


distress than men


Baiter,


1973).


Cooperstoc k


(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


tresses and


problems in their environment and their vague, often subjective impres-


sions of anxiety (Williams,


1977)


It is very often this failure to


recogn1


why they are anxious that makes it difficult for women to


cope with anxiety.


Several


factors seem to be especially significant


why women are anxious.


Contemporary thought hold


in discussing


that changes in


their role in society have resulted in increased stress and anxiety


for women in particular


Cooperstock,


1976).


tresses arising from


potentially conflicting social


roles


(for example, wife, mother


worker) and pressures from multipi


roles are


creating problems for


women that


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


976).


They feel anxious


, for example,


when


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out that as women


assess


their individual


potentials for self-growth,


they often notice


inadequacies


in their abilities to assert their


personal


rights.


Moreover


, anxiety about interpersonal


conflicts


often inhibits their trying out new rol


and seeking new relation-


hips.


Thus, many women are caught


in the paradoxical


situation


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

anxieties.


Anxiety,


however


can be treated.


Although it i


generally con-


sidered a psychological


phenomenon, many individual


first manifest


anxiety symptomatically


, varying from somatic complaints such as head-


aches or insomnia to direct


indication


of anxiety


uch a


feeling


fearful or nervous. Since

individuals actually feel,


These complaints may be the only distr


the primary-care physician is often the


first professional


they approach for treatment.


Because of the physi-


cian


s medical


orientation,


the treatment often takes the form of


drug therapy


This can be expensive and


in some


Frequently a drug which eliminates a person


ide effects such as drowsiness or impairment


cases


debil ilating.


anxiety also causes

of psychomotor functions,


thereby reducing the patient'


overall


functioning (Greenblatt &


Shader


, 1974)


Moreover


, 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.


Such methods


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


f-directed behaviors.


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


acceptable.


Some of these, such as encounter and sensitivity groups,


Transactional Analysis and communication skill


have enjoyed immense


popularity.


However, most of these methodology


are based upon


the principle of increasing self-awareness and not specific adaptive


behaviors.


Therefore, there i


a need for methods which emphasize


situational applications and help individuals focus emotional energy


toward alleviating specific difficulties


or problems.


One of these methodologies, assertion training, is especially








professionals and the


lay public become


interested in it.


Lange and


Jakubowski


(1976


attribute thi


current interest to two important


cultural changes which seem to have taken place in the


ixties.


First,


as it became more difficult to achieve a feeling of


self-worth through


more traditional


sources


value their personal


, such as work and marriage, people began to


relationships


as a major source of life satis-


faction.


Many individual


sought to


improve the


interpersonal


necessary to better their personal


relationships and to overcome the


anxious feelings inhibiting the expression of needs


Second


as the


range of


socially acceptable


behaviors widened and alternative


life-


became more acceptable, many people found themsel


and anxious about either making choi


their choices


unprepared


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


their


lives


Since many of


these problematic


aspects of people


es' lives are anxiety


producing, assertion training ha


the potential


to alleviate or pre-


vent some instances of


tate anxiety experienced when trying out new


behaviors and trait anxiety with its more pervasive


influence.


would follow then that assertive training might also alleviate some


of the


symptomatic manifestations of this anxiety


Assertive behavior has been defined


involving the direct,


as any interpersonal


honest and appropriate verbal


response


and nonverbal


expression of one's feelings


belief


and personal


rights,


without


K











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


-Spector, 1973).


Although at


thepresent time there is a lack of general agreement about which

specific procedures actually constitute assertion training, the pro-


cess


generally incorporates four basic procedures:


(1) teaching


people


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


excessive anxiety


guilt and anger


(4) developing assertive


kills through active-practice methods


1975)


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


showing that


as individual


become more assertive


e, manifest anxiety


decreases (Percell


Berwick & Beigel


, 1974), while self-confidence


(Gay, Hollandsworth & Galassi, 1975) and personal adjustment (Galassi


& 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.


Since beina








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.


1974


study


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

symptomization.

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


anxiety.








reported situational anxiety of an interpersonal nature which they


experienced symptomatically


The physicians were briefed on the


nature of the treatment and suggested participation on the basis

of the above criteria.


Hypotheses


The following null hypotheses were tested:


Hypothesis 1


There is no difference in women


level of


assertion as a result of participation in

an assertion training group.


Hypothesis


There is no difference in women


s level of


state anxiety


as a result of participation


in an assertion training group.


Hypothesis 3:


There is no difference in women's level of trait


anxiety


as a result of participation in an


assertion training group.


Hypothesis 4:


There i


no difference in number and inten-


sity of symptoms expressed by women as a

result of participation in an assertion

training group.


Definition of Terms


Terms relative to this study are defined below:

Assertive Behavior


Assertive behavior is interpersonal behavior involving the honest











assertive behavior may be divided into four separate and specific


response patterns:


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


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


these feelings.

Behavioral Assignments


The assertiveness trainer makes behavioral assignments which call


for the


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


Behavioral rehearsal is rol


playing the desired assertive be-


haviors the client must use in interpersonal encounters in her life.

Primary-Care Physician








Psychotherapeutic Drugs


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


prescription channels


(Parry, Baiter, Mellinger


Cisin


Manheimer,














CHAPTER II

REVIEW OF THE LITERATURE


Anxiety


Anxiety


as a Problem


Today'


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


Spiel berger,


1966).


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


Shader, 1974)


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









13
prescriptions for psychotherapeutic drugs were filled in United States


drugstores.

that year.


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


of drugs


- 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 (


Increase


1977)


The fact


that 75 to 80 percent of all psychoactive drugs prescribed by physicians


in private practi


tranquility or


vidual


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


the skill


Books which provide insight,

and profess to actually teach


necessary for happiness and fulfillment have received


widespread acceptance.


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


June


1977, p.


Your


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

lives.

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.


Anxiety


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


resses


itself in one of two ways


An individual


may be considered to be either (1) generally anxious or (


because of particular circumstances,


anxious


The two conditions reflect


entirely different interpretations of the construct,anxiety.


The for-


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


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1







The term chronic anxiety also needs explanation.


Usual ly when


the word chronic


is used to described a state or condition it i


inter-


preted to mean a condition of relatively


low intensity or indefinite


duration.


When applied to an emotional condition


1 ike anxiety,


how-


ever, what


is actually meant by


chronic


is a


high pronenes


or predis-


position to experience


anxiety


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-


pron


individuals are predisposed to respond anxiously more frequently


and in a wider variety of situations than their peers


(Levitt,


1967).


The distinction between acute or situational


anxiety and anxiety-


proneness or predisposition has been delineated by Spielberger (1966).


Situational a

response to a


nxiety is defined


timulus


as a transitory state that occurs in


generally circumstances that are received


as threatening) and is


likely to vary in intensity and fluctuate


over time.


Anxiety-proneness


is conceptualized a


a personality


trait.


Trait anxiety refers to relatively stable individual


dif-


ferences in anxiety


level.


The high trait anxious


individual


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,


1966).


This study concerns


itself with both state and


trait anxiety.








Anxiety as a Problem for Women


Although common to both


that anxiety i


sexes,


available data support the view


particularly a problem for women.


Prevalence rates


for the use of medically prescribed therapeutic drugs are


tially higher for women than for men (29% compared to


ubstan-

(Balter


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


- the


minor tranquilizer/sedative group.


Parry et al.


(197


) discuss certain tentative


explanations of


these differences

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


ription


drugs.


In this sample women were


significantly more


likely than men


to report visiting a physician in the year preceding the


survey:


total


of the women compared to 46% of


the men.


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


psyc


hotherapeutics


for men.


(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


level


of psychic


distress.


They are also more


ly to report having undergone specific


situ-














In addition to the societal and psychological factors, Parry et


al. (1973


mention some definite physical factors which might explain


why women take more psychotherapeutic drugs than men.


First, mal


do not go through the oestrous cycle


pregnancy


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


especially


significant in discussing why women are anxious.


Gove and


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


culture


- 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.


"Females


are schooled from birth into the more highly valued norms of the male


culture


but they are also taught to be helpful, unassertive, de-


pendent


... girl


are drawn to the more powerful and rewarding masculine


world even a


they are also learning to accept as natural that they


"-' 'r







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


iden


, 1976)


Statistically,


they hold lower


tatus,


lower-paying


than do men, which often poses psychological


if not


economic


problems for them.


Another source of anxiety


fact that more women are working,


their feeling


losely tied to the


guilt about


or very real conflict between the demand of occupational


maternal


roles and


Contemporary American society relies primarily on


mothers alone for child care, expecting


little participation by older


children


, husbands or other relatives


(Gove & Tudor,


1973; Seiden


1976)


These assumption


are not,


however


, without challenge.


example, Cooperstock (1976) disagrees with the speculation that having


a number of social


role


such


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.


"The evidence


to date


that contemporary women filling numerous roles have somewhat


less illness


and take fewer tranquilizers and


than women filling the traditional


sleeping medications


female role of housewife"


(Cooper-


stock,


1976, p.


763)


. Nathanson (1975) concluded that


"employment


has perhaps the most positive effec


t on women'


health of any variable


investigated to date"


(Nathanson,


p. 60).


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.


Housewives


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


fulfillment.


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.


Moreover,


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


Medical Approaches







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,


1977).


Because of the physician


s medical orientation, treatment


of anxiety frequently involves the prescription of -psychotherapeutic


drugs


These drugs are often prescribed in


cases


where a physical


condition may have been caused by, be further aggravated by


perhaps result in anxiety (Parry et al


1973)


Caster (1977) differentiates anxiety into four distinct cate-


gories:


(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


sease


is a specific example of situational


anxiety where anxious feeling is related to consequences of the


illness


. 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


well as


other external events such as the availability of alternate treatment


modalities.


Lader (1976) suggests that when a patient complains of


anxiety the physician should first try to establish its cause.


Often


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


(Lader, 1976).


former patients may need long-term treatment and psychological sup-


port.


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


state-anxiety.


Their symptoms will probably subside of their own


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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.


Dosag


can be increased when discomfort is most severe and reduced


or eliminated during remission.

make these adjustments themselv


Patients are often encouraged to


es.


Patients experiencing state anxiety can be further differentiated.

For instance, a patient receiving medication to deal with a single


episode crisis


situation of


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


especially


, dealing with the effects of unresolved anger)


(Cline-Naffziger


, 1974)


Both of these


cases


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


skill


A large proportion of psychotropic drug prescriptions are written


by family Dractitioners.


Fvpn thninnh n vrhiM-tric-c and noirnilnn iee


i











physician group accounts for 50% of the total


psychotherapeutic drugs


prescribed (Balter & Levine,


1971


It must be remembered that while


family practitioners represent only 31


of all


physi


cians,


they account


of all


patient visits


Baiter,


1973)


The family physician and other primary-care physician


involvement with emotional


have an


the p


hiatrist


s experience, which frequently involves the manage-


ment of severe psychiatric disorder


in a hospital or crisis inter-


vention setting.


Primary-care physi


severe and often situational


cians


emotional


see a wide range of 1


in their everyday


practice,


including anxiety reactions, p


chosomatic disorders,


grief reactions


school


problems,


sexual


and marital


probl ems


etc.


Patients with these type


of problems are frequently troubled in a


more general and nonspecific


way.


Unfortunately,


the pressure


on the doctor to produce a quick cure.


Faced with a busy


schedule


is often just easier to write out a prescription for a


tranquilizer


than to


listen to the patient'


problem


(Watts,


1976; Muller,


The potential ne

anxiety are numerous.

Greenblatt & Shader,


!gative aspects of such a


The presence of side effects


1974)


tem of dealing with


(Muller,


such as drowsiness, could reduce the


patient


overall


evel of functioning.


Moreover,


treating the


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


problems


I








(1976)


interprets a physician's involvement


in these problem areas


as an expansion of the bound


of medical


care.


She eyes such expan-


sion critically


"If financial


difficulties,


loneliness


and dis-


obedience of children are common problems presented to physicians,


then it i


hardly surpri


sing that psychotropic drug consumption ha


increased


o much during the past decade"


(Cooperstock,


1976


761).


The medical model


has expanded to encompass


more aspects of our


lives.


Critic


"social


of thi


pathologi


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


labeled as


illnesses and treated by drugs"


(Balter


, 1973, p.


Psychological Approaches


Self-help approaches.


Reflecting our country


long-standing


emphasis on individualism,


current


self-help books emphasis


what


might be called psychological


success


(Schur


, 1977)


Lewin (197


maintains that though these self-help method


differ in catch phrases


or style


objective


they seem to share


life i


erta i n values.


The most important


the happiness and fulfillment of the


individual


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


spel


Selfl


ess


involvement in


social


causes


is considered bad unl


ess


it enhance


one'


personal


- ---












individuals completely responsible for their


lives and tend to


overlook the person's


interaction with the social


environment.


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


cannot.


Farson (1977) claims that by offering fulfillment, communi-


cation, effective


childrearing practi


etc.


, these methodologies


frequently


et up standards that individuals will


never be abl


meet.


Raising expectations


creates


a discrepancy between what per-


sons feel


they might have and what they do have.


This disparity


can frequently be a source of anxiety rather than an effective


treatment for


Traditional


approaches.


There is disagreement among therapists


about whi


ch therapeutic approach or technique


is best for treating


anxiety.


Therapists choose those therapeutic techniques which best


reflect their theories and philosophies.


Anxiety plays a central


role in psychoanalytic theory.


Generally,


it is thought of as a product of guilt produced by repressed early


learning experiences.


Anxiety is


likely to occur when the ego


(according to Freudian theory,


transactions with the


external


that part of the psyche that handles

environment) receives threats from


the environment


the id


(the unconscious


and most primitive part of


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Ah. -I -^ A


* "


:-,-..1


*11JJI S. '* I Ir'l **SI .. *I *l*lZL L *r IIIII ~O ~ I


,,,\


vr











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.


Therapeutic methods


of the anal


t would most likely involve helping the


lient develop


insight by conjuring up painful past experiences.


The therapist


aware of the interplay of unconscious forces and the way in which


they affect the


person's symptoms.


The crux of therapy is to


share with the client full insight into hi


unconscious (Psychology


Today


An Introduction,1972;


Stefflre, 1965).


Rational-emotiv


therapy operates on the assumption that emotions


are largely controlled by cognitive, ideational processes.


It holds


that an individual '


emotion


and motivations represent learned re-


actions.


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


, 1966)


The client-centered therapist holds that all behavior i


function of an individual


perceptions at the moment.


People


nnrrni t1 a iiha +- 1c &nnrnnro nfvn'h navcnnc with t- hoiry


aol f-rnnrcntc











experiences.


When an individual's self-concept is threatened, his


field of perception is narrowed and distorted.


In counseling,the


therapist seeks to reduce threat and remove it as an obstacle to


clearer perceptions and more effective behaviors.


The establishment


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


the client


own self-exploration by reflecting and clarifying hi


self-referent feelings and statements (Blocher, 1966; Steffire


, 1965).


The theories described above are representative of traditional


psychological approaches to anxiety. The

the psychological treatment of anxiety ha


*y reflect the fact that


historically involved


extended and intensive psychotherapeutic relationships.


methods are often


Such


expensive and time-consuming and, though generally


required to achieve lasting solutions to the problems trait anxiety


precipitates,


they are not usually necessary when dealing with


state anxiety


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


more anxiety.


Behavior


Therapy Approache


Some recently developed counseling


method


have potential


applicability to the treatment of anxiety.


are generally


expensive,


threatening and time-consuming,


and in many

approaches.


cases


more well-known than traditional


Some of these,


such a


therapeutic


encounter and sensitivity groups,


Transactional Analysis and communication skills training have en-


joyed


immense popularity


However


most of


these methodologies


are based upon the principle of


increasing self-awareness


specific adaptive behaviors.


There are


, however, alternatives to


these theories and techniques in the field of learning theory and

behavior therapy.


In the


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


or painful


stimulus"


Steffire


, 1965, p.


147).


Behavi oral


therapist


who advocate a direct approach to the elimination of anxiety generally


manipulate the


client


environment directly,


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


(Stefflre,


1965).








The more direct or behavioral


training approaches to psycho-


therapy are based on a


response acquisition model


of treatment.


"Within this model


, maladaptive behaviors are construed in terms


of the absence of specific response skill


The therapeutic objec-


tive


to provide clients with direct training in precise


ly those


kill


lacking in their response repertoires.


Very


little attention


given to eliminating existing maladaptive behaviors,


instead,


assumed that a


skillful


, adaptive responses are acquired


hearsed and reinforced


, the previous


maladaptive responses


will


displaced and will disappear"


(McFall


& Twentyman,


1973


199).


A therapeutic procedure which exemplifies this indirect behavioral


approach to anxiety is assertive training


considers the


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 Training


Assertive behavior is


interpersonal


behavior involving the


honest and straightforward expressing of feelings.

ponents of assertive behavior may be divided into


The main com-


four separate


and specific response patterns:


the ability to say "no";


the ability


to ask for favors or make request


ability to express positive


and negative feelings; and the ability to


initiate,


continue


terminate general


conversations


(Lazarus,


1973).








Assertive training is a therapy technique which is used with


individuals who are inhibited,


shy and therefore unable


to express


themselves in


situation


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 is to


increase


individual


ability to express these


feeling


Historical Antecedents of Assertive


Training


The work of Andrew Salter played an important role in the develop-


ment of the current conceptualization of assertive training.


Salter


(1961) applied the conditioning principles


of Pavlov to the


full


spectrum of neurotic behaviors


(Wolpe,


alter & Reyna


1965


People, according to Salter


develop,


, are born "excitatory."


many of their excitatory responses


ment and they become inhibited.


Thos


individual


are paired with punish-


inhibited response patterns


which are conditioned during childhood may remain in a person


adult


life.


For Salter the goal


in therapy i


"unlearning" of these


inhibited responses through the reconditioning of faulty inhibitory


patterns of


earl ier


life.


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.


those


"The happy person does


not waste time thinking.


Self-control


comes from no control


at all.


114






Salter's therapeutic technique

excitation through verbalization.


implemented to increase


Pauses and silences are not valued


since


excitation i


desired, not insight.


The first technique is


called feeling talk.


Using feeling talk means spontaneously expressing


felt emotions, being truthful and emotionally outspoken.


The second


rule of conduct


facial


talk, refers to the congruence between one's


emotions and facial


expressions.


The third technique is to contra-


dict and attack.


When individual


differ with someone they


should


freely express their true feelings and not pretend to agree.


fourth technique requires


the deliberate use of the word I as much


as possible.


The fifth tec


hnique is to express agreement when praised


and to volunteer praise of


self.


Improvisation,


the sixth and last


rule of conduct, refers to being completely spontaneous


Salter


, 1949,


100)


Salter is not concerned by what his patients tell


him they think.


He is more interested in what they say they did because that


is how


they got to the state they are in and how they are also going to get


out of


"To change the way a person feel


and think


about himself,


we must


change the way he acts toward others; and by constantly


treating inhibition, we will


be constantly getting at the roots of


his problem"


(Salter


1949


. 100).


Salter'


state of


excitation bears great similarity to the


modern concept of assertiveness


between them.


There are three basic differences


First, Salter advocates excitatory procedures for


virtually every conceivable psychological disorder.


Therapists using











current assertive training techniques would not assume that every


client is primarily in need of assertive training.


Second, whereas


Salter views assertiveness as a generalized trait, the present con-

ceptualization of assertiveness is that of a situation-specific


behavior.


That is


assertiveness invol


the questions "to what


degree?" and "in what situations?" (Mize, 1975


47).


Third,


Salter


showed little concern for the interpersonal consequences


especially negative, of excitatory behavior.


Being assertive, by


present definition, involves being socially appropriate.


Assertive


persons take into account the consequences of their behavior and


the impact it may hav


on others.


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


principle:


"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


71).


basic hypothesis


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


the term


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.


"The context


in which assertive behavior is an appropriate therapeutic instrument


are numerous.


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


ike him


... and unable to


express affection, admiration or praise because he finds such expres-


sion embarrassing"'


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


or s


situation.


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,


1958, p.


114).


Wolpe


assumes that some measure of resentment


is present with


the feelings


of anxiety and helplessness at most times.


The anxiety inhibits the


expression of the resentment.


He further suggests that,


ince anxiety


inhibit


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


least.


"Each time th


patient, by


expressing his


anger


inhibits


his anxiety


he weakens in some measure the anxiety habit"


The role of the therapist is to


increase


(Wolpe,


the clients'


motivation to express


themselves


assertivel


s, Wolpe


suggests,


can be accomplished by means of various exhortations,


pointing out to clients


including


the emptiness of their fears and showing


them how their fearful modes


of behavior have


put them at the mercy of others (Wolpe,


1958, p.


incapacitated them and


115)


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


maladaptive"


(Wolpe,


118).


By this statement he means that the client feel


anxiety in a


situation even when there is no valid reason to do so,


when no


negative


repercussions can reasonably be expected.


In situations


that call for some action,


but in which direct assertion would be


inappropriate, Wolpe advocates the use of


indirectly aggressive








Wolpe utilizes a form of behavior rehearsal


training. In

people in real


in his assertive


an attempt to prepare the patient to deal with real

relationships, the therapist and the patient act out


short exchanges


setting


from the patient


s life.


While patients


represent themselves,


the therapist assumes the role of


someone


towards whom the patient feel


unadaptively anxious and inhibited.


In actual


fact


, a certain amount of deconditioning of anxiety can


occur during the behavior rehearsal


itself


(Wolpe,


1958


There are two other theorists who have contributed directly


or indirectly to


the contemporary as


sertive training process.


is O


Moreno


, the founder of psychodrama


a method of psychotherapy


that invol


the use of role playing in order to achieve insight.


Assertion training draws from psyc


hodrama


employment of staged


dramatizations of the real


life attitudes and conflicts of those


participating


clients.


Psychodrama also strongly emphasis


sponta-


neity and improvisation


playing strategy


both of whi


psychodrama


h Salter stressed.


is similar to one of Wolpe


a rol


s principal


assertive techniques


behavior rehearsal


is used in assertive


training.


The goal


in psy


chodrama


for the client


to achieve in-


sight through the acting out of

goal of behavior rehearsal in a


expand the client


existing relationships,


assertive training


whereas the


to enhance and


repertoire of assertive behaviors (Mize,


1975,


A second theorist whose contributions are


indirectly related to


-~~. S S -- S


.1 ~ .I


A








he call


"fixed-role therapy"


(Kelly


, 1955)


Fixed-role therapy


is based upon Kelly


"personal 1


construct" theory of personality


According to Kelly,


people


look at the world and the events


that


happen to them in terms of constructs they have developed from their


own individual experiences.


Fixed-role therapy involves


ascertaining


client


particular constructs as well as determining the con-


structs the client must have in order to resolve problems.


therapy involve


deriving a personality sketch of a fi


individual who is free of the anxieti


and behavioral


titious

inadequacies


which plague the client.


lient is then asked to assume the


role of the


hypothetical


person who possesses the desirable


constructs.


Thi s


includes behaving


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


longer feel


they are


assuming roles


(Kelly


, 1955).


The role-playing features are quite


similar to the behavior rehearsal


technique


used in


assertive


training.


Even though training is not specifically aimed at modi-


flying a client's cognitions


Rimm and Masters (1974) report that


case


histories suggest that


individual


do undergo certain attitu-


dinal


changes


as a result of treatment, especially in relation to


self-perception.


Research on


Treatment Procedures and Behaviors Important to Assertive-


ness


In the therapeuti


setting the a


sser


tive training procedure


traditionally one of therapist modeling with role-playing inter-








four components:


modeling by the therapist of appropriate assertive


behaviors, behavioral


rehearsal


on the part of the client,


feedback


to the client from the therapist and reinforcement of the client's


assertive attempts


(generally by the therapist's verbal


expression


of approval).


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


behavior.


Lazarus


(1971


consider


behavior rehearsal


to be the primary


methodology of assertive training.


1966 he reported what he


claimed to be the first


"objective"


clinical


study of behavior re-


hearsal


He compared it with direct advice and nondirective therapies


in training patients to be more assertive.


Behavior rehearsal was


shown to be effective


of the


cases


in which it wa


used,


whereas the other approaches were only 44% and


ective,


respectively (Lazarus,


1966)


For those


clients who are very non-


assertive


e, Lazarus advocates the use of behavioral


hierarchical manner


similar to that used in


rehearsal


stematic


in a


desensitization.


This methodology, called rehearsal


desensitization (Piaget & Lazarus,


1969


, involves gradual


presentation of anxiety-arousing


situations,


starting from the


least anxiety-provoking and moving to the most


anxiety-provoking.


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


First,


the behavior rehearsal


standardized.


Second


treat-


the behavior


rehearsal


technique was typically applied to poorly defined and un-


pecified behavior classes.


able, objective


Third


laboratory and/or


, there were no satisfactory, reli-

real life measures available to


assess


the behaviors typically treated with behavior rehearsal


What followed was a sern


and development of behavior re


experiments aimed at the evaluation

hearsal therapy.


In the first study of


series


McFall


and Marston (1970)


developed a standardized


semiautomated behavior rehearsal


treat-


ment procedure and used it in examining two experimental


questions:


simple rehearsal


ired changes


alone


, sufficient to produce


in the problem behavior and


(2) what i


significant and


the therapeutic


importance of response feedback -- specifically

playback of tape recorded rehearsal responses?


feedback via


Results of behavioral,


self-report and psychophysiological


laboratory measures


, as


well as


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


feedback


tended to augment these effects although not to a significant degree.


In a subsequent study McFall and Lillesand


treatment components,


(1971) added two new


symbolic modeling and therapist coaching,


the rehearsal with feedback procedure.


They focused on


the more


limited and homogeneous response


ass


of refusal


behavior


Results


I S .. a -e -







therapist coaching made significant contributions to the assertive

training procedure.


The rehearsal-modeling group was divided


into


two part


One-


half of the

rest engaged


individual


engaged in overt response rehearsal while the


in covert rehearsal


Overt response rehearsal occurs


externally and allows the therapist to monitor the subject'


during training.


responses


Covert procedures, on the other hand, occur within


the imagination


(Cautela,


1970).


They are more difficult to monitor,


but they do offer the advantages


of being more flexible


easier to


arrange and often


less


threatening


(McFal 1


& Lillesand


, 1971).


results of this study indicated that covert rehearsal


at least


as effective


in refusal


training


as overt rehearsal,


if not more so.


McFal and Twentyman


(197


further assessed the contributions


of rehearsal, modeling and coaching to an experimental


assertion-


training program in four


experiments.


training components


rehearsal and coaching both contributed significantly to the


subjects'


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-


hearsal


plus coaching.


This was true regard


of the particular


type of model


employed (tactful


presentation (audiovisual


versus abrupt) or the means of


or auditory).


No differences were found


among


the three modes of rehearsal


examined


(covert rehearsal


overt 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


-life


situations.


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


low-assertive male


and female college students


(low a


ssertive refers to the


inability of


a person to engage in behavior which indicated he feel


entitled to


exercise certain rights) were


signed to one of


six treatment


conditions:

role playing


modeling

(students


(student


observed assertive models)


enacted the rol


of assertive model,


directed

following


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


eted)


modeling plus directed role playing;


assertiv


script (students


imply read


ilently to


themsel v


assertive script employed


in the other treatment conditions


nonassertive script which wa


designed as a control


group


primary behavioral measure involved taping the students'


with a


interactions


live confederate who became increasingly annoying to them.


students'


verbal


responses


were rated by blind judges on five


verbal


categories


(threat, demand,


insult,


strong disagreement,


request to stop).


The total


number of responses in all


five catego-


ries gave a Sum Assertion score.


Subjects also filled out a


series


of personality tests


including an Assertiveness test constructed








The overall


effectiveness of these treatment procedures


changing


assertive behavior was substantial.


treatment elicited between 44% and


havior at posttesting.


81% of low assertive mal


live-modeling


criterion (assertive)


The most promising result was that 69


and female


be-

% to


in the modeling-plus-directed-


role-playing condition


howed assertive behavior at posttreatment


testing which was equivalent to members of an independently assessed


high assertive


group


Friedman also found that the


improvised role-


playing condition eli


cited high


levels of assertive behavior at


posttesting for 50% of male


and female


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


incapable of


thinking up and


improvising


assertive responses during role playing were unable to


profit a great deal


from the


improve


sed rol


playing procedure.


goes even further and


says


that the


improve


sed rol


playing was as


effective as the directed role playing condition.


Consequently


explicit cues to guide training part


cipants'


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


important practical


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.


where individual


In instances


have assertive responses in their repertoires


but fail to employ them frequently or appropriately


an improvised


e-playing technique might be appropriate.


In thi


instance,


modeling would probably be extraneous.

Although the above studies contributed significantly to the

understanding of assertive training, they failed to specifically


enumerate those


iveness.


behaviors which are considered important in assert-


While a variety of techniques had been used to increase


assertiveness (e.g


., behavior rehearsal, audio and/or videotape


feedback and modeling) there was little attention directed toward


specifying what actual behaviors are altered a


assertive training.


Hersen (1973


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


Inter-


action


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.


havior

vidual


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


differentially affected


changes in these specific factors.


instance, they found that in modifying a subject's loudness


him verbal instructions about what he


giving


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


This study


Hersen and Miller (1973)


that just practicing behaviors without the addition of techniques


such


as instructions


, modeling, or a combination of the two will not


lead to behavioral change in terms of the components of assertive-


ness.


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-

ligible.


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


responses


to 1


ess familiar persons.


At the same time the


experimenters sought


to identify some of the


behavioral


component


of positive assertion by using some


situations


that typically elicit positive


responses


Results demonstrated


significant differences between how patients

requiring positive or negative assertions.


responded in situations

The results also supported


a stimulu


who i


s-specific theory of


assertiveness


able to be assertive in one


interpers(


(that is, an individual

onal context may not be


in a different situation)


Rathus


1973)


hypothesized that college women who observed video-


taped model


and practiced


specific assertive respon


would report


more assertive behavior and be rated more assertive by judges than


women in two control


groups.


The group


met for one hour


sessions


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:


assertive


talk


, feeling talk,


greeting talk


disagreeing passively and actively,


asking why,


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 -,--- -











interactions.


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.


Kazdin


1974, 1975,


1976) ha


investigated the problem of


developing assertive behavior with covert modeling from several


perspectives.


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


individual's


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.


Control


Participants in all of the


treatment groups,


including the no-model condition


showed improve-


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:


forcement


and of the

formance);


The participants

single model/rein-


subjects imagined a person similar to themselves in age

same sex and favorable consequences followed model per-


sing 1


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


it aloud.


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


Results


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.


Hence


, 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


several


model


performing


asser


tively) and model reinforcement.


The results


of thi


study were unclear.


Covert modeling did lead to


significant


increases in assertive behavior and imagining several model


engaging


in assertive behavior with favorable consequences did enhance the


f raza mont nfCfrb


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Kazdin


studies demonstrate that imagining a person modeling


assertion in different situations and


following the model


imagining a


assertion are effective way


favorable outcome


instigating


assertive behavior.


Nietzel


Martorano and Melnick


(1977) claim


that given the typically fragile nature of early assertive attempts,


client


should also be trained to deal with the noncompliance or


negative consequences which


ome of


their assertions will


provoke.


They designed a covert modeling


plus reply training,


treatment


procedure which involved two elements:


the visualization of a non-


complying response


to initial


assertion by the model and then


visualization of a second


assertive counterreply by the model


reply training condition resulted in


in behavioral


significantly greater changes


assertion than the modeling alone.


When Young, Rimm and Kennedy (197


) assessed the value of ver-


bally reinforcing female


coll


student


' 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


skill


that can be


learned through the


systematic application of a


variety of behavioral


tudy to


techniques.


see if the acqui


Winship and Kelley (1976) designed


sition of assertive behavior might be


facilitated by yet another


strategy


-- the use of a


specific verbal











components that were taught systematically:


(1) an empathy statement


(the ability to


see the


situation through the other person's eyes),


(2) a conflict statement (the individual


communicative rationale


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,


behavior rehearsal


, 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.


icant


Signif-


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.


Galassi, Galassi


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.


Exper-


mental subjects received eight training sessions consisting of video-


tape modeling


behavior rehearsal; video


peer and trainer feedback;


bibl iotherapy


group support


homework assignments; trainer exhortation and peer

The sessions were held twice a week for an hour and


a half in three 30-minute segments.


sess


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


into dyad


assertive interactions.


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


ces


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


(Galassi


Kostka & Galassi,


1974


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


(Eisler


Hersen & Miller,


McFall & Lillesand


1971


McFall


& Marston,


1970)


Making


the point that response latency is determined by many factors other


than anxiety aroused by being assertive,


such as cultural and geo-


graphic differences,


the authors (Galassi


Galassi & Litz


, 1974)


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


These persons


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.


Individual


involved ranked


it a


number


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


significance


McFall and Twentyman (1973)


found that audiovisual modeling added little to training in a


ssertive-


ness, and a number of other researchers have found, contrary to


expectations,


that videotaped feedback did not contribute to the


therapeutic impact of behavior rehearsal


(Aiduk & Karoly,


Melnick & Stocker,


1977)


Gormally


Hill


, 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


Lillesand


McFall


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


complex


treatment program.


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


weeks)


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


follow-up procedure.


The follow-up in the Galassi study was con-


ducted in the laboratory whereas the McFall studies relied primarily


on in-vivo follow-up (


self-report diari


or phone calls).


Although


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


assi


, Kostka & Galassi,


1974)


Another issue relevant to treatment procedures in assertiveness


training i


the question of whether the training should be carried out


individually or in a group.


With the


exception of a few studies


(Rathus, 1973; Galassi, Kostka & Gal


assi, 1974) all of the above


research involved treatment on an individual basis.


However


, 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


162)


He is


one of only a few authors who have published a clinical description


of such a gr

efficient.


oup.


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


comprised exclusively


of women (Gambrill & Richey, 1975; Winship & Kelley


1976


Rathus,


1973).


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 &

Litz, 1974).








This review of the research


literature indicates that assertive


training i


an effective procedure for use with individual


the social and interpersonal


skills to ensure successful


lack


functioning.


Assertive training is specifically directed toward teaching them more


effective way


of responding.


evidence also indicates


that


lack


of assertion i


generally


rarely a generalizable trait.


limited to specific types of situations.


Deficienci


For instance, a


person who is quite assertive in impersonal


situations might be quite


the opposite


in personal


interactions


, 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


assertiveness training


understanding of the elements necessary


for change has been reached.


The assertiv


training procedure can


be conceptualized as an active process taking place between the


therapist and the patient or the


relationship i


leader and the participant.


similar to that between teacher and


Their


student:


therapist instructs, models, coaches and reinforces appropriate verbal


and nonverbal


respon


ses;


the client practices newly acquired skills


first in a protected environment and then in real


life situations


(Hersen


Eisler & Miller,


1973).


Applications of Assertive


Training


Case Studies on


the Applications of Assertive


Training


There have been widespread


t~riininn


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

various problems.


Walton


1961) reported a ca


in whi


ch assertive training was


used in treating violent somnambulistic behavior of a 35-year-old


male against hi


wife


The patient related hi


behavior to his poor


relationship with hi


mother, whom he


found domineering and authori-


tarian.


The therapist hypothesized that during wakefulness the


patient


intense anxiety prevented hi


solving this problem.


sleep hi


learned fear responses were reduced


hence hi


behavior.


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


completely di


ssipated by the time of follow-up two months


later.


There was neither recurrence nor evidence of symptom substitution


Cautela


(1966) combined


reassurances


, (2) relaxation


desensitization and


(4) assertive training to treat three individual


exhibiting pervasive,

nation and reassurance


free-floating anxiety


He used desensiti-


inhibit their anxiety and a


assertive training


and relaxation to help them realize they could control


their own


behavior.


The first case was that of a 23-year-old


ingle female school


teacher who wa


so fearful


of other people that her


job was in jeop-


ardy.


After


3 hours of behavior therapy she had almost a complete


remission of symptoms.


The second case was that of


a 25-year-old











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


own.


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:


married


talking about


sex, religion and being


criticism and teasing and any parental disapproval.


After


sess


ions she was able to control her fear and anxiety in all real-


life situations.


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


independent.


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-


tive.


With him


, however, a really


significant decrease in anxiety


was noted only after desensitization about sexual activity with his

wife.


Seitz (1971) described the treatment of a neurotically depressed


36-year-old widowed ma


patient who was hospitalized following a


suicide attempt.


Here assertive training wa


used in combination


with three other behavior modification techniques.


Assertive training


was initiated in order to increase annronrilate ncial intpractinn








by the patient.


This patient showed


improvement after eight weeks


of therapy.

Lambley (1976) treated a 38-year-old woman suffering from migraine

headaches with a combination of assertive training and psychodynamic


insight.


Lambley makes the point that since migraine i


essentially


a psychosomatic condition, and as such,


involves the functioning of


both somatic and p


hological


systems,


treatment methods must be


multidimensional


including both behavioral and psychodynamic


insight


techniques.


This


woman's case hi


story data revealed several areas of possible


psychodynamic confli


t with


specific people


such as her husband and


her mother and behavioral anal


indicated that


he was unable to


assert herself


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

occurring altogether.


Foy, Ei


ler and Pinkston (1975) reported the


case


of a 56-year-


old mal


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-


havior.


six month follow-up showed that changes


in behavior had


been maintained and had generalized to the natural


Eisler


environment.


, Hersen and Miller (1974) reported the modification of periodic








The main emphasis in these


consequences of a


cases


lack of appropriate


has been on the


asser


interpersonal


tive behavior or on the


somatic symptoms that have been considered


ide effects associated


with unexpressed impul


ses.


Rimm


(1967) examined another response


which sometimes occurs in response to the inhibition of anger-crying.


The ca


he worked with


involved a


8-year-old man who cried


exces-


ively in response to


situations which made him angry


Rimm made


the point that


excess


ive crying is


inappropriate behavior for males.


However,


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


initiated.


To teach the


patient to be assertive rather than fearful


inducing


in the face of anger-


timuli, a shock escape technique was employed, an unusual


procedure in the assertiv


training


literature.


Improvement was


noted after two months of therapy.


These case studies illustrate the versatility of assertive

training as a therapeutic tool. Although treatment methods are pre-


sented


, the precise evaluation of particular techniques is unavailable


in most cases


Except for Foy et al.


(1975) and Eisler et al


(1974)


the case studies mentioned above offer only global


clinical


judgments


of improvements.


Research Studies on the Applications of Assertive


Training


Behavior therapy research has generally focused on demonstrating

that behavior can be changed. The widespread attention of researchers








Changing an individual


behavior


however


would seem to be of


little con


sequence if the person still


feel


anxious,


unhappy


upset


and/or worthless.

and attitudinal c


It seems necessary to also as


changess which accompany changes


sess t

in the


:he cognitive


individual


behavior (Percell


et al


., 1974).


The following studies attend to


this need and can be divided into two category


which corre-


late assertiveness with other variables and those which have a


training component to


show whether becoming more assertive can


fact, change other variables.


Research has


indicated that the assertive individual


is expressive,


spontaneous


well


defended


confident and able to influence and lead


others while the nonassertive person more often feel


inadequate and


inferior


, has a marked tendency to be oversolicitous of


emotional


support from others and exhibits


excessive


interpersona


anxiety


(Galass


, De Lo, Gal


assi & Bastien,


1974)


It would seem,


then


that there


is an association between


assertiveness and such variables


locus of control


, self-confidence,


self-concept,


personal adjust-


ment and anxiety.


There


is some research available which supports


assumption.


The concept of locus of control


refers to


the extent to which


individuals view rewards as contingent on their own behavior.


When


a reinforcement i


perceived by individual


as contingent on their


own behavior


, Rotter (1966) terms thi


a belief in internal


control.


When individual


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


Signifi-


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-


forcements


as externally controlled.


It follows that nonassertive


individuals can be considered more compliant to external demand


than their more assertive peers.


substantiated that internal


externals.


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


control


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


line


, however, with Gay


Hollandsworth and Galassi'


(1975) findings


that locus of control did not discriminate between low- and high-

assertive subjects.

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.


Cor-


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


Zimmerman


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


Test (for


assertion) and the Self-Acceptance Scal


of the California


Psychological Inventory to a group of outpatient psychiatric patients.


Later, in an experiment to


assess


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


adjustment.


Galassi and Galassi (1974) found that students who sought


personal adjustment counseling were significantly less assertive than


both noncounsel


ees


and students who sought only vocational-educational


counseling


Gay et al.


an assertiveness


(1975) reinforced this when their study of


inventory for adults revealed that individual


seeking


personal adiustment cnunsPl ino


scnred sinnificantlv oIwer on the








on the Adjective Check List Counseling Readiness Scale


(these scores


are thought to reflect


self-dissatisfaction)


The data


suggested


that constricted males are


tolerant of their own


lack of


assertiveness in comparison to constricted females for whom a demure,


passive


sex role alternative is sanctioned by society


The variable which has received the most attention regarding its


relationship to assertive behavior i


have 1

social


anxiety.


Behavior therapists


peculated about the relationship between social


anxietie


and lack of assertive behavior


fears or


The association


between them has been supported by a number of


Morgan


investigations.


1974) administered the Wolpe-Lang Fear Survey Schedul


and the

a small

ness and


Rathu


Assertivenss Schedule to psychology students and found


but statistically


social


significant relationship between assertive-


fear.


- Bates and


immerman


(1971) administered the Constriction Scale


and the Multiple Affect Adjective Check List to 600


students as one


of the validation procedures for the Constriction


Scale.


They found


significant correlation between scores on the two scales which


affirmed their hypothesis that anxiety is positively correlated with

being nonassertive.


Galassi, De Lo

students scoring lo


Galassi and Bastien


1974) found that college


w on a measure of assertiveness


selected adjectives


on a


hecklist that indicated


excess


interpersonal anxiety.


Students who scored high, on the other hand, were confident.








Gay et al.


(1975)


using 464 subjects ranging in age from


18 to


60 years, administered the Adult Self-Expression Scale and the


Manifest Anxiety Scale


Taylor' s


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


Percell


et al.


(1974)


hypothesized that there would be


igni


ficant negative correlation between measures of assertiveness and


anxiety.


The hypothesis was supported


in a


study with


100 psychiatric


patients.


Orenstein, Orenstein and Carr


(1975) found the same using


450 college students.


Besides these correlational


studies there have been


several


assessments of the effectiveness of assertiveness


training in elimi-


nating or reducing anxiety.


Rathus


(1973) administered both an


assertiveness


inventory and a fear survey to groups of female students


receiving either assertive training, a placebo treatment or no treat-


ment.


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

assertive training.


Rimm, Hill


Brown and Stuart (1974)


volunteers reporting a history of exp


ress


reported that male student

ing anger in an inappropriate


or antisocial manner reported


of uptightnesss"


significantly greater decreases in feelings


after receiving eight hours of assertive training


than did controls.








Percell et al. (1974) tested the hypothesis


psychiatric


that outpatient


patients would exhibit a decrease in anxiety after receiving


assertive training.


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


group.


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


behave


more effectively and solve some of their problems.


The asser-


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


scores


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








aggressiveness.


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


Scale.


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


could


ead to antisocial aggression if


eft unresolved.


Assertive Training for Women


Recently a number of writers have proposed that nonassertiveness


is a pervasive cultural phenomenon among women


Jakubowski-Spector


1973


Lange & Jakubowski


, 1976; Osborn & Harris


1975


Bloom, Coburn


& 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.


Persons


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








situations.


This emphasis has kindled a burgeoning


interest in


assertiveness training for women.


Assertive training is considered a


kill-building pro


cess


much as a


therapeutic procedure.


Hartsook, Olch and de Wolf


(1976)


have


studied the personality characteristics of women who


assert ivenes


training and found that these women are


"overly con-


cerned with the approval


of others and moderately inhibited in


ex-


pressing their feelings, but in most respects are integrated and


autonomous"


(Hartsook et al


., 1976, p.


326)


The assertivenes


to teach women assertive


training procedure ha


kills (Rathus,


been used successfully


1973) and has the potential


to help them become more effective and fulfilled.


Much of the


infor-


nation we have about women and the effectiveness of assertive training


is ancillary to research conducted with mal


and females about


treatment strategies


in assertive training.


We know,


for example,


that assertive training results


were


significantly improved for


both men and women with the addition of behavior rehearsal


(McFall


& Marston


, 1970)


modeling and role playing


(Friedman,


1971


Kazdin


1974) and coaching (McFall


& Lillesand


, 1971)


We also know some


things about treatment results;


for instance Percell


et al.


(1974)


found that both male and female psychiatric patients


anxiety and


improved in


self-concept as a result of an assertive training program.


Except for the study by Percell

involved treatment on an individual


et al.

basis.


(1974) all

Several t


the projects


:heorists have








conducted in groups (Lange & Jakubowski


, 1976;


Osborn & Harris,


1975).


There is some research available which supports the idea


that assertive-


ness training i


effectively carried out in group


with women (Rathus,


1973


Gambrill & Richey,


1975


Winship & Kelley,


1976; Pearlman &


Mayo


, 1977), but not that it i


necessarily better than assertiveness


training conducted


individually,


nor that


is more effective with


all-women groups than mixed


-sex


groups.


Pearlman and Mayo


s (1977) data


from a follow-up


urvey indicated


that 65% of women partic


ipating


in group assertiveness training felt


their assertive


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


assertive behavior


group.


Remarks suggested that


had generalized beyond the situations


practiced


in the group and that group members


' interpersonal


relations


with


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


beyond their


group participation and generalize their assertive behaviors to real-

life situations.


Summary


The preceding review of the research


literature suggests that


assertive training can be an effective treatment procedure for


S .- .. 1 -- -- -..


,.-. I.. -- P -- I








deficits.


With patients who simply do not evidence the requisite


social and interpersonal


skills to ensure successful


functioning,


assertive training is specifically directed toward teaching new

modes of responding.


Frequently the


lack of these interpersonal


skills can precipitate


a state of anxiety for an individual.


This anxiety often manifests


itself f


symptomatically.


patients become more


skilled in routine


interpersonal


interactions


, the probability of their receiving rein-


forcement from their


social mileau is


increased.


At that point


symptomatic behaviors become nonfunctional and are eliminated from


their repertoires (Hersen,


Eisler & Miller


1973


specific techniques contributing to the overall


success of


assertive training have been examined


Although a


full


understanding


of all


the elements producing change ha


not been achieved, some


definite patterns have emerged.


Most


striking


is the extent to which


an active process takes place between the therapist and the patient.


The relationship approximates that of teacher and student.


therapist instructs,


model


s, coaches and reinforces appropriate


verbal and nonverbal


responses.


Concurrently,


the clients first


practice their newly developed repertoires in the consulting room


and then in actual


situations requiring assertive responses


(Hersen


et al


1973)


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

of symptomization.















CHAPTER III

METHODS AND PROCEDURES


Many women evidence moderate to severe


interpersonal


behavioral


deficits.


Frequently the lack of these


interpersonal


skill


precipitates


a state of anxiety which in turn manifest


Accordingly there is


itself symptomatically.


a need for methods to help women become more


effective


interpersonally.


Assertivenes


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.


Chapter

procedures,


ign used


III deal


with the hypotheses, population, sampling


instrumentation,

in this study.


treatment proceduresand experimental

It also includes an explanation of how


the data were collected and analyzed.


election of Subjects


Physician Group


Although it


many individual


is generally considered a psychological


first manifest anxiety in a


phenomenon,


somatic manner.










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

treatment.


Primary care is defined


as basic or first-contact care.


Provision


of primary care is the function of the family practitioner


pediatrician or gynecologist


, internist,


This particular study dealt with adult


women who approach their primary-care physician with symptoms of


anxiety.


The physician sample was drawn from those primary-care


physicians who have adult women


loners


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


of December


, 1977 and those family practitioners, gynecologists and


internists listed in the Gainesville, Florida, telephone directory


who were practicing in Gainesvill


during January, 1978.


This


generated a list of approximately 20 family practice residents, 20


family practitioners, 21 internists and 14 gynecologists.


Three of


the physicians were women.

Subject Sample


This sample was


composed of


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.


They were











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


about thing


indications of anxiety such as feeling fearful, nervous-


ness or shakiness inside, heart pounding or racing or feeling tense

or keyed up.

Sampling Procedures


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


This


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-


lowing symptoms:


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;


indications







inferiority; indications of depression such as loss of sexual interest

or pleasure, poor appetite, crying easily, feeling blue and worrying


or stewing about things


and/or indication


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.


eligibi


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.








Please call


Yes,


as I


need more information.


want to participate and have indicated at


least


three (3)


times I


will


be available.


The time periods


listed are


10:00 AM


- 12:00 PM


inn0


- 3:00 PM


3:00

group


- 5:00 PM and


sess


- 9:00 PM on Monday through Saturday.


ions were held during those time period


most frequently


requested.

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


session

12 to 1


subject would be able to attend all


The names of interested women were held until


6 was attained.


seven


a pool of


The women were then assigned to either a


treatment or control


group.


The treatment group compositions were


established according to times each


subject indicated as convenient.


The subject recruitment process described above wa


continued until


a subject pool


women was reached.


Women


in the experimental


groups began to receive the training


as soon as possible


Members


of the control groups were offered the training after the posttesting.


Assessment Measures


Participants were asked to complete a personal


data sheet


(Appendix


and three self-report instruments:


the Adult Self-Expression Scale


(ASES), a measure of


assertiveness;


the State-Trait Anxiety


Inventory


(STAI) and the Hopkins Symptom Checklist (HSCL), a clinical


cralo which rofltorc th0 ncvrhninnirm l


rating


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.


During the


last testing


session the experimental


groups were also asked to fill


out a


short


questionnaire evaluating their experiences during the training

(Appendix F).

Descriptions of the assessment measures follows.


The Adult


elf-Expression Scale (ASES)


The Adult Self-Expression


report measure of


, 1974)


assertiveness designed for general


Its construction was based upon a


two-dimensional model


is a 48 item


use with adults.


assertive-


ness.


One dimension


pecified interpersonal


situations in which


assertive behavior might occur


uch as


interactions with family,


the public, authority figures and friend


A second dimension


specified assertive behaviors that might occur in these interpersonal


situations.


The behaviors included express


ing personal opinions,


refusing unreasonable requests,


taking the initiative in conversations


and in dealing with others, exp


ress


ing positive feel ing


standing up


legitimate rights, expressing negative feelings and asking favors


of others.


Both situation-specifi


and generalized components of


behavior were taken into account in the design.


A factor anal


ysis


procedure resulted in


factors that accounted


for 55.91


of the


variance.


Forty-five of the 4


items on the


- A-


- a r


a I..j- n S a n 1 44~n at t\ -.~ ..4- -. a *hf A%~ 4--- *~* f -- &.ft'


A I. LI: UArl CIALAIA


nn ,,,,,,,. L,,,







defined


in terms of types of assertive behavior (also mentioned above).


Three types of assertive behavior were represented by two factors


each:


expressing positive feelings,


standing up for one'


s legitimate


rights


and taking the


initiative


in one'


dealings with others.


The ASES uses a five-point Likert format


(0-4).


Respondent


are asked to answer the questions by indicating how they generally


express themselves


n a variety of


situations


They indicate


either


"almost always" or "always"


"seldom"


"usually"


), or "never" or "rarely"


"sometimes"


instructions tell


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


in that


should not reflect how they feel


situation


they


ought to act or how they would like to act but rather how they generally


do act


It takes about


A total


15 minutes to complete the ASES.


score for the ASES can range from 0 to


There are


positively worded and


negatively worded


items.


negatively


worded items must be reverse


scored prior to calculating the total


score.


The mean ASES total


score obtained from 640 adults ranging


age from


18 to 60 was approximately 11


with a


standard deviation of


approximately 20


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


subjects.


Both


sample


r oiiorl f-ho


initiWI


1-ocf adminict-ratinn at thp


came time


The ASFS








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.


, 1975).


Gay (1974) conducted several studies to establish validity data


for the ASES.


Construct validity was established by correlating


the total


scores


of individual


taking the ASES with their


scores


on the 24 scales of the Adjective


Check List.


The ASES was found


to correlate positively at the p


Adjectives Checked and the Self-Confidence


< .001 level with the Number of


, Ability, Achievement,


Dominance, Affiliation


Aggression and Change


Heterosexuality, Exhibition


Autonomy,


ales of the Adjective Check List.


The ASES


was found to correlate negatively at the p


< .001 level with the


Succorance, Abasement and Deference scales of the Adjective Check

List.


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


= 114











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


pro-


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


1,56)


20.51


, p <.001 did significantly discriminate between low and high


assertive groups.


Locus of control F


1,56)


- 1.14, p


<.291 did not.


Hopkins Symptom Checklist (HSCL)


The Hopkins Symptom Checklist (initially developed by Parloff,


Kel mar


Frank


, 1954) is a multidimensional symptom


sel f-report


inventory.


comprised of


items which are representative of


the symptom configurations commonly observed among medical outpatients.


It is scored on five underlying symptom dimensions:


obsessive-compulsive


The basi


somatization,


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


researchers


Uhlenhuth & Lazar, 1968)


asked highly experienced clinicians to assign the symptoms


of the HSCL to homogeneous clinical


experience.


lusters based on their clinical


Symptoms that were assigned with a high level of consis-


tency were returned and provided HSCL cluster definitions.


Results of











Will iams and her


assoc


iates (Williams, Lipman, Rickel


Covi,


Uhlenhuth & Mattsson


of a large sampi


, 1968) performed a factor analysis of


of 1,115 anxious neurotic patients.


self-ratings


Lipma n


(1969) factor analyzed psychiatrists' HSCL rating


of 837 of


the same patients.


In both of these studies five


clinically meaning-


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


constancy.


the dimension


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


dimensions (somatization


obsessive-compulsive,


irascibility


anxiety


and depression) in a study of the factorial invariance of the HSCL.

They derived these dimensions by factor-analyzing the HSCL self-ratings


of 1


,066 anxious neurotic outpatients and psychiatrists' ratings for


a subsampi


patients.


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.


Each indicated


a high level of invariance for the HSCL symptom dimensions both among


patients and between patients and psychiatrists.


On the Somatization


dimension riv


s were above


.95 for all three p


sychiatrist-patient







comparisons was


.76 while that among patients was .60.


The dimension


of General Neurotic Feelings exhibited moderate to high similarity


coefficients across the three patient groups.


The coefficients


ranged from


.74 between the upper-middle class and lower-cl


.48 for the working cl


versus lower class contrast.


patients


The com-


parsons of thi


factor with the psychiatrists' dimensions resulted


in almost equivalent coefficients.


Anal


is of the Irascibility factor


showed riv'


.64 and .67 between the upper-middle class and the


working-class groups, respectively, and the psychiatrist's ratings.


Derogati


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


(Somatization


Depressive


Obsessive-Compulsive,


Anxiety and Inter-


personal Sensitivity)


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


ass.


They had similarity coefficient


.97 and .96, respectively.


The dimension of Interpersonal Sensitivity also reflected high agree-


ment between the two sample


(niv


.81).


The Depression dimension


showed considerable invariance (riv


yet at the same time


reflected overtones unique to each of the diagnostic cl


asses.


Anxiety dimension was not significant because of a failure to sustain

a distinct dimensional representation of anxiety for the depressed


neurotics.


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.


particularly


Self-deprecation, feelings of


uneasiness and marked discomfort during interpersonal interactions


are characteristic


of persons with high scores on thi


dimension.


Other typical sources of distress are feelings of acute self-conscious-

ness and negative expectancies regarding interpersonal communication.


There are


seven items which make up this dimension.


Possible scores


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


signs


of withdrawal of interest in activities, lack of motivation, and loss


of energy.


This dimension also includes feelings of hopelessness and


futility.


Eleven items comprise thi


factor.


Possible


scores range


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.,


"trembling."


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


scaleP


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


as follows:


= "not-at-all ."


= "a little bit," 3


= "quite a bit," 4


= "extremely."


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.


Twelve


items contribute to this dimension.


Possibi


scores range from 12


to 48.

The items that form the dimension obsessive-compulsive reflect

symptoms that are closely identified with the clinical syndrome of


this name.


The focus of this measure is on thoughts, impul


actions that are experienced by the individual as irresistable and


unremitti

nature.


ng.


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


that different


temporal


limits may be used.


Under standard conditions


however


time context used is seven days.


Respondents are asked to respond


in terms of "How have you felt during the past seven days including

today?"

Two of the major normative samples for the HSCL have been developed


around neurotic disorder


with primary symptom manifestations of anxiety


and depression


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


included


in the


research on the HSCL.


Reliability


estimates of the


internal


consistency


of the HSCL symptom dimensions


are uniformly hiah.


Alpha coefficients


based on an N of 1435 range from


4 to


Item-total


correlations


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


they ranged


from .75 for anxiety to .84 for the obsessive-compulsive dimension.


The patients


involved were all


parti


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


medication.


I' n 'Snrnu II~ I ~ r


L a a


F


II








83
distress levels on the HSCL was identical to the rank ordering suggested


by clinical practitioners and independent external


criteria.


high internal consistency of the various symptom


dimensions


also


contributes to their validity.

Another study indicates even more extensive validity for the HSCL.


Rickels, Lipman


level


Garcia and Fisher (1972) contrasted HSCL distress


observed at initial visit in two groups of gynecological normal


patients (N=1


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.


consistent.


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-


report scal


for measuring two distinct anxiety concepts:


state


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,


that i


differences between people in the tendency to respond to


situation


perceived as threatening with elevations in A-State intensity"


(Spielberger et al.,


1970, p.


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


under stress


Levitt,


1967).


The STAI A-Trait


Scale consists of 20 statements that ask people


to describe


, 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


test form.


This study


will make use of both scales.


The range of possible scores for Form


of the STAI varie


from


a minimum of


0 to a maximum of 80 on both the A-State and A-Trait


subscales.


ects repond to each


item by rating themselves


on a four-point scale:


very much


almost never;


(1) not-at-all;


The category


sometimes;


somewhat t


for the A-Trait


often; and


) moderately


cale are:


(4) almost always.


The A-State scale is balanced for an acquiescence set,


with ten


directly scored and ten reversed


items.


The A-Trait


Scale has seven


ylrl n ,nv~- 4Inm nr mF IYr ,,nr 1 ) ..k4. naa, s Ji....







The STAI was designed to be self-administering and may be given


either individually or in groups.


Complete


instructions for both


scal


are printed on the test form.


inventory has no time


limit.


It generally requires


about


15 minutes to complete both scales, de-


pending upon the educational


level


and/or


level of disturbance of the


respondents.

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


inventory.


Normative data for the STAI


scal


are available for


large samples


of college freshmen


undergraduate college students and high school


students.


Normative data are also reported for male psyc


hiatric


patients


genera


medical and surgical


patient


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


situations.


essential qualities evaluated by the


A-State scale involve feelings of tension, nervousness,


worry and


apprehension"


(Spielberger et al.,


Validity of the A-State


1970, p.


inventory depends


having a clear understanding of the


"state"


upon the respondents


instructions which require


them to report how they feel


"at thi


moment.


instructions may


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


always be


early


pecified.


Parti


cipants in this study were in-


structed


in the following way:


Please think back during the past week to a
situation which called for you to make an


assertive response.


In other words


called upon to express your feeling


, you were
s honestly


and openly in a manner which took into account


the feeling


of the other person


It is not


important whether or not you acted assertively,


only that the incident occurred.


questions as
Try to pick a


Answer the


though you were in that situation.


situation which wa


you.


The following incidents were given as


to those


difficult for


example


participants who needed further clari-


action.


Suppose you were in a clothing


clerk tries to


by using flattery
something doesn't


the clerk keeps
look good in it.


You can


store.


you a garment


that


look right on you,


insisting that you really


A good friend asks to borrow a


this person return


it, you find


book.


When


writing all over the margins and coffee


stains


on s


that book


one.


several


pages.


he returns


, 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


years


1


and had not intended to do
year.


charity


ast three
it again


Test-retest correlationsfor the A-State


Inventory were relatively


low, as was expected for an instrument designed to be


influenced by


situational


factors.


scale does,


however


show a


high degree of


i t ha s









formula K-R 20 as modified by Cronbach (1951) for the normative


samples.


These reliability coeffi


lent


... ranged from


.83 to


for A-State"


(Spielberger et al.,


1970


, p.


The STAI manual


(Spielberger et al


, 1970) reports evidence


bearing on the construct validity of the A-State


ale.


The A-


State scale was administered to a group of college


students under


normal


conditions with


standard instructions.


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


just be-


Mean scores for the two

ratios for the differences


correlations are reported.


The mean score for A-State was considerably higher in the exam


condition t

Additional


han


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


undergraduate stu-


dents under four condition


in a single testing


session


The first


admini


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


scale a


interrupted after


third time (exam condition)


10 minutes to take the

last administration was


mediately after the students viewed a stressful movie (movie condition).







The mean


score for the A-State scale, a


well


as the scores for


individual A-State items, were


lowest in


the relax condition and


highest in the movie condition.


The A-Trait Scale reflects differences


in peoples


' dispositions


to respond to stressful


situations


with varying amount


of A


tate.


"In general


, it would be expected that those who are high in A-Trait


will


exhibit A-State elevations more frequently than


low A-Trait


individual


becau


they tend to react to a wide range of


situations


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


self


-esteem"


(Spielberger et al.


, p.


Validity of the A-Trait


cale depends upon the respondents having


a clear understanding of the


"trait"


instructions whi


ch require them


to report how they "generally" feel


To preserve thi


validity the


A-Trait scal


will


be administered before the A-State scale.


This


way the respondents will


not be confused by the special


set of


instructions they will


Test-ret


use for the A-State scale


est reliability data for the A-Trait inventory showed


relatively high correlations, ranging from


cale


shows a high degree of


internal


consistency


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


Taylor


uc kerman


Afffort 8Adiart iun rhnrl, lic*


MaI nI lanr


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