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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
Creator:
Little, Gertrude Gies, 1947-
Publication Date:
Language:
English
Physical Description:
xii, 160 leaves : ; 28 cm.

Subjects

Subjects / Keywords:
Anxiety ( jstor )
Assertiveness ( jstor )
Behavior modeling ( jstor )
Control groups ( jstor )
Gene therapy ( jstor )
Physicians ( jstor )
Psychology ( jstor )
Rehearsal ( jstor )
Symptomatology ( jstor )
Women ( jstor )
Anxiety ( lcsh )
Assertiveness (Psychology) ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Women -- Psychology ( lcsh )
City of Gainesville ( local )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Bibliography: leaves 151-159.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Gertrude Gies Little.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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05320961 ( OCLC )
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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. .. -- -


A -- ..-. l --


-, L.. -..--. -,


L..,-I..~-.~L -I








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


-. .a.a a-


I II I


.1 I


~L- II..--._.~I I II








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


flfl~~hnlnnrzA nnnt~ cna c nn v\ 1 1 )C 46 n v-a~ -. n.. nh ...


~nv; nf\, rt~+n


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


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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


Fnrm rc,,i 1-fn in o -,irlonro




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INGEST IEID E8FISH15F_YY536A INGEST_TIME 2011-08-09T14:36:45Z PACKAGE AA00002205_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES


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
UNIVERSITY OF FLORIDA
1978

University of Florida, George A
Digitized by the Internet Archive
ÍP2EM WMflüíráing from
Smathers Libraries with support from LYRASIS and the Sloan Foundation
http://www.archive.org/details/impactofassertivOOIitt

ACKNOWLEDGMENTS
There have been many wonderful and supportive people who have
helped me during my years as a doctoral student. I 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 individuals
who helped me make my dissertation a reality. Thank you to:
Dr. 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. His
special ability to help me organize was invaluable.
Mr. and Mrs. William Gies, my parents, who have continued thei
love 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.
Dr. George Little, my husband, who has never known me without
my dissertation. His love and patience have been very sustaining
and his support is what made this particular study possible.
Dr. David Lane for his continued encouragement, guidance and
friendship during my entire doctoral program. He will always be a
very special friend.
Dr. Richard Anderson for his willingness to give me the time
and effort necessary to serve on my doctoral committee.

Ms. Sue Rimmer for her invaluable assistance with the statistical
analyses 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.
TV

TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS iii
LIST OF TABLES viii
ABSTRACT x
CHAPTER I - INTRODUCTION 1
Need for the Study 3
Purpose of this Study 8
Plan of the Study 8
Hypotheses 9
Definition of Terms 9
Assertive Behavior 9
Assertive Training 10
Behavioral Assignments 10
Behavioral Rehearsal 10
Primary-Care Physician 10
Psychotherapeutic Drugs 11
CHAPTER II - REVIEW OF THE LITERATURE 12
Anxiety 12
Anxiety as a Problem 12
Types of Anxiety 14
Anxiety as a Problem for Women 16
Treatment of Anxiety 19
Medical Approaches 19
Psychological Approaches 24
v

Page
Assertive Training 29
Historical Antecedents of Assertive Training 30
Research on Treatment Procedures and Behaviors
Important to Assertiveness 36
Applications of Assertive Training 53
Case Studies on the Applications of Assertive
Training 53
Research Studies on the Application of Assertive
Training 57
Assertive Training for Women 64
Summary 66
CHAPTER III - METHODS AND PROCEDURES 69
Selection of Subjects 69
Physician Group 69
Subject Sample 70
Sampling Procedures 71
Assessment Measures 73
The Adult Self-Expression Scale (ASES) 74
The Hopkins Symptom Checklist (HSCL) 77
The State-Trait Anxiety Inventory (STAI) Form X 83
Hypotheses 89
Treatment Procedures 89
Design 91
Analysis of the Data 92
CHAPTER V - RESULTS 93
Description of Subjects 93
Attendance 99
vi

Page
Analysis of the Data 101
Hypothesis 1 101
Hypothesis 2 102
Hypothesis 3 104
Hypothesis 4 105
Evaluation of Training 114
CHAPTER V - SUMMARY, LIMITATIONS, DISCUSSION AND IMPLICATIONS 116
Summary 116
Limitations 118
Discussion 119
Implications 122
APPENDICES
APPENDIX A - Doctor's Letter 126
APPENDIX B - Personal and Professional Data 128
APPENDIX C - Patient's Letter 129
APPENDIX D - Postcard 130
APPENDIX E - Personal Data Sheet 131
APPENDIX F - Evaluation Form 132
APPENDIX G - Treatment Procedures 133
APPENDIX H - Consent Form 144
APPENDIX I - Second Doctor's Letter 145
APPENDIX J - Experimental Group Members' Comments 146
REFERENCES 151
BIOGRAPHICAL SKETCH
160

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
LIST OF TABLES
Page
93
Age of Subjects
Marital Status 94
Years in Present Marriage 95
Subjects' Numbers of Children 96
Subjects' Highest Grade Completed 97
Subjects' Employment Status 98
Chi Square Analyses of Demographic Data 98
Number of Members in Each Group 99
Analysis of Covariance on the Adult Self-Expression
Scale 101
Adjusted Mean Scores for the Adult Self-Expression
Scale 102
Analysis of Covariance on the A-State Scale 103
Adjusted Mean Scores for the A-State Scale 103
Analysis of Covariance on the A-Trait Scale 104
Adjusted Mean Scores for the A-Trait Scale 105
Analysis of Covariance on the Hopkins Symptom
Checklist Total Score 106
Adjusted Mean Scores for the Hopkins Symptom
Checklist Total Score 106
Analysis of Covariance on the Hopkins Symptom
Checklist Somatization Dimension 107
Adjusted Mean Scores for the Hopkins Symptom
Checklist Somatization Dimension 108
vm

TABLE
Page
19
Analysis of Covariance on the Hopkins Symptom
Checklist Obsessive-Compulsive Dimension
108
20
Adjusted Mean Scores for the Hopkins Symptom
Checklist Obsessive-Compulsive Dimension
109
21
Analysis of Covariance on the Hopkins Symptom
Checklist Interpersonal-Sensitivity Dimension
110
22
Adjusted Mean Scores for the Hopkins Symptom
Checklist Interpersonal-Sensitivity Dimension
110
23
Analysis of Covariance on the Hopkins Symptom
Checklist Anxiety Dimension
111
24
Adjusted Mean Scores for the Hopkins Symptom
Checklist Anxiety Dimension
112
25
Analysis of Covariance on the Hopkins Symptom
Checklist Depression Dimension
112
26
Adjusted Mean Scores for the Hopkins Symptom
Checklist Depression Dimension
113
27
Means and Standard Deviations for the Treatment
Evaluation Form
114
IX

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
By
Gertrude Gies Little
August 1978
Chairman: Larry C. Loesch
Major Department: Counselor Education
The purpose of this 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
symptomatically.
The sample for this study was composed of 82 female volunteers
between the ages of 20 and G5 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¬
intestinal distress, dizziness and muscle soreness; indications of
interpersonal sensitivity such as temper outbursts, feelings of
x

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; indications of anxiety
such as feeling fearful, 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. Members of the control
groups were tested, waited seven weeks and were posttested. All
training and testing was done by the researcher.
All 82 women provided all the data requested. Data consisted
of scores on nine criterion variables: the Adult Self-Expression
Scale, a measure of assertiveness; the A-State and A-Trait Anxiety
Scales 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 women also completed a Personal Data Form.
The members of the experimental group filled out a form evaluating
the training during the posttesting period.
Chi square analyses were used to evaluate the differences between
the treatment and the control groups on the demographic data. Group
assignment was shown to be independent of the personal data variables.
xi

Analyses 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
iterns.
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's somatization, obsessive-compulsivity,
interpersonal sensitivity, anxiety and total symptomization.
xi i

CHAPTER I
INTRODUCTION
There are several clear indications that managing or coping with
anxiety and stress is a problem for a large segment of the population
today. From the volume of anxiolytic drugs prescribed,it is clear
that physicians are aviare of anxiety in their patients. Surveys
(e.g., Greenblatt & Shader, 1974) have shown that approximately 15%
of adult Americans regularly take antianxiety agents on an outpatient
basis. This suggests that anxiety is 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 is 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 "self-
help" phenomenon identified self-awareness as a new panacea: "Across
the country, Americans are frantically trying to 'get in touch' with
themselves, to learn how to 'relate' better, and to stave off outer
turmoil by achieving inner peace" (Schur, 1977). Our culture actively
encourages people to seek out solutions to their problems and to seek
self-fulfillment in the process. Accordingly,it has provided these

2
methodologies to help individuals deal with the anxiety and turmoil
such searches can precipitate.
Anxiety is difficult to define precisely. Since stresses change
and situations vary, anxiety is usually episodic 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 the individual encounters further
stresses. Accordingly, Spielberger (1966) distinguishes between two
types of anxiety. Trait anxiety refers to anxiety levels and prone¬
ness that are relatively stable. High trait anxious persons are pre¬
disposed to respond anxiously to a wide range of stimuli (or situations)
that they perceive as threatening or dangerous. Because it is relatively
constant, this type of anxiety has a pervasive effect on individuals'
lives. Time-consuming and often costly treatments are generally
required to achieve lasting solutions to the problems trait anxiety
precipitates.
This study addresses the issue of trait anxiety and Spielberger's
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 responds in an anxious manner (often
even when unprovoked), an individual's experience of state anxiety
can frequently be connected to identifiable stressful events or
situations. Accordingly, the treatment of state anxiety is generally
of shorter duration.

3
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 anxiety and emotional distress than men
(Balter, 1973). Cooperstock (1976) confirms that women exceed men
in their consumption of psychotropic drugs in a consistent ratio of
two to one.
Many women fail to make a connection between the stresses and
problems in their environment and their vague, often subjective impres¬
sions of anxiety (Williams, 1977). It is very often this failure to
recognize why they are anxious that makes it difficult for women to
cope with anxiety.
Several factors seem to be especially significant in discussing
why women are anxious. Contemporary thought holds that changes in
their role in society have resulted in increased stress and anxiety
for women in particular (Cooperstock, 1976). Stresses arising from
potentially conflicting social roles (for example, wife, mother,
worker) and pressures from multiple 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 desire to overcome them
(Lange S Jakubowski, 1976). They feel anxious, for example, when
the "women's movement" stimulates them to grow while they feel unpre¬
pared to fulfill these aspirations. Jakubowski-Spector (1973) points

4
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 roles and seeking new relation¬
ships. Thus, many women are caught in the paradoxical situation
of experiencing anxiety within their existing situations or roles
(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 is generally con¬
sidered a psychological phenomenon, many individuals first manifest
anxiety symptomatically, varying from somatic complaints such as head¬
aches or insomnia to direct indications of anxiety such as feeling
fearful or nervous. Since these complaints may be the only distress
individuals actually feel, 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 cases débililating.
Frequently a drug which eliminates a person's anxiety also causes
side effects such as drowsiness or impairment of psychomotor functions,
thereby reducing the patient's 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
effective behavior change.

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. Thus,there exists a strong possibility
that the use of such methods may in fact produce even more anxiety.
Indeed this possibility seems likely, since by definition state-
anxious individuals are ineffectively using self-directed behaviors.
Some of the more recent professional counseling methods have
potential applicability to the treatment of anxiety. They are generally
less expensive, threatening and time-consuming and more socially
acceptable. Some of these, such as encounter and sensitivity groups,
Transactional Analysis and communication skills have enjoyed immense
popularity. However, most of these methodologies are based upon
the principle of increasing self-awareness and not specific adaptive
behaviors. Therefore, there is 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
useful in this regard. It has a long history, but only recently have

6
professionals and the lay public become interested in it. Lange and
Jakubowski (1976) attribute this current interest to two important
cultural changes which seem to have taken place in the sixties. First,
as it became more difficult to achieve a feeling of self-worth through
more traditional sources, such as work and marriage, people began to
value their personal relationships as a major source of life satis¬
faction. Many individuals sought to improve the interpersonal skills
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¬
styles became more acceptable, many people found themselves unprepared
and anxious about either making choices about how to behave or defending
their choices 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 peoples' lives are anxiety
producing, assertion training has the potential to alleviate or pre¬
vent some instances of state anxiety experienced when trying out new
behaviors and trait anxiety with its more pervasive influence. It
would follow then that assertive training might also alleviate some
of the symptomatic manifestations of this anxiety.
Assertive behavior has been defined as any interpersonal response
involving the direct, honest and appropriate verbal and nonverbal
expression of one's feelings, beliefs and personal rights, without
violating the rights of another person (Rimm & Masters, 1974).

7
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 people identify and accept
both their own personal rights and the rights of others; (3) reducing
existing cognitive and affective obstacles to acting assertively,
e.g. irrational thinking, excessive anxiety, guilt and anger; and
(4) developing assertive skills through active-practice methods
(Mize, 1975).
A number of variables appear to be theoretically or conceptually
related to assertion. These include locus of control, self-confidence,
personal adjustment and anxiety. Research has been carried out
showing that as individuals become more assertive, manifest anxiety
decreases (Percell, Berwick & Beigel, 1 974), while self-confidence
(Gay, Hoilandsworth & 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 being
nonassertive, having ineffective interpersonal relationships and
lacking identity almost always result in an individual being anxious,
women who have these problems might be helped by assertion training.

8
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
anxiety. It also looked at the relationship between assertion training
and those feelings of anxiety specific to the time of the assertion.
Two unique features of this study 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 (3) 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
participation in an interpersonal skills training group. The women

9
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's level of
assertion as a result of participation in
an assertion training group.
Hypothesis 2:
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 is 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
and straightforward expression of feelings. The main component of

10
assertive behavior may be divided into four separate and specific
response patterns: the ability 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 individuals
who are inhibited, shy and therefore unable to express themselves
in 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 is to increase the individual's ability to express
these feelings.
Behavioral Assignments
The assertiveness trainer makes behavioral assignments which call
for the client 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 role playing the desired assertive be¬
haviors the client must use in interpersonal encounters in her life.
Primary-Care Physician
Primary care is basic or first contact care. It is the care of
common disorders. Provision of primary care is usually the function
of the family practicioner, internist, gynecologist or pediatrician.

11
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, Balter, Mel linger, Cisin & Manheimer,
1973).

CHAPTER II
REVIEW OF THE LITERATURE
Anxiety
Anxiety as a Problem
Today's 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 (Spielberger, 1966).
There are several clear indications that anxiety is a pervasive
psychological phenomenon in modern society. One of the most clear-
cut of these indicators is 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¬
sored by the Psychopharmacology Research Branch of the National
Institute of Mental Health) reported that in 1972 almost 215 million
12

13
prescriptions for psychotherapeutic drugs were filled in United States
drugstores. This was 16% of the 1,400,000,000 prescriptions filled
that year. Approximately 44% of these prescriptions for psychothera¬
peutic drugs was accounted for by a single class of drugs - the anti-
anxiety agents (Balter, 1973). More recently, National Prescription
Audit results indicated that Valium, a minor tranquilizer, was the
most prescribed drug in 1976 (2.5% Increase ..., 1977). The fact
that 75 to 80 percent of all psychoactive drugs prescribed by physicians
in private practice were prescribed for the purposes of sedation,
tranquility or sleep (Balter, 1974) would indicate that many indi¬
viduals come to physicians with problems that require calming down.
Another manifestation of anxiety in contemporary life is the
widespread public pursuit of psychological happiness and fulfillment.
This quest is clearly evidenced by the current proliferation of mass-
distributed personal guidance books. Books which provide insight,
challenge people to grow emotionally, and profess to actually teach
the skills 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 27, 1977, p. 82). Your
Erroneous Zones, described by the New York Times Book Review
as a "self-help pep talk" has been on the hardback best-seller
list for 54 consecutive weeks. And Looking Out for Number One,
a compilation of tips and practical suggestions unified by a basic

14
philosophy of self-interest, joined the best-seller list just two
weeks after its publication (Publishers Weekly, June 27, 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 exhausting state of tension and alertness"
(Psychology Today: An Introduction, 1972, p. 720).
Anxiety usually expresses itself in one of two ways. An individual
may be considered to be either (1) generally anxious or (2) anxious
because of particular circumstances. 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 implies that the anxiety is immediate and most
likely temporary. Usually these two types of anxiety are referred to
as chronic and acute.
Acute as a descriptive term is used most often when describing a
pathological anxiety state. Generally the phrase "acute anxiety
attack" is used in referring to the severely stressed person who often
requires psychiatric care. Usually, when speaking about the notice¬
able, but lesser, anxiety of a more normally stressed individual, the
terms situational or transient are used (Levitt, 1967).

15
The term chronic anxiety also needs explanation. Usually when
the word chronic is used to described a state or condition it is inter¬
preted to mean a condition of relatively low intensity or indefinite
duration. When applied to an emotional condition like anxiety, how¬
ever, what is actually meant by chronic is a high proneness 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-
prone 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 anxiety is defined as a transitory state that occurs in
response to a stimulus (generally circumstances that are preceived
as threatening) and is likely to vary in intensity and fluctuate
over time. Anxiety-proneness is conceptualized as a personality
trait. Trait anxiety refers to relatively stable individual dif¬
ferences in anxiety level. The high trait anxious individual is
predisposed to respond with an anxiety state reaction to a wide range
of stimulus situations that are perceived as threatening or dangerous
(Spielberger, 1966). This study concerns itself with both state and
trait anxiety.

16
Anxiety as a Problem for Women
Although common to both sexes, available data support the view
that anxiety is particularly a problem for women. Prevalence rates
for the use of medically prescribed therapeutic drugs are substan¬
tially higher for women than for men (29% compared to 13%) (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. (1973) discuss certain tentative explanations of
these differences which were uncovered by the NIMH study of psycho¬
therapeutic drug use in the United States: (1) A visit to a physician
is generally the first step in acquiring psychotherapeutic prescription
drugs. In this sample women were significantly more likely than men
to report visiting a physician in the year preceding the survey: a
total of 58% of the women compared to 46% of the men. (2) Male
prevalence rates for drugs such as alcohol and marihuana were sub¬
stantially higher than female rates, indicating that these psycho¬
tropic substances may serve as substitutes for the prescription
psychotherapeutics for men. (3) Women in our society, particularly
middle-aged and older women, are permitted and often encouraged to
have mild symptoms of psychic distress and to see a doctor for them.
(4) Women are more likely to report higher levels of psychic distress.
They are also more likely to report having undergone specific situ¬
ational stresses. (5) Women were significantly more likely than men
to take a tranquilizer in advance of a possibly unpleasant event.

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, males
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 actuariaI 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 this 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 norms of the male culture - being assertive, autonomous,
competitive and achieving (Walstedt, 1974). Walstedt (1974) maintains
that women are marginals 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 ... girls are drawn to the more powerful and rewarding masculine
world even as they are also learning to accept as natural that they
should never enter the world. The clash of two possible self-definitions
is usually experienced by girls and women as undifferentiated feelings
of frustration, anxiety or discontent" (Walstedt, 1974, p. 640).

18
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
(Seiden, 1976). Statistically, they hold lower status, lower-paying
jobs than do men, which often poses psychological if not economic
problems for them. Another source of anxiety, closely tied to the
fact that more women are working, is their feelings of guilt about
or very real conflict between the demand of occupational roles and
maternal roles. 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 assumptions are not, however, without challenge. For
example, Cooperstock (1976) disagrees with the speculation that having
a number of social roles 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
suggests that contemporary women filling numerous roles have somewhat
less illness and take fewer tranquilizers and sleeping medications
than women filling the traditional female role of housewife" (Cooper-
stock, 1976, p. 763). Nathanson (1975) concluded that "employment
has perhaps the most positive effect on women's health of any variable
investigated to date" (Nathanson, 1975, p. 60). She cited studies
showing that working women present fewer symptoms than nonworking
women of the same age, and report fewer days of disability and less
anxiety.

19
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
Anxiety can be treated. Although it is generally considered a
psychological phenomenon, many individuals first manifest anxiety in
a somatic manner. Patients often come to their physicians with a

20
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, or
perhaps result in anxiety (Parry et al., 1973).
Caster (1977) differentiates anxiety into four distinct cate¬
gories: (1) anxiety neurosis, (2) situational anxiety, (3) anxiety
as an aspect of disease,and (4) psychophysiologic disorders. He
defines anxiety neurosis as a recurring emotional state without
recognizable etiology which is manifested by apprehension, tearful¬
ness or a sense of impending doom and is associated with autonomic
nervous system discomfort. Situational anxiety is identified as
that of an individual of relatively normal emotional background
whose anxiety is provoked by identifiable stressful life events.
Anxiety as an aspect of disease 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.

21
The use of anti anxiety agents in these four different groups of
disorders will vary depending upon the specific conditions as 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 ascertai n whether the patient has suffered
from life long "personality" anxiety or whether the present episode
has occurred in a previously calm individual (Lader, 1976). The
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 use of antianxiety agents is not
the treatment of choice for those who could benefit from therapy
leading to behavioral change (Caster, 1977).
These latter patients experience the equivalent of Spielberger1s
state-anxiety. Their symptoms will probably subside of their own
accord and then recur when the patient once again encounters a stress¬
ful situation. The rationale for psychotherapeutic drug use with

22
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.
Dosages can be increased when discomfort is most severe and reduced
or eliminated during remission. Patients are often encouraged to
make these adjustments themselves.
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) is different from a patient receiving periodic doses
of medication to improve functioning or living in recurrent situ¬
ations (e.g., meeting deadlines, coping with emergencies, or, especially
in the case of women, dealing with the effects of unresolved anger)
(Cline-Naffziger, 1 974). Both of these cases are quite different
from the patient who uses medication to offset anxiety or discomfort
(e.g., fear of the dentist, fear of confronting other people). It
seems important to make the distinction that where medication might,
in fact, be all that is necessary in the first case, the others might
yield greater benefit from therapy aimed at bettering their coping
skills.
A large proportion of psychotropic drug prescriptions are written
by family practitioners. Even though psychiatrists and neurologists
generally prescribe at higher dosages when they employ these agents,
greater numbers of prescriptions are actually written by family
physicians (Hesbacher, Rickels, Rial, Segal & Zamostien, 1976). This

23
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 physicians, they account
for 38% of all patient visits (Balter, 1973).
The family physician and other primary-care physicians have an
involvement with emotional problems that is markedly different from
the psychiatrist's experience, which frequently involves the manage¬
ment of severe psychiatric disorders in a hospital or crisis inter¬
vention setting. Primary-care physicians see a wide range of less
severe and often situational emotional problems in their everyday
practice, including anxiety reactions, psychosomatic disorders,
grief reactions, school problems, sexual and marital problems, etc.
Patients with these types of problems are frequently troubled in a
more general and nonspecific way. Unfortunately, the pressure is
on the doctor to produce a quick cure. Faced with a busy schedule
it is often just easier to write out a prescription for a tranquilizer
than to listen to the patient's problems (Watts, 1976; Muller, 1972).
The potential negative aspects of such a system of dealing with
anxiety are numerous. The presence of side effects (Muller, 1972;
Greenblatt & Shader, 1974) such as drowsiness, could reduce the
patient's overall level of functioning. Moreover, treating the
symptom without helping the patient identify and learn to cope with
the anxiety-provoking stimuli does little to promote effective behavior
change.
Job, marriage, and financial problems are areas patients frequently
cite as common sources of anxiety (Williams, 1977). Cooperstock

(1976) interprets a physician's involvement in these problem areas
as an expansion of the bounds 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 is hardly surprising that psychotropic drug consumption has
increased so much during the past decade" (Cooperstock, 1976, p. 761)
The medical model has expanded to encompass more aspects of our lives
Critics of this change claim that physicians are trying to treat
"social pathologies rather than medical 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. 59).
Psychological Approaches
Self-help approaches. Reflecting our country's long-standing
emphasis on individualism, current self-help books emphasize what
might be called psychological success (Schur, 1977). Lewin (1977)
maintains that though these self-help methods differ in catch phrases
or styles they seem to share certain values. (1) The most important
objective in life is the happiness and fulfillment of the individual
who is 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 is considered an inappropriate response
which the person must work to dispel. (4) Selfless involvement in
social causes is considered bad unless it enhances one's personal
fulfillment. These values seem very oversimplified. They hold

25
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 practices, etc., these methodologies
frequently set up standards that individuals will never be able to
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 it.
Traditional approaches. There is disagreement among therapists
about which 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, that part of the psyche that handles
transactions with the external environment) receives threats from
the environment, the id (the unconscious and most primitive part of
the psyche comprising drives, needs and instinctual impulses), or
the superego (the partially unconscious part of the psyche which
incorporates parental and social standards of morality). The function

26
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 analyst would most likely involve helping the client develop
insight by conjuring up painful past experiences. The therapist
is 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 his unconscious (Psychology
Today: An Introduction,1972; Stefflre, 1965).
Rational-emotive therapy operates on the assumption that emotions
are largely controlled by cognitive, ideational processes. It holds
that an individual's emotions and motivations represent learned re¬
actions. These can potentially be reviewed, modified and recon¬
structed by the individual. The rational-emotive therapist would
likely view anxiety as a result of irrational thoughts clients
were telling themselves were true. 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 is a
function of an individual's perceptions at the moment. People
perceive what is appropriate for persons with their self-concepts
to perceive. Anxiety is generated when the person's perception
of himself, his self-concept, is incongruent with his actual

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's own self-exploration by reflecting and clarifying his
self-referent feelings and statements (Blocher, 1966; Stefflre, 1965)
The theories described above are representative of traditional
psychological approaches to anxiety. They reflect the fact that
the psychological treatment of anxiety has historically involved
extended and intensive psychotherapeutic relationships. Such
methods are often 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¬
cability to women. Most significant seems to be the criticism that
psychotherapy encourages women to talk rather than act. This talking
tends to diffuse emotion and fails to involve the women in any
reality-based confrontations with the self (Chesler, 1971; Seiden,
1976). Chesler (1971) also has suggested that for women the

28
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 Approaches. Some recently developed counseling
methods have potential applicability to the treatment of anxiety.
These are generally less expensive, threatening and time-consuming,
and in many cases more well-known than traditional therapeutic
approaches. Some of these, such as 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, not
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
is a learned or acquired emotional reaction to originally neutral
stimuli which were presented a number of times together with a noxious
or painful stimulus" (Stefflre, 1965, p. 147). Behavioral therapists
who advocate a direct approach to the elimination of anxiety generally
manipulate the client's environment directly, either in the therapist's
office or in the outside world, to produce anxiety reduction. A
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 skills. The therapeutic objec¬
tive is to provide clients with direct training in precisely those
skills lacking in their response repertoires. Very little attention
is given to eliminating existing maladaptive behaviors, instead, it
is assumed that as skillful, adaptive responses are acquired, re¬
hearsed and reinforced, the previous maladaptive responses will be
displaced and will disappear" (McFall & Twentyman, 1973, p. 199).
A therapeutic procedure which exemplifies this indirect behavioral
approach to anxiety is assertive training. Assertive training
considers the 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 straighforward expressing of feelings. The main com¬
ponents of assertive behavior may be divided into four separate
and specific response patterns: the ability 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).

30
Assertive training is a therapy technique which is used with
individuals who are inhibited, shy and therefore unable to express
themselves in 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 is to increase the individual's
ability to express these feelings.
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, Salter & Reyna, 1965, p. 114).
People, according to Salter, are born "excitatory." As individuals
develop, many of their excitatory responses are paired with punish¬
ment and they become inhibited. Those inhibited response patterns
which are conditioned during childhood may remain in a person's adult
life. For Salter the goal in therapy is the "unlearning" of these
inhibited responses through the reconditioning of faulty inhibitory
patterns of earlier 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 those
clients seen as suffering from inhibition. "The happy person does
not waste time thinking. Self-control comes from no control at all.
The excitatory act, without thinking. The inhibitory think, without
acting, and delude themselves into believing that they are highly
civilized types" (Salter, 1949, p. 42).

31
Salter's therapeutic techniques are implemented to increase
excitation through verbalization. Pauses and silences are not valued
since excitation is 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 individuals differ with someone they should
freely express their true feelings and not pretend to agree. The
fourth technique requires the deliberate use of the word I_ as much
as possible. The fifth technique 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,
p. 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 it. "To change the way a person feels and thinks 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, p. 100).
Salter's state of excitation bears great similarity to the
modern concept of assertiveness. There are three basic differences
between them. 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 involves the questions "to what
degree?" and "in what situations?" (Mize, 1975, p. 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 have 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). His basic hypothesis is
that assertive responses or behaviors are incompatible with anxiety.
In other words, when individuals express themselves assertively,
anxiety is reduced and assertive responses are strenghtened.
Wolpe applies the term assertive "to any overt expression of
spontaneous and appropriate feelings other than anxiety. Assertive
behavior is used to overcome anxiety that is evoked in interpersonal
situations and that inhibits appropriate verbal responses together

33
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 contexts
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 like 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 things he cannot do because of fear, there may be others
he cannot stop doing. For example, he may compulsively reach for
the lunch check again and again to ward off a fear of incurring an
obiigation"(Wolpe, 1973, p. 81).
Whereas Salter describes nonassertion as a generalized trait,
Wolpe defines it as a conditioned response to a specific circumstance
or 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 range of interactions
and feels Salter's term "the inhibitory personality" is descriptively
appropriate to that group. In situations such as these he suggests
almost any social interaction might be suitable for assertive training.

34
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, since anxiety
inhibits 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
at least. "Each time the patient, by expressing his anger, inhibits
his anxiety, he weakens in some measure the anxiety habit" (Wolpe,
1973, p. 85). The role of the therapist is to increase the clients'
motivation to express themselves assertively. This, Wolpe suggests,
can be accomplished by means of various exhortations, including
pointing out to clients the emptiness of their fears and showing
them how their fearful modes of behavior have incapacitated them and
put them at the mercy of others (Wolpe, 1958, p. 115).
Wolpe advises that the therapist should encourage assertive
behavior on the part of the client only when "the anxiety evoked
by the other person concerned is maladaptive" (Wolpe, 1958, p. 118).
By this statement he means that the client feels 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
tactics (Wolpe, 1973, p. 90).

35
Wolpe utilizes a form of behavior rehearsal in his assertive
training. In an attempt to prepare the patient to deal with real
people in real relationships, the therapist and the patient act out
short exchanges in settings from the patient's life. While patients
represent themselves, the therapist assumes the role of someone
towards whom the patient feels 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 assertive training process. One
is J. L. Moreno, the founder of psychodrama, a method of psychotherapy
that involves the use of role playing in order to achieve insight.
Assertion training draws from psychodrama its employment of staged
dramatizations of the real life attitudes and conflicts of those
participating clients. Psychodrama also strongly emphasizes sponta¬
neity and improvisation, both of which Salter stressed. As a role-
playing strategy, psychodrama is similar to one of Wolpe1s principal
assertive techniques, behavior rehearsal, as it is used in assertive
training. The goal in psychodrama is for the clients to achieve in¬
sight through the acting out of existing relationships, whereas the
goal of behavior rehearsal in assertive training is to enhance and
expand the client's repertoire of assertive behaviors (Mize, 1975,
p. 50).
A second theorist whose contributions are indirectly related to
current assertive training practices is G. Kelly who has devised what

36
he calls "fixed-role therapy" (Kelly, 1955). Fixed-role therapy
is based upon Kelly's "personal 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
the client's particular constructs as well as determining the con¬
structs the client must have in order to resolve problems. The
therapy involves deriving a personality sketch of a fictitious
individual who is free of the anxieties and behavioral inadequacies
which plague the client. The client is then asked to assume the
role of the hypothetical person who possesses the desirable
constructs. This includes behaving in a manner consistent with the
role as well 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 techniques used in assertive
training. Even though training is not specifically aimed at modi¬
fying a client's cognitions, Rimm and Masters (1974) report that
case histories suggest that individuals 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 therapeutic setting the assertive training procedure is
traditionally one of therapist modeling with role-playing inter¬
change between the client and therapist. This essentially encompasses

37
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) considers behavior rehearsal to be the primary
methodology of assertive training. In 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 in 86% of the cases in which it was used,
whereas the other approaches were only 44% and 32% effective,
respectively (Lazarus, 1966). For those clients who are very non-
assertive, Lazarus advocates the use of behavioral rehearsal in a
hierarchical manner similar to that used in systematic 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 Marston (1970) cited the lack of systematic research
on behavior rehearsal and pointed out several factors which needed to
be reckoned with in studying the effectiveness of behavior rehearsal

38
therapy in assertive training. First, the behavior rehearsal treat¬
ment procedure had never been standardized. Second, the behavior
rehearsal technique was typically applied to poorly defined and un¬
specified behavior classes. Third, there were no satisfactory, reli¬
able, objective laboratory and/or real life measures available to
assess the behaviors typically treated with behavior rehearsal.
What followed was a series of experiments aimed at the evaluation
and development of behavior rehearsal therapy.
In the first study of this series McFall and Marston (1970)
developed a standardized, semiautomated behavior rehearsal treat¬
ment procedure and used it in examining two experimental questions:
(1) is simple rehearsal, alone, sufficient to produce significant and
desired changes in the problem behavior and (2) what is the therapeutic
importance of response feedback -- specifically, feedback via the
playback of tape recorded rehearsal responses? Results of behavioral,
self-report and psychophysiological laboratory measures, as well as
an unobtrusive in-vivo assertive test, revealed that individuals
receiving response practice improved significantly more than those
in placebotherapy and untreated controls, and that response feedback
tended to augment these effects although not to a significant degree.
In a subsequent study McFall and Lillesand (1971) added two new
treatment components, symbolic modeling and therapist coaching, to
the rehearsal with feedback procedure. They focused on the more
limited and homogeneous response class of refusal behavior. Results
on a behavioral measure, a self-report measure and an in-vivo follow¬
up measure supported the conclusion that both symbolic modeling and

39
therapist coaching made significant contributions to the assertive
training procedure.
The rehearsal-modeling group was divided into two parts. One-
half of the individuals engaged in overt response rehearsal while the
rest engaged in covert rehearsal. Overt response rehearsal occurs
externally and allows the therapist to monitor the subject's responses
during training. 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 (McFall 8 Lillesand, 1971). The
results of this study indicated that covert rehearsal is at least
as effective in refusal training as overt rehearsal, if not more so.
McFall and Twentyman (1973) further assessed the contributions
of rehearsal, modeling and coaching to an experimental assertion¬
training program in four experiments. The training components of
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 regardless of the particular
type of models employed (tactful versus abrupt) or the means of
presentation (audiovisual 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).
Positive treatment effects generalized from trained to untrained

situations, and in the final experiment there was some evidence that
the treatment effects generalized from laboratory to real-life
situations.
An even broader study of assertive behavior was that of Friedman
(1971) who investigated the effectiveness of modeling, role playing
and modeling plus role playing. One hundred five low-assertive male
and female college students (low assertive refers to the inability of
a person to engage in behavior which indicated he feels entitled to
exercise certain rights) were assigned to one of six treatment
conditions: modeling (students observed assertive models); directed
role playing (students enacted the role of assertive model, following
a script); improvised role playing (students were given the same
script as those in the directed role playing condition except that
their responses were deleted); modeling plus directed role playing;
assertive script (students simply read silently to themselves the
assertive script employed in the other treatment conditions) and
nonassertive script which was designed as a control group. The
primary behavioral measure involved taping the students' interactions
with a live confederate who became increasingly annoying to them.
The 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
for this experiment composed of short descriptions of ten behavioral
situations with five or six alternative reactions to each situation.

41
The overall effectiveness of these treatment procedures in
changing assertive behavior was substantial. The live-modeling
treatment elicited between 44% and 63% criterion (assertive) be¬
havior at posttesting. The most promising result was that 69% to
81% of low assertive males and females in the modeling-plus-directed-
role-playing condition showed 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 elicited high levels of assertive behavior at
posttesting for 50% of males and females. 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 improvised role playing procedure. He
goes even further and says that the improvised role playing was as
effective as the directed role playing condition. Consequently,
explicit cues to guide training participants' behavior would not
seem to be necessary for those individuals who can construct their
own assertive responses during a role playing procedure.
Perhaps the most important practical implication of this study
is the importance of matching the treatment program to the needs of
the particular clients. For nonassertive persons who have no rep¬
ertoire of assertive responses, it would seem that a treatment

42
consisting of modeling plus directed role playing or behavior re¬
hearsal would be much better than modeling alone. In instances
where individuals have assertive responses in their repertoires
but fail to employ them frequently or appropriately, an improvised
role-playing technique might be appropriate. In this instance,
modeling would probably be extraneous.
Although the above studies contributed significantly to the
understanding of assertive training, they failed to specifically
enumerate those behaviors which are considered important in assert¬
iveness. 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 as a consequence of
assertive training. To examine this question Eisler, Miller and
Hersen (1973) videotaped psychiatric patients interacting in a
series of role-played situations with a live stimulus model. Inter¬
actions were then rated on nine behavioral components of assertiveness
which had been compiled by researchers. Several experienced clinicians
had listed specific behaviors that they felt might be related to
acting assertively in negative contexts. They identified nine be¬
haviors and five specific factors capable of differentiating indi¬
viduals high in assertiveness from those low in assertiveness.
There were two verbal indices: compliance content (whether or not
the person acquiesced to an unreasonable request) and content re¬
questing new behavior (from the model). And there were three non¬
verbal indices: loudness of speech, latency of response and affect
(emotional tone of voice).

43
In a later study Hersen, Eisler, Miller, Johnson and Pinkston
(1973) demonstrated that different assertive training procedures
differentially affected changes in these specific factors. For
instance, they found that in modifying a subject's loudness, giving
him verbal instructions about what he should do was more effective
than modeling alone, whereas in modifying his compliance content
modeling was a much more helpful training procedure. This study
also confirmed earlier findings by Eisler, 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 simply 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 Eisler, Hersen, Miller and Blanchard
(1975) examined the effects of social context on interpersonal
behavior in assertive situations. They explored the idea that
behaviors which are socially appropriate in one circumstance may
not be so in another. Male psychiatric inpatients role played

44
scenes with nonpatient males and females 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 his responses to less familiar persons.
At the same time the experimenters sought to identify some of the
behavioral components of positive assertion by using some situations
that typically elicit positive responses. Results demonstrated
significant differences between how patients responded in situations
requiring positive or negative assertions. The results also supported
a stimulus-specific theory of assertiveness (that is, an individual
who is able to be assertive in one interpersonal context may not be
in a different situation).
Rathus (1973) hypothesized that college women who observed video¬
taped models and practiced specific assertive responses would report
more assertive behavior and be rated more assertive by judges than
women in two control groups. The groups met for one hour sessions
once a week for seven weeks. The assertive training group viewed a
videotape each week in which assertive models were observed interacting
and discussing their assertive experiences. The models demonstrated
nine types of assertive responses: assertive talk, feeling talk,
greeting talj<, 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
20 assertive behaviors each week and kept a record of their

45
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) has investigated the problem of
developing assertive behavior with covert modeling from several
perspectives. In one of his initial studies (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). Control
subjects received delayed treatment. 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
separated and combined effects of multiple models and favorable model
consequences in developing assertive behavior. A major purpose of
this study was to also assess aspects of the subjects' imagery as

46
they imagined scenes in the treatment sessions. The participants
were assigned to one of three treatment groups: single model/rein¬
forcement (subjects imagined a person similar to themselves in age
and of the same sex and favorable consequences followed model per¬
formance); single model/no reinforcement; multiple models/reinforce-
inent (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 alloted time. Results
indicated that imagining multiple models 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
models performing assertively) and model reinforcement. The results
of this study were unclear. Covert modeling did lead to significant
increases in assertive behavior and imagining several models engaging
in assertive behavior with favorable consequences did enhance the
treatment effects. However, in general, the multiplicity of models
seemed to have its best effect on self-report measures while model
reinforcement affected the behavioral measures.

47
Kazdin's studies demonstrate that imagining a person modeling
assertion in different situations and imagining a favorable outcome
following the model's assertion are effective ways of instigating
assertive behavior. Nietzel, Martorano and Melnick (1977) claim
that given the typically fragile nature of early assertive attempts,
clients should also be trained to deal with the noncompliance or
negative consequences which some 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. The
reply training condition resulted in significantly greater changes
in behavioral assertion than the modeling alone.
When Young, Rimm and Kennedy (1973) assessed the value of ver¬
bally reinforcing female college students' 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 is a
skill that can be learned through the systematic application of a
variety of behavioral techniques. Winship and Kelley (1976) designed
a study to see if the acquisition of assertive behavior might be
facilitated by yet another strategy -- the use of a specific verbal
response model. The model focused upon specific verbal response

48
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's 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. The
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. Signif¬
icant 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¬
inforcement, 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
in several ways. First, students were taught to emit a series of
assertive responses rather than a single response. They learned a

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
imental subjects received eight training sessions consisting of video
tape modeling; behavior rehearsal; video, peer and trainer feedback;
bibliotherapy; homework assignments; trainer exhortation and peer
group support. The sessions were held twice a week for an hour and
a half in three 30-minute segments. During the first part of each
session 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 assertive interactions. They then divided
into dyads and practiced the modeling scenes. Group members who
were practicing received feedback from their peers and/or the trainer
The assertive group's performance on self-report and behavioral
indices 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.
These studies were the first to question the value of using
decreased response latency as a variable in assessing assertive
behavior. They failed to find significant differences in response

50
latency between the experimental and control groups as were present
in the findings of other investigators (Eisler, Hersen 8 Miller,
1973; McFall 8 Lillesand, 1971; McFall 8 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 8 Litz, 1974)
say that in their study it was necessary to train some individuals
to increase rather than decrease response latency. These persons
were taught not to blurt out ineffectual responses when confronted
by another individual but rather to concentrate on producing appro¬
priately assertive statements.
The contribution of videotaped feedback to assertive training
was not really assessed by this study. Individuals involved ranked
it as numbers 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 assertive¬
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 8 Karoly, 1975;
Melnick 8 Stocker, 1977). Gormally, Hill, Otis and Rainey (1975),
evaluating a microtraining approach for training situationally non-
assertive clients in assertive expression, found the use of video¬
tape feedback had little effect. Their results indicated that
training which includes specific behavioral feedback and rehearsal
is a more effective change producer than is insight-oriented counseling

dealing with why the person is not able to be more assertive. The
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). McFall and Marston
(1970), on the other hand, have shown that audio-tape feedback was
an important component in assertive training.
In contrast to earlier studies (McFall & Marston, 1970; McFall
& Lillesand, 1971; McFall & Twentyman, 1973) the Galassi, Kostka
and Galassi (1974) follow-up study strongly indicates the long¬
term effects of assertive training. There are two possible reasons
for the discrepancy in these results. 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 diaries 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

52
in the McFall studies might have been confounded by other variables
that make results difficult to interpret (Galassi, Kostka S Galassi,
1974).
Another issue relevant to treatment procedures in assertiveness
training is 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 & Galassi, 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" (1972, p. 162). He is
one of only a few authors who have published a clinical description
of such a group. Group treatment also has the advantage of being
efficient. 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 groups 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).

53
This review of the research literature indicates that assertive
training is an effective procedure for use with individuals who lack
the social and interpersonal skills to ensure successful functioning.
Assertive training is specifically directed toward teaching them more
effective ways of responding. The evidence also indicates that lack
of assertion is rarely a generalizable trait. Deficiencies are
generally limited to specific types of situations. 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 in assertiveness training
have been examined and some understanding of the elements necessary
for change has been reached. The assertive training procedure can
be conceptualized as an active process taking place between the
therapist and the patient or the leader and the participant. Their
relationship is similar to that between teacher and student: the
therapist instructs, models, coaches and reinforces appropriate verbal
and nonverbal responses; 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 clinical applications of assertion
training. The following case studies illustrate how assertive training

54
has been used either alone or with other treatment strategies for
various problems.
Walton (1961) reported a case in which assertive training was
used in treating violent somnambulistic behavior of a 35-year-old
male against his wife. The patient related his behavior to his poor
relationship with his mother, whom he found domineering and authori¬
tarian. The therapist hypothesized that during wakefulness the
patient's intense anxiety prevented his solving this problem. In
sleep his learned fear responses were reduced, hence his 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 dissipated by the time of follow-up two months later.
There was neither recurrence nor evidence of symptom substitution.
Cautela (1966) combined (1) reassurances, (2) relaxation, (3)
desensitization and (4) assertive training to treat three individuals
exhibiting pervasive, free-floating anxiety. He used desensiti¬
zation and reassurance to inhibit their anxiety and assertive training
and relaxation to help them realize they could control their own
behavior.
The first case was that of a 23-year-old single female school
teacher who was so fearful of other people that her job was in jeop¬
ardy. After 33 hours of behavior therapy she had almost a complete
remission of symptoms. The second case was that of a 25-year-old

55
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 whose 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: talking about sex, religion and being
married; criticism and teasing and any parental disapproval. After
32 sessions 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 his feelings 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. As 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 male patient who was hospitalized following a
suicide attempt. Here assertive training was used in combination
with three other behavior modification techniques. Assertive training
was initiated in order to increase appropriate social interaction
behaviors. The rationale was that this type of behavior would be
incompatible with the depressive, self-defeating behavior exhibited

56
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 is essentially
a psychosomatic condition, and as such, involves the functioning of
both somatic and psychological systems, treatment methods must be
multidimensional including both behavioral and psychodynamic insight
techniques.
This woman's case history data revealed several areas of possible
psychodynamic conflict with specific people such as her husband and
her mother and behavioral analysis indicated that she 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, Eisler and Pinkston (1975) reported the case of a 56-year-
old male 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. A six month follow-up showed that changes in behavior had
been maintained and had generalized to the natural environment.
Eisler, Hersen and Miller (1974) reported the modification of periodic
rages in a 28-year-old man who had difficulty expressing anger in
interpersonal situations.

57
The main emphasis in these cases has been on the interpersonal
consequences of a lack of appropriate assertive behavior or on the
somatic symptoms that have been considered side effects associated
with unexpressed impulses. Rimm (1967) examined another response
which sometimes occurs in response to the inhibition of anger-crying.
The case he worked with involved a 38-year-old man who cried exces¬
sively in response to situations which made him angry. Rimm made
the point that excessive 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 in the face of anger-
inducing stimuli, a shock escape technique was employed, an unusual
procedure in the assertive 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
in the area of assertive training to treatment procedures which will
enhance subjects' assertive skills reflects this focus.

58
Changing an individual's behavior, however, would seem to be of
little consequence if the person still feels anxious, unhappy, upset
and/or worthless. It seems necessary to also assess the cognitive
and attitudinal changes which accompany changes in the individual's
behavior (Percell et al., 1974). The following studies attend to
this need and can be divided into two categories: those which corre¬
late assertiveness with other variables and those which have a
training component to show whether becoming more assertive can, in
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 feels inadequate and
inferior, has a marked tendency to be oversolicitous of emotional
support from others and exhibits excessive interpersonal anxiety
(Galassi, De Lo, Galassi & Bastien, 1974). It would seem, then,
that there is an association between assertiveness and such variables
as locus of control, self-confidence, self-concept, personal adjust¬
ment and anxiety. There is some research available which supports
this 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 is perceived by individuals as contingent on their
own behavior, Rotter (1966) terms this a belief in internal control.
When individuals see events as independent of their own actions,
as a result of luck or chance, then he terms it a belief in exter¬
nal control.

59
Bates and Zimmerman (1971) have directly investigated the
relationship between assertiveness and locus of control. Signifi¬
cant results were obtained from individuals taking the Rotter I-E
Scale, 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 demands
than their more assertive peers. Appelbaum, Turna and Johnson (1975)
substantiated that internals are significantly more assertive than
externals. Rimm et al. (1974) tested a small group of subjects
participating in assertion training to modify antisocial aggression
to see 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's (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
subjects scoring high on their Adult Self-Expression Scale (ASES)

60
described themselves a$ more self-confident than low scorers. Cor¬
relational data for the ASES with the Adjective Check List need scales
indicated that high scorers are more achievement oriented, more likely
to seek leadership roles 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 Scale 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 noncounselees and students who sought only vocational-educational
counseling. Gay et al. (1975) reinforced this when their study of
an assertiveness inventory for adults revealed that individuals seeking
personal adjustment counseling scored significantly lower on the
Adult Self-Expression Scale (ASES) than adults in general. Bates and
Zimmerman (1971) related scores on their Constriction Scale to scores

61
on the Adjective Check List Counseling Readiness Scale (these scores
are thought to reflect self-dissatisfaction). The data suggested
that constricted males are less 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 is anxiety. Behavior therapists
have long speculated about the relationship between social fears or
social anxieties and lack of assertive behavior. The association
between them has been supported by a number of investigations.
Morgan (1974) administered the Wolpe-Lang Fear Survey Schedule
and the Rathus Assertivenss Schedule to psychology students and found
a small but statistically significant relationship between assertive¬
ness and social fear.
. Bates and Zimmerman (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
a significant correlation between scores on the two scales which
affirmed their hypothesis that anxiety is positively correlated with
being nonassertive.
Galassi, De Lo, Galassi and Bastien (1974) found that college
students scoring low on a measure of assertiveness selected adjectives
on a checklist that indicated excessive interpersonal anxiety.
Students who scored high, on the other hand, were confident.

62
Gay et al. (1975), using 464 subjects ranging in age from 18 to
60 years, administered the Adult Self-Expression Scale and the Taylor's
Manifest Anxiety Scale as one of the validation studies for ASES.
They found that the measure of anxiety clearly differentiated low
from high assertives as identified by the ASES.
Percell et al. (1974) hypothesized that there would be signi¬
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 assertive 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) reported that male student
volunteers reporting a history of expressing anger in an inappropriate
or antisocial manner reported significantly greater decreases in feelings
of "uptightness" after receiving eight hours of assertive training
than did controls.

63
Percell et al. (1974) tested the hypothesis that outpatient
psychiatric 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 results of
the study supported the hypothesis that anxiety would decrease as
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
literature deals with the relationship between assertiveness and

64
aggressiveness. Galassi, De Lo, Galassi and Eastien (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 (as
*
opposed to temerity) in certain critical social situations (Rimm
et al., 1974), although not significant, did suggest that assertive
training may provide an effective means for dealing with anger which
could lead to antisocial aggression if left 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¬
zation, 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
themselves and to experiment with different role behaviors in new

65
situations. This emphasis has kindled a burgeoning interest in
assertiveness training for women.
Assertive training is considered a skill-building process as
much as a therapeutic procedure. Hartsook, Olch and de Wolf (1976)
have studied the personality characteristics of women who seek
assertiveness 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 assertiveness training procedure has been used successfully
to teach women assertive skills (Rathus, 1973) and has the potential
to help them become more effective and fulfilled. Much of the infor¬
mation we have about women and the effectiveness of assertive training
is ancillary to research conducted with males 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 improved in
anxiety and self-concept as a result of an assertive training program.
Except for the study by Percell et al. (1974) all the projects
involved treatment on an individual basis. Several theorists have
suggested that assertive training for women is most effective when

66
conducted in groups (Lange 8 Jakubowski, 1976; Osborn 8 Harris, 1975).
There is some research available which supports the idea that assertive¬
ness training is effectively carried out in groups with women (Rathus,
1973: Gambrill 8 Richey, 1975; Winship 8 Kelley, 1976; Pearlman 8
Mayo, 1977), but not that it is necessarily better than assertiveness
training conducted individually, nor that it is more effective with
all-women groups than mixed-sex groups.
Pearlman and Mayo's (1977) data from a follow-up survey indicated
that 65% of women participating in group assertiveness training felt
their assertive skills increased moderately or greatly in the six to
eighteen months after their training had finished. Hartsook et al.
(1976) asked for verbal appraisal of their training experience from
members of an all-female assertiveness group. Remarks suggested that
assertive behaviors had generalized beyond the situations practiced
in the group and that group members' interpersonal relations with
significant others had undergone radical changes for the better.
These findings suggest that women who have participated in assertive
training are able to expand their use of the skills 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
patients who evidence moderate to severe interpersonal behavioral

67
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 symptomatically. As 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).
The specific techniques contributing to the overall success of
assertive training have been examined. Although a full understanding
of all the elements producing change has 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. The
therapist instructs, models, 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 was to determine whether an
assertive training program using well-defined research procedures
can effectively reduce anxiety in a population of women who

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 skills precipitates
a state of anxiety which in turn manifests itself symptomatically.
Accordingly there is a need for methods to help women become more
effective interpersonally. Assertiveness training has been used
successfully to teach women assertive skills and has the potential
to help them become more interpersonally effective and fulfilled.
This study examined the effectiveness of assertive training in re¬
ducing anxiety in a group of women who experience symptomatic mani¬
festations of that anxiety.
Chapter III deals with the hypotheses, population, sampling
procedures, instrumentation, treatment proceduresand experimental
design used in this study. It also includes an explanation of how
the data were collected and analyzed.
Selection of Subjects
Physician Group
Although it is generally considered a psychological phenomenon,
many individuals first manifest anxiety in a somatic manner. The
somatic complaint, a headache or gastro-intestinal upset, or other
69

70
symptoms may, in fact, be the only distress the person feels. Thus,
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, internist,
pediatrician or gynecologist. 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 as patients, namely family practit¬
ioners, 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 Gainesville 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 82 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
women who, in the physician's estimation, were experiencing one or
more of the following symptoms as a consequence of anxiety: somatic
complaints such as headaches, gastro-intestinal distress, dizziness

71
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 loss of sexual interest
or pleasure, poor appetite, crying easily or worrying and stewing
about things; 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. This
letter explained the nature of this research project and asked the
physicians to refer fanale patients who met the criteria. The
researcher followed this letter with a phone call to each physician
asking if he would like more information about the project. An
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 as soreness of muscles,
headaches, gastro-intestinal distress, pain in the heart or chest;
trouble getting their breath and faintness or dizziness; indications
of interpersonal sensitivity such as feeling critical of others,
feeling easily annoyed or irritated, temper outbursts and feelings of

72
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 indications 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 as a consequence of anxiety.
No patient with evidence of organicity, psychosis, addictive disorder
or sociopathy was included. The physicians were asked to tell their
eligible 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). Attached to this
"patient's letter" was a postage-paid card (Appendix D) which provided
space for the women to either express an interest in the training and
list times they would be available, 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. The letter 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.
The women were asked to check the following responses on the card
before returning it:

73
Please call as I need more information.
Yes, I 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, 1:00 - 3:00 PM,
3:00 - 5:00 PM and 7:00 - 9:00 PM on Monday through Saturday. The
group sessions were held during those time periods 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 subject would be able to attend all seven
sessions. The names of interested women were held until a pool of
12 to 16 was attained. 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 was continued until
a subject pool of 82 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
E) 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 rating
scale which reflects the psychological symptom configurations commonly

74
observed among medical outpatients. Administration of all of the
instruments took approximately one hour. This occurred during the
hour immediately preceeding 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 Self-Expression Scale (ASES)
The Adult Self-Expression Scale (Gay, 1974) is a 48 item self-
report measure of assertiveness designed for general use with adults.
Its construction was based upon a two-dimensional model of assertive¬
ness. One dimension specified interpersonal situations in which
assertive behavior might occur, such as interactions with family,
the public, authority figures and friends. A second dimension
specified assertive behaviors that might occur in these interpersonal
situations. The behaviors included expressing personal opinions,
refusing unreasonable requests, taking the initiative in conversations
and in dealing with others, expressing positive feelings, standing up
for legitimate rights, expressing negative feelings and asking favors
of others. Both situation-specific and generalized components of
behavior were taken into account in the design.
A factor analysis procedure resulted in 14 factors that accounted
for 55.91% of the variance. Forty-five of the 48 items on the ASES
obtained factor loadings of .40 or greater. Four of the 14 factors
were defined in terms of the interpersonal situations in which asser¬
tiveness occurs (mentioned above). The remaining 10 factors were

75
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's dealings with others.
The ASES uses a five-point Likert format (0-4). Respondents
are asked to answer the questions by indicating how they generally
express thenselves in a variety of situations. They indicate either
"almost always" or "always" (0), "usually" (1), "sometimes" (2),
"seldom" (3), or "never" or "rarely" (4). The instructions tell the
respondents that if a particular situation does not apply to them
they should answer as they think they would respond in that situation.
They are told their answers should not reflect how they feel they
ought to act or how they would like to act but rather how they generally
do act. It takes about 15 minutes to complete the ASES.
A total score for the ASES can range from 0 to 192. There are
25 positively worded and 23 negatively worded items. The 23 negatively
worded items must be reverse scored prior to calculating the total
score. The mean ASES total score obtained from 640 adults ranging in
age from 18 to 60 was approximately 115 with a standard deviation of
approximately 20. This would mean that ASES scores falling above 135
are considered high scores while those falling below 95 could be con¬
sidered low scores.
Test-retest reliability for the ASES was established by adminis¬
tering the instrument to two samples of subjects. Both samples re¬
ceived the initial test administration at the same time. The ASES

76
was administered a second time to one sample at the end of a two-week
period, to the second sample at the end of a five-week period. A
Pearson-product moment correlation was computed establishing two
and five week reliability coefficients of .88 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 results (.79) indicated that the
ASES possesses moderate homogeneity. A Spearman Brown £ of .88 was
obtained for the full test (Gay, 1 974; Gay et a 1., 1 975).
Gay (1974) conducted several studies to establish validity data
for the ASES. Construct validity was established by correlating
the total scores of individuals 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 < .001 level with the Number of
Adjectives Checked and the Self-Confidence, Ability, Achievement,
Dominance, Affiliation, Heterosexuality, Exhibition, Autonomy,
Aggression and Change Scales 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 = 101.81) on
the ASES than did noncounseled subjects ()( = 114.20).
Discriminant validity was established for the ASES by examining
the relationship between assertiveness and anxiety (as measured by

77
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,
Kelmar & Frank, 1954) is a multidimensional symptom self-report
inventory. It is comprised of 58 items which are representative of
the symptom configurations commonly observed among medical outpatients.
It is scored on five underlying symptom dimensions: somatization,
obsessive-compulsive, interpersonal sensitivity, anxiety and depression
The basic symptom constructs underlying the HSCL have been deter¬
mined through clinical-rational clustering and factor analytic studies.
In clustering studies (Lipman, Covi, Rickels, Uhlenhuth & Lazar, 1968)
researchers asked highly experienced clinicians to assign the symptoms
of the HSCL to homogeneous clinical clusters based on their clinical
experience. Symptoms that were assigned with a high level of consis¬
tency were returned and provided HSCL cluster definitions. Results of
the two studies produced four configurally similar clusters labeled
anxiety, depression, anger-hostility and obsessive-compulsive phobic.
The HSCL clusters have been used often as criterion measures of im¬
provement, and have been shown to be highly sensitive to change in
numerous clinical traits (Lipman et al., 1968).

78
Williams and her associates (Williams, Lipman, Rickels, Covi,
Uhlenhuth & Mattsson, 1968) performed a factor analysis of self-ratings
of a large sample of 1,115 anxious neurotic patients. Lipman et
al. (1969) factor analyzed psychiatrists' HSCL ratings 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 is the question of factorial invariance or dimensional
constancy. This question has to do with the generalizabi1ity of
the dimensions developed from a specific sample to other samples.
Derogatis, Lipman, Covi and Rickels (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 subsample of 837 patients. The patients were assigned to one of
three social class groups in terms of Hollingshead Two-Factor Index
of Social Position. 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 psychiatrist-patient
contrasts while the average for the among-patient comparison was .87.
Psychiatrist-patient contrasts on the Obsessive-Compulsive factor
ranged from .81 to .92 with an average among-patient comparison of
.75. On the Anxiety dimension the average of the psychiatrists'

79
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-class patients
to .48 for the working class versus lower class contrast. The com¬
parisons of this factor with the psychiatrists' dimensions resulted
in almost equivalent coefficients. Analysis of the Irascibility factor
showed riv's of .64 and .67 between the upper-middle class and the
working-class groups, respectively, and the psychiatrist's ratings.
Derogatis, Lipman, Covi and Rickels (1972) factor-analyzed the
HSCLself-ratings of two patient samples - 641 anxious patients and
251 depressed neuortics. Five 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
class. They had similarity coefficients of .97 and .96, respectively.
The dimension of Interpersonal Sensitivity also reflected high agree¬
ment between the two samples (riv = 0.81). The Depression dimension
showed considerable invariance (riv = 0.53) yet at the same time
reflected overtones unique to each of the diagnostic classes. The
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
in the appropriate direction.

80
The symptoms that are fundamental to interpersonal sensitivity
focus on feelings of personal inadequacy and inferiority, particularly
in comparison with other individuals. Self-deprecation, feelings of
uneasiness and marked discomfort during interpersonal interactions
are characteristic of persons with high scores on this 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 28.
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 this 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 is comprised of 6 items.
Possible scores range from 6 to 24.
Fourteen items from the scale are not included in any dimension.
This study will be concerned with the dimensions of somatization,
interpersonal sensitivity, depression and anxiety as well as a total
score or index of symptom distress.

81
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:
1 = "not-at-al1," 2 = "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. Possible 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, impulses and
actions that are experienced by the individual as irresistable and
unremitting. They are,at the same time,of an ego-alien or unwanted
nature. Behaviors indicative of a more general cognitive difficulty
(e.g. mind going blank, trouble remembering) also load on this
dimension. Eight items comprise this dimension. Possible scores
range from 8 to 32.

82
The HSCL has a flexible time context which means that different
temporal limits may be used. Under standard conditions, however, the
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 disorders with primary symptom manifestations of anxiety
and depression. A third normative sample is composed of individuals
who were administered the HSCL as part of a more extensive health sur¬
vey. This group represents a complete random sample and contains a
high proportion of normals.
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 high. Alpha coefficients
based on an N of 1435 range from .84 to .87. Item-total correlations
were also calculated for the items which contributed substantially
to each dimension. All of these coefficients were above .50, and
most were at about .70. Test-retest coefficients are also available.
Based on a sample of 425 anxious neurotic outpatients, they ranged
from .75 for anxiety to .84 for the obsessive-compulsive dimension.
The patients involved were all participants in a psychotropic drug
trial with antianxiety agents. The test-retest evaluations were per¬
formed one week apart, prior to the initiation of treatment with
medication.
An indication of the construct validity of the HSCL has been
provided by Rickels, Lipman, Garcia and Fisher (1972). This study
showed that the rank ordering of patient groups according to their

83
distress levels on the HSCL was identical to the rank ordering suggested
by clinical practitioners and independent external criteria. The
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, Garcia and Fisher (1972) contrasted HSCL distress
levels observed at initial visit in two groups of gynecological normal
patients (N=135). Gynecological patients were classed by their treat¬
ment physicians as either emotionally labile, i.e., mildly tense or
anxious, or nonlabile. Neurotic patients were categorized as unimproved,
mildly improved or markedly improved. Results of this study were highly
consistent. They showed that the rank ordering of the groups on all
five HSCL dimensions proceeded from gynecological nonlabile at the
lowest distress levels 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 scales for measuring two distinct anxiety concepts: state
anxiety (A-State) and trait anxiety (A-Trait). The theoretical bases
underlying the construction of the STAI, as outlined by Spielberger
(1966) are as follows: "State anxiety (A-State) is conceptualized
as a transitory emotional state or condition of the human organism
that is characterized by subjective, consciously perceived feelings
of tension and apprehension" (Spielberger, Gorsuch 5 Lushene, 1970,

84
p. 3). 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 is, to
differences between people in the tendency to respond to situation
perceived as threatening with elevations in A-State intensity"
(Spielberger et al., 1970, p. 3). 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 single test form. This study
will make use of both scales.
The range of possible scores for Form X of the STAI varies from
a minimum of 20 to a maximum of 80 on both the A-State and A-Trait
subscales. Subjects repond to each STAI item by rating themselves
on a four-point scale: (1) not-at-all; (2) somewhat; (3) moderately
so, (4) very much. The categories for the A-Trait Scale are: (1)
almost never; (2) sometimes; (3) often; and (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
reversed items and 13 which are scored directly.

85
The STAI was designed to be self-administering and may be given
either individually or in groups. Complete instructions for both
scales are printed on the test form. The 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 scales are available for large samples
of college freshmen, undergraduate college students and high school
students. Normative data are also reported for male psychiatric
patients, general medical and surgical patients and young prisoners.
The A-State Scale is considered "a sensitive indicator of the
level of transitory anxiety experienced by clients and patients in
counseling, psychotherapy, behavior therapy or on a psychiatric ward.
It may also be used to measure changes in A-State intensity which
occur in these situations. The essential qualities evaluated by the
A-State scale involve feelings of tension, nervousness, worry and
apprehension" (Spielberger et al., 1970, p. 3).
Validity of the A-State inventory depends upon the respondents
having a clear understanding of the "state" instructions which require
them to report how they feel "at this moment." The instructions may
be modified to evaluate the level of A-State intensity for any situation
or time interval that is of interest to the researcher, but the precise

86
period for which the subjects' A-State responses are desired must
always be clearly specified. Participants 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, you were
called upon to express your feelings honestly
and openly in a manner which took into account
the feelings of the other person. It is not
important whether or not you acted assertively,
only that the incident occurred. Answer these
questions as though you were in that situation.
Try to pick a situation which was difficult for
you.
The following incidents were given as examples
to those participants who needed further clari¬
fication.
(1) Suppose you were in a clothing store. A
sales clerk tries to sell you a garment
by using flattery. You can tell that
something doesn't look right on you, but
the clerk keeps insisting that you really
look good in it.
(2) A good friend asks to borrow a book. When
this person returns it, you find it has
writing all over the margins and coffee
stains on several pages. As she returns
that book, she then asks to borrow another
one.
(3) Your neighbor calls you to do some charity
work collecting money on your block. You
have done the same job for the last three
years and had not intended to do it again
this year.
Test-retest correlations for the A-State Inventory were relatively
low, as was expected for an instrument designed to be influenced by
situational factors. The scale does, however, show a high degree of
internal consistency as evidenced by alpha coefficients "computed by

87
formula K-R 20 as modified by Cronbach (1951) for the normative
samples. These reliability coefficients ... ranged from .83 to .92
for A-State" (Spielberger et al., 1970, p. 10).
The STAI manual (Spielberger et al., 1970) reports evidence
bearing on the construct validity of the A-State Scale. 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 just be¬
fore an important final examination. Mean scores for the two
testing conditions as well as critical ratios for the differences
between these means and point-biserial correlations are reported.
The mean score for A-State was considerably higher in the exam
condition than in the norm condition for both males and females.
Additional validity data for the A-State Scale was obtained in a
study in which the scale was administered to 197 undergraduate stu¬
dents under four conditions in a single testing session. The first
administration was at the beginning of the testing session (normal
condition); the second followed a 10-minute period of relaxation
training (relax condition). Then the students were asked to work
on an IQ test and were interrupted after 10 minutes to take the
scale a third time (exam condition). The last administration was im¬
mediately after the students viewed a stressful movie (movie condition).

88
The mean score for the A-State scale, as 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 amounts of A-State.
"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
individuals because they tend to react to a wide range of situations
as dangerous or threatening. High A-Trait persons are also more
likely to respond with increased A-State intensity in situations
that involve interpersonal relationships which pose some threat to
self-esteem" (Spielberger et al., 1970, p. 3).
Validity of the A-Trait Scale depends upon the respondents having
a clear understanding of the "trait" instructions which require them
to report how they "generally" feel. To preserve this validity the
A-Trait scale will be administered before the A-State scale. This
way the respondents will not be confused by the special set of
instructions they will use for the A-State scale.
Test-retest reliability data for the A-Trait inventory showed
relatively high correlations, ranging from .73 to .86. The scale
shows a high degree of internal consistency as evidenced by alpha
coefficients ranging from .86 to .92.
Correlations of the STAI with the IPAT Anxiety Scale, the Taylor
Manifest Anxiety Scale (TMAS) and the General Form of the Zuckerman
Affect Adjective Checklist (AACL) General Form resulted in evidence
of the concurrent validity of the STAI A-Trait scale. The correlations

89
between the STAI, the IPAT and the TMAS were moderately high for
college males and females and a population of general medical patients.
Those correlations ranged from .75 between the STAI and the IPAT for
college females to .80 between the STAI and the TMAS for college females.
The STAI was only moderately correlated with the AACL, General Form.
Hypotheses
This study focused on hypotheses related to the effectiveness
of assertion training. The following null hypotheses were tested.
1. There is no difference in women's level of assertion as
a result of participation in an assertion training group.
2. There is no difference in women's level of state anxiety
as a result of participation in an assertion training
group.
3. There is no difference in women's level of trait anxiety
as a result of participation in an assertion training
group.
4. There is no difference in the number and intensity of
symptoms expressed by women as a result of participation
in an assertion training group.
Treatment Procedures
Jakubowski-Spector (1973) has suggested that assertiveness
training for women is particularly effective when a group format
is employed. The treatment in this study used a group format.
Subjects in this study were assigned to either a treatment or a
control group. There were six treatment groups with six to eight
members in each group and 6 control groups with six to eight members
in each group.

90
The procedure in this study involved two one-hour group sessions
and five two-hour group sessions. The total treatment period was 12
hours. Sessions were held once a week for seven weeks. The one-hour
sessions were the first and last meetings.
Pretests were given to the groups during the hour preceeding the
first treatment session. Posttests were given at the end of the final
treatment session.
The researcher led all of the groups. She has an M.Ed. degree
and an Ed.S. degree in Counselor Education from the University of
Florida and has completed all coursework and experience requirements
for a doctoral degree. She is an experienced trainer who has been
leading assertiveness training groups for four years. A copy of her
vita is available in Appendix B.
The treatment method was a semi-structured assertiveness training
procedure which incorporated a number of techniques the researcher has
found successful in her previous assertiveness training experiences.
An explanation of the seven treatment sessions can be found in Appendix
G. The goals of the approach are those specified by Jakubowski-Spector
(1973): the identification of personal rights and emotional blocks,
the reduction of emotional blocks and the development of assertive
behaviors through practice. The approach made use of the following
techniques: group discussion focused on personal rights and emotional
blocks, information giving, behavior rehearsal, role play reversal,
modeling, coaching, feedback, reinforcement, analysis of nonverbal
behavior and behavior assignments.

91
Design
The design used for this study was the randomized pretest-
posttest control group design (Campbell and Stanley, 1963):
R 01 X 02
R 03 04
R = Randomization
X = The Assertiveness Training treatment
0] = Pretest of training group members on the State-Trait
Anxiety Inventory, the Assertiveness Inventory and the
Hopkins Symptom Checklist
02 = Posttest of training group members
= Pretest of control group members
04 = Posttest of control group members
The subject recruitment process described earlier continued until
a subject pool of 82 women was reached. The first 12 to 16 volunteers
were assigned to either a treatment or a control group on the basis
of times each subject indicated as convenient. These two groups of 6
to 8 each were then pretested. The members of the experimental group
were tested as a group by the experimenter immediately before the
first training session. The members of the control qroup were pre¬
tested within five days of the experimental group. An attempt to
convene control subjects as a group failed, so they were tested
on an individual basis. The experimental group received the treat¬
ment for seven weeks and was posttested immediately following the
seventh training session. The control group received no attention
during the seven-week period. They were posttested individually
within five days of the experimental group.

92
The second 12 to 16 volunteers were similarly randomly assigned
to either a treatment or a control group. The same testing procedure
and timing was followed for this group that was described for the
first group. The same occurred for the last groupings of volunteers.
After 82 volunteers were assigned the researcher wrote a follow¬
up letter to the physicians (Appendix I) thanking them for their
referrals and informing them of the cut-off date for referrals.
Analysis of the Data
This study focused on five demographic variables: age, educational
level in terms of highest grade completed, number of children, race
and employment. The data collection yielded pre- and postscores on
the A-State and A-Trait Scales, on the Adult Self-Expression Scale
and on the Hopkins Symptom Checklist and its five symptom clusters:
somatization, obsessive-compulsivity, interpersonal sensitivity,
depression and anxiety. Each of the experimental subjects also
completed an evaluation of the training program.
The data collected for each subject were processed at the Univer¬
sity of Florida computer center. Chi square analyses were used to
evaluate the relationships between the treatment and the control
groups on each of the demographic variables. Analyses of covariance,
using pretest scores as covariates, were used to evaluate each of
the nine scale scores on each of the demographic variables. Means
and standard deviations also were computed for the evaluation forms.
In all comparisons, the 0.05 level of significance was established
for testing the null hypotheses.

CHAPTER 4
RESULTS
Included in this chapter are description of subjects, discussion
of attendance at the training sessions and analysis of the data.
Description of Subjects
All subjects completed a personal data form during the pretesting
period (Appendix E). Breakdowns of responses are presented in Tables
1 through 6. All of the women were white.
Table 1
Age of Subjects
Age
Total
Experimental Groups
Control Groups
19-24
6
2
4
25-29
12
5
7
30-34
13
10
3
35-39
15
7
8
40-44
9
4
5
45-49
10
5
5
50-54
13
7
6
55-59
2
0
2
60-64
2
1
1
Mean Age
38.96
38.71
39.12
93

94
The compositions of both experimental and control groups evidence
a representative cross section of age categories (Table 1). The
experimenter had asked for referrals of women between the ages of
18 and 65 because her experience had been that younger and older
women did not share enough commonalities to contribute to or benefit
from a group of mixed ages.
Table 2
Marital Status
Marital Status
Total
Experimental Groups
Control Groups
Married
60
30
30
Single
7
4
3
Divorced
10
5
5
Widowed
5
2
3
The composition of the experimental and control group was also
very balanced in terms of married, single, divorced or widowed members.
Both the groups were comprised predominantly of women who were married
at the time of the training.

95
Table 3
Years in Present Marriage
Number of Years Total
Experimental Groups
Control Groups
1-5
11
3
8
6-10
9
5
4
11-15
7
5
2
16-20
9
5
4
21-25
12
6
6
26-30
6
4
2
31-35
5
1
4
36-40
1
1
0
Mean Years
16.80
17.63
15.97
Married
subjects were
evenly distributed between
the treatment
and control
groups by how
long they had been in their
present marriages
(Table 3).
Both the groups had 18 members married 20
years or less
and 12 members married 20 years or more. One third more subjects
had been involved in marriages of 20 years or less duration than had
been involved in marriages of 20 years or more duration.
As can be observed in Table 4, the subjects were almost evenly
divided between the experimental and control groups according to how
many children they had.

96
Table 4
Subjects' Numbers of Children
Number of
Chi 1 dren
Total
Experimental Groups
Control Groups
0
15
7
8
1-2
45
23
22
3-4
19
10
9
5-6
2
0
2
7-8
1
1
0
Mean Number
of Chi 1 dren 1.93
2.02
1.83
Fifteen subjects had no children. These 15 women were almost
evenly divided between the experimental and control groups and made
up less than one-fifth of the total sample.
Almost two-thirds of the sample had completed more than a high
school education and one-half of those had completed a college degree
or higher. These data are presented in Table 5.

97
Table 5
Subjects' Highest Grade Completed
Grade
Total
Experimental Groups
Control Groups
9
1
0
1
11
2
1
1
12
21
10
11
13
8
4
4
14
14
8
6
15
5
4
1
16
14
8
6
17
4
2
2
18
10
2
8
19
0
0
0
20
2
1
1
Mean Grade
14.45
14.33
14.56
The average
i subject
had completed 14 1/2 years of
school (Table
5). It clearly
would be
improper to try to generalize
the results of
this experiment
to a population of women with less than
a high school
education.
The subjects' employment status is reflected in Table 6. Employed
and unemployed women were well distributed between the treatment and
control groups.

98
Table 6
Subjects' Employment Status
Employed Total
Experimental Groups
Control Groups
Yes 45
25
20
No 37
16
21
Chi square analyses
of the demographic data revealed
that the
treatment and the control
groups were independent on
each
of these
personal data variables (Table 7).
Table 7
Chi Square Analyses of Demographic Data
Variable
Degrees of Freedom
X2
Age
34
27.33
Marital Status
3
0.34
Years in Present Marriage
28
30.13
Number of Children
6
4.79
Highest Grade Completed
9
7.01
Employment
1
0.79

None of the chi square values were significant at the .05 level,
which indicates that the sample was balanced between experimental and
control groups.
Attendance
Eighty-two women were assigned to four treatment or four control
groups. The groups had six to eight members each. Specific group
compositions can be seen in Table.8.
Table 8
Number of Members in Each Group
Number of
Members
Group
1
Group
2
Group
3
Group
4
Group
5
Group
6
Total
Experimental
7
8
8
6
7
6
42
Control
7
8
8
6
7
5
41
Experimental group 6 had six members who participated in the
assertive training. Only five of these women were actually experi¬
mental subjects. The sixth member was a control subject from group
1 who took her posttests as the other members took their pretests.
She was added to experimental group 6 in an attempt to make it
equivalent in size to the other experimental groups. She was not
posttested as a member of experimental group 6.

100
The women were assigned to a group according to times they could
attend. One person who took the pretests and attended the first session
did not return thereafter; her data were therefore dropped from the
analyses.
Participants in the experimental groups were told that it was
very important for them to attend all of the training sessions. All
of the women in the experimental groups either attended all of the
sessions or attended a make-up session which was scheduled individually
at a time before the next scheduled session for that individual.
Twenty-five women attended all seven regularly scheduled sessions.
Eleven women attended all but one of the regularly scheduled sessions
and made up one session. Five women attended five of the regularly
scheduled sessions and made up two sessions.
Members of the control groups were pre- and posttested individ¬
ually. The researcher called each woman in the control group and
arranged to administer the pretests to her individually either in
her home or the experimenter1s. The pretests were administered to
the members of the control group within one week of the administration
of the pretests to the members of the experimental groups. At the
time the pretests were administered, the control subjects were told
that they would be called in seven weeks and asked to take the instru¬
ment again. After a seven week interlude the members of the control
group were called and told that they would receive the instruments
in the mail within two days. They were asked to follow the directions
printed on each instrument as they had done before. A self-addressed

101
stamped envelope was enclosed for the women to return the instruments
to the researcher. The women were instructed to complete the instru¬
ments and return them to the researcher within five days after they
received them. The members of the control group took the posttests
within five days of their respective experimental group members.
Analysis of the Data
An analysis of the data is presented for each hypothesis tested.
Hypothesis 1
There is no difference in women's level of assertion as a result
of participation in an assertion training qroup.
Table 9 depicts the results of the Analysis of Covariance on
the Adult Self-Expression Scale.
Table 9
Analysis of Covariance on
the Adult Self-Expression Scale
Source
SS
df
MS
F
Covariates
20454.56
1
20454.46
75.16
Main Effects
5352.84
1
5352.84
19.67*
Explained
25807.30
2
12903.65
47.42
Residual
21499.37
79
272.14
Total
47306.66
81
584.03
*£ < .05

102
The obtained F ratio of 19.67 was statistically significant at
the .05 level, indicating that there was a difference in women's
level of assertion as a result of participation in an assertion
training group. The adjusted means (Table 10) show that this dif¬
ference was in the direction of greater assertion as a result of the
training. The postmeans are adjusted to eliminate random differences
between the groups that existed before the treatment.
Table 10
Adjusted Mean Scores
for the Adult Self-Expression Scale
Group
Premean
Postmean
Adjusted Postmean
Experimental
98.71
120.44
124.41
Control
108.88
111.81
107.83
Hypothesis 2
There is no difference in women's level of state anxiety as a
result of participation in an assertion training group.
Participants in this study were instructed to answer these
questions in terms of how they felt when they were trying to be
assertive during the past week. They were to pick a situation they
considered challenging, not one they handled with ease.
Table 11 depicts the results of the Analysis of Covariance on
the A-State Scale.

103
Table 11
Analysis of Covariance
on the A-State Scale
Source
SS
df
MS
F
Covariates
2933.81
1
2933.81
40.75
Main Effects
1229.56
1
1229.57
17.08*
Explained
4163.37
2
2081.69
28.91
Residual
5687.77
79
72.00
Total
9851.14
81
121.62
*p < .05
The obtained F ratio of 17.08 was statistically significant at
the .05 level. This indicates that there was a significant difference
in the women's level of state anxiety (present during times they
were trying to be assertive) as a result of their participation in
an assertion training group. The adjusted means (Table 12) indicate
that this difference was in the direction of less state anxiety as
a result of the training.
Table 12
Adjusted Mean Scores for the A-State Scale
Group Premean Postmean Adjusted Postmean
Experimental 57.05 44.46 43.15
Control
51.78
49.73
51.05

104
Hypothesis 3
There is no difference in women's level of trait anxiety as a
result of participation in an assertion training group.
The instructions on the A-Trait Scale indicate that all respon¬
dents are to answer the questions according to how they generally
feel.
The results of the Analysis of Covariance on the A-Trait scale
can be inspected in Table 13.
Table 13
Analysis of Covariance on the A-Trait Scale
Source
SS
df
MS
F
Covariates
4239.94
1
4239.94
65.02
Main Effects
291.74
1
291.74
4.47*
Explained
4531.67
2
2265.84
34.75
Residual
5151.24
79
65.21
Total
9682.91
81
119.54
*J3 < .05
The obtained F ratio of 4.47 was statistically significant at
the .05 level. This indicates that there was a difference in women's
levels of trait anxiety as a result of participation in an assertion
training group. The adjusted means (Table 14) show that this

105
difference was in the direction of less trait anxiety as a result of
the training.
Table 14
Adjusted Mean Scores for the A-Trait Scale
Group
Premean
Postmean
Adjusted Postmean
Experimental
45.63
33.95
36.74
Control
39.56
38.46
40.68
Hypothesis 4
There is no difference in the number and intensity of symptoms
expressed by women as a result of participation in an assertion training
group.
To test this hypothesis this study used a total score on the
Hopkins Symptom Checklist as well as the scores for its five basic
underlying symptom clusters: somatization, obsessive-compulsivity,
interpersonal sensitivity, depression and anxiety. The results for
each of these measurements will be discussed individually.
HSCL Total Score: Table 15 depicts the results of the Analysis
of Covariance on the HSCL Total Scores.

106
Table 15
Analysis of Covariance on
the Hopkins Symptom Checklist Total Score
Source
SS
df
MS
F
Covariates
10721.12
1
1 0721.12
57.52
Main Effects
2403.53
1
2408.53
12.92*
Explained
13129.65
2
6564.82
35.22
Residual
14724.80
79
136.39
Total
27854.45
81
343.88
*£ < .05
The obtained F ratio of 12.92 was statistically significant at
the .05 level, indicating that there was a difference in women's
total symptom configurations as a result of participation in an
assertion training group. The adjusted means (Table 16) show that
this difference was in the direction of fewer and less intense symptoms
as a result of the training.
Table 16
Adjusted Mean Scores
for the Hopkins Symptom Checklist Total Score
Group
Premean
Postmean
Adjusted Postmean
Experimental
102.12
88.02
85.21
Control
93.59
93.51
96.33

107
HSCL-Somatization: The results of the Analysis of Covariance
on the Somatization dimension of the HSCL can be inspected in Table
17.
Table 17
Analysis of Covariance on the
Hopkins Symptom Checklist Somatization Dimension
Source
SS
df
MS
F
Covariates
845.57
1
845.57
77.92
Main Effects
128.17
1
128.17
11.81*
Explained
973.74
2
486.87
44.86
Residual
857.23
79
10.85
Total
1831.02
81
22.61
< .05
The obtained F ratio of 11.81 was statistically significant at
the .05 level indicating that there was a difference in the women's
amounts of somatization after participation in an assertion training
group. The adjusted means (Table 18) show that this difference was
in the direction of less somatization as a result of the training.

108
Table 18
Hopkins
Adjusted Mean Scores for the
Symptom Checklist Somatization
Dimension
Group
Premean
Postmean
Adjusted Postmean
Experimental
18.00
16.44
16.38
Control
17.85
18.83
18.88
HSCL-Obsessive-Conpulsi ve: Table 19 depicts the results of the
Analysis of Covariance on the Obsessive-Compulsive dimension of the
HSCL.
Table 19
Analysis of Covariance on the
Hopkins Symptom Checklist Obsessive-Compulsive Dimension
Source
SS
df
MS
F
Covariates
370.91
1
370.907
48.70
Main Effects
63.68
1
63.68
8.36*
Explained
434.59
2
217.29
28.53
Residual
601.71
79
7.62
•
Total
1036.30
81
12.79
< .05

109
The obtained F ratio of 8.36 was statistically significant at
the .05 level indicating that there was a difference in women's obses-
sive-compulsivity as a result of participation in an assertion training
experience. The adjusted means (Table 20) show that this difference
was in the direction of less obsessive-compulsivity as a result of
the training.
Table 20
Adjusted Mean Scores for the
Hopkins Symptom Checklist Obsessive-Compulsive Dimension
Group
Premean
Postmean
Adjusted Postmean
Experimental
15.00
12.83
12.56
Control
14.02
14.07
14.34
HSCL-Interpersonal Sensitivity:
Table 21
depicts the results
of the Analysis of Covariance on the Interpersonal-Sensitivity dimension
of the HSCL.

no
Table 21
Analysis of Covariance on the
Hopkins Symptom Checklist Interpersonal-Sensitivity Dimension
Source
SS
df
MS
F
Covariates
144.37
1
144.37
20.74
Main Effects
33.48
1
33.48
4.81*
Explained
177.85
2
88.93
12.77
Residual
550.05
79
6.96
Total
727.90
81
8.99
*£ < .05
The obtained F ratio of 4.81 was statistically significant at
the .05 level, indicating that there was a difference in the women's
interpersonal sensitivity as a result of participation in an assertion
training experience. The adjusted means (Table 22) show that this
change was in the direction of less interpersonal sensitivity as a
result of the training.
Table 22
Adjusted Mean Scores for the
Hopkins Symptom Checklist Interpersonal-Sensitivity Dimension
Group
Premean
Postmean
Adjusted Postmean
Experimental
13.73
11.34
10.92
Control
11.95
11 .83
12.26

in
HSCL-Anxiety: The results of the Analysis of Covariance on the
Anxiety dimension of the HSCL can be inspected in Table 23.
Table 23
Analysis of Covariance on the
Hopkins Symptom Checklist Anxiety Dimension
Source
SS
df
MS
F
Covariates
167.21
1
167.21
37.80
Main Effects
36.61
1
36.61
8.28*
Explained
203.82
2
101.91
23.04
Residual
349.46
79
4.42
Total
553.28
81
6.83
*£ < .05
The obtained
F ratio of 8.
.28 was
statistically
significant at
the .05 level, indicating that there was a difference in the women's
anxiety after the assertion training experience. The adjusted means
(Table 24) show that this change was in the direction of less anxiety
as a result of the training.

112
Table 24
Adjusted Mean Scores for the
Hopkins Symptom Checklist Anxiety Dimension
Group
Premean
Postmean
Adjusted Postmean
Experimental
12.24
10.34
9.93
Control
10.83
10.90
11.31
HSCL-Depression: The results
of the Analysis
of Covariance on
the HSCL dimension of Depression are depicted in Table 25.
Table
25
Hopkins
Analysis of Covariance on the
Symptom Checklist Depression Dimension
Source
SS
df MS
F
Covariates
700.27
1 700.27
47.56
Main Effects
47.15
1 47.15
3.20
Explained
747.42
2 373.71
25.38
Residual
1163.17
79 14.72
Total
1910.59
81 23.59
The obtained F value of 3.20 did not reach the .05 level of
significance. Therefore, we cannot say that there was a significant

113
difference in the symptom depression after training. The adjusted
means (Table 26) do indicate that what change did occur was in the
desired direction of less depression, however.
Table 26
Adjusted Mean Scores for the
Hopkins Symptom Checklist Depression Dimension
Group
Premean
Postmean
Adjusted Postmean
Experimental
20.66
17.71
16.99
Control
18.27
17.83
18.55
The F ratio for the subscale Depression was not statistically
significant at the .05 level. Therefore, on the basis of the analyses
there was no significant difference in the symptom Depression as a re¬
sult of participation in an assertion training group. However,
differences in the Somatization, Obsessive-Compulsive, Interpersonal-
Sensitivity and Anxiety subscales and on the Total Score were all
significant at the .05 level. This indicates that there was a dif¬
ference in the number and intensity of symptoms expressed by women
as a result of participation in an assertion training group. The
adjusted means show that this change was in the direction of fewer
and less intense symptoms.

114
Evaluation of Training
An Evaluation Form (Appendix F) containing six multiple-choice
items was administered as a posttest. Forty of the 41 women in the
experimental group completed the form. Respondents were instructed
to circle the appropriate letter of their choice (a. excellent, b.
very good, c. good, d. fair, e. poor). For scoring purposes a = 1,
b=2, c = 3, d = 4 and e = 5. Means and standard deviations for each
question may be found in Table 27.
Table 27
Means and Standard Deviations
for the Treatment Evaluation Form
Evaluation Questions
Mean
S.D.
I thought the training program was: a. excellent
b. very good, c. good, d. fair, e. poor
1.38
0.49
The ideas and materials presented by the leader
were: a. excellent, b. very good, c. good,
d. fair, e. poor
1.30
0.52
The way the material was presented was: a.
excellent, b. very good, c. good, d. fair,
e. poor
1.38
0.54
The behavior rehearsal experiences were a.
excellent, b. very good, c. good, d. fair,
e. poor
1.80
0.69
The help I received from the aroup leader was:
a. excellent, b. very good, c. good, d. fair,
e. poor
1.55
0.55
The help I received from other members of the
group was: a. excellent, b. very good, c.
good, d. fair, e. poor
2.05
0.82
Note: For scoring purposes a = 1, b = 2, c = 3, d = 4, e = 5.

115
Most of the comments about the assertive training experience were
very favorable. The means for the first five questions all placed
between excellent and very good. These questions were directed at
ascertaining the group members' responses to the training experiences
and to the leader. Question 4, which asked for an evaluation of the
behavior rehearsal experiences, had the highest mean of these first
five, which indicates a less favorable response to that question.
This could reflect the fact that not all participants seemed as
comfortable or willing as others to participate in the behavior
rehearsal exercises. Question 6 was directed at ascertaining the
group members' responses to one another. Their mean response,
though not as positive as for the other five questions, did fall
between very good and good.
A number of the group members added statements commenting on
the effectiveness of their group experience. These are cited in
Appendix J.
These self-report measures are of limited significance except
in giving subjective impressions of the effectiveness of the groups.
The basic purpose of the groups was to aid in establishing better
communications and to reduce women's anxieties and symptomatizations.
The fact that the women reported benefits from the group cannot be
ignored.

CHAPTER 5
SUMMARY, LIMITATIONS, DISCUSSION AND IMPLICATIONS
Summary
The purpose of this study was to investigate whether assertion
training, using well-defined and researched procedures, could effec¬
tively 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 symptomatically.
Specifically, the study investigated four main hypotheses:
1. There is no difference in women's level of assertion as a
result of participation in an assertion training group.
2. There is no difference in women's level of state anxiety
as a result of participation in an assertion training
group.
3. There is no difference in women's level of trait anxiety
as a result of participation in an assertion training group.
4. There is no difference in number and intensity of symptoms
expressed by women as a result of participation in an
assertion training group.
Eighty-two women were referred by their primary-care physicians
for the training. These women were assigned to one of six treatment
or six control groups. Members of the experimental groups were tested,
116

117
received assertion training and were posttested. Members of the
control groups were tested, waited seven weeks and were posttested.
All 82 women provided all the data requested. Data consisted
of scores on nine criterion variables: the Adult Self-Expression
Scale, the A-State Anxiety Scale, the A-Trait Anxiety Scale and
the Hopkins Symptom Checklist which yields a total score and a score
on five subscales (Somatization, Interpersonal-Sensitivity, Obsessive-
Compulsive, Anxiety and Depression). Pre- and postscores on all of
the instruments were totaled for all subjects. Subjects also completed
a Personal Data Form. Forty members of the experimental group filled
out a form evaluating the training after the training period.
Chi square analyses were used to evaluate the differences between
the treatment and the control groups on the demographic data. Group
assignment was shown to be independent of the personal data variables.
Analyses 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 items of the
evaluation forms. Most of the participants' comments were very favor¬
able.
Based upon these statistical findings, the assertive training
group was better than the control group in developing assertive be¬
havior, in lessening general and situation-specific anxiety and in

118
lessening the women's somatization, obsessive-compulsivity, inter¬
personal-sensitivity, anxiety and total symptom configurations.
Limitations
This study has the following limitations which suggest recommen¬
dations for future research.
1. A lack of true randomization in assignment of the women
to either treatment or control group somewhat limits the
generalizability of the results. However, the chi square
analyses of the demographic data did reveal that there
were no significant differences between the experimental
and control group on any of the demographic variables.
With this type of population it is very difficult to maintain
subject interest long enough to assure random assignment
to treatment or control group. Scheduling individuals in a
two-hour group once a week for seven weeks is especially
difficult when not dealing with individuals in an institu¬
tional setting.
2. The researcher administered and scored all of the inventories
herself. This could possibly introduce an element of experi¬
menter bias. The researcher is not aware of that having
occurred.
3. There was no in-vivo test of assertion used. Since a very
important part of becoming more assertive is developing a
belief in oneself and an assertive attitude, this instru¬
ment is effective. However, it might be of further value
to include an in-vivo test in future research.

119
4. To control for attitudinal lag or lapses which may occur
when training is suspended, future studies should consider
using a posttest measurement in a time span sequence.
Discussion
An assertion training experience appears to have a definite effect
on the assertion skills, anxiety and symptomization of a normal group
of white women referred by their physicians. The results of this study
indicate systematic effects among an assertion training experience and
the criterion measures selected for investigation.
The statistical findings in this study indicate that members of
the experimental group did significantly increase assertive behavior
after participation in an assertive training group. This is in line
with the results of earlier studies (Rathus, 1973; Kazdin, 1974, 1975,
1976). These results also confirm earlier findings that techniques
such as behavior rehearsal (McFall & Lillesand, 1971; McFall 8 Marston,
1970) and behavior assignments (Rathus, 1973) are effective tools in
training persons to become more assertive.
The main ASES total score obtained from 640 adults ranging in
age from 18 to 60 was approximately 115 with a standard deviation
of approximately 20 (Gay, 1974). This means that ASES scores falling
around 135 are considered high scores while those falling below 95
could be considered low. The 124.41 adjusted mean of the experimental
group puts the average of posttest scores of the experimental group
in the high assertive range.

120
Some of the literature reviewed in Chapter 2 revealed that
assertive training has helped persons become less anxious (Percell,
1974; Rathus, 1973; Rimm, Hill, Brown and Stuart, 1974). The signifi¬
cant results for the assertive training group on the A-Trait and
A-State scales add credence to those findings. It follows that if
women become less anxious in situations calling for them to be asser¬
tive they will be able to be assertive more often and consequently
become less anxious in general.
The assumption in this study was that if the assertion training
is effective in reducing the levels of state and trait anxiety in
women, the level and intensity of symptomization would also be re¬
duced. A number of conclusions can be drawn from the Hopkins Symptom
Checklist data. The HSCL is scored on the basis of five symptom
clusters: somatization, interpersonal-sensitivity, obsessive-compul-
sivity, depression and anxiety. This study also used a total score
for the Checklist which included answers for the five dimensions
plus 14 items from the scale which were not included in any dimension.
The experimental groups were significantly different from the control
groups in the direction of less symptomization on all dimensions,
except depression, and also on the total score.
The items which comprise the dimension somatization reflect
distress arising from perceptions of bodily dysfunction. Twelve items
contribute to the dimension including complaints such as headaches,
backaches and other somatic equivalents of anxiety. Possible scores
ranged from 12 to 48. The AN0C0VA indicated a significant change for

121
the better on this dimension. The adjusted mean of 16.38 for the
experimental group would indicate that on the average the women in
these groups were not severely distressed by these types of symptoms.
The focus of the obsessive-compulsive measure is on thoughts,
impulses and actions that are experienced by the individual as irre-
sistable and unremitting. They are at the same time of an unwanted
nature. Behaviors indicative of a more general cognitive difficulty
(e.g. mind going blank, trouble remembering) also are part of this
eight item dimension. Possible scores range from 8 to 32. Experi¬
mental subjects also differed significantly from control subjects
on this dimension. They became less likely to experience obsessive-
compulsive symptoms.
The interpersonal-sensitivity dimension is made up of seven items
which focus on feelings of personal inadequacy and inferiority,
particularly in comparison with other individuals. The ANOCOVA indi¬
cated a significant change for the better on this dimension which
should be an indicator that the women are experiencing less discom¬
fort during interpersonal interactions and fewer feelings of uneasi¬
ness and self-deprecation. Scores on this dimension range from 7 to
28. The adjusted mean of 12.26 for the experimental group indicates
that the women in these groups were not seriously bothered by feelings
of interpersonal sensitivity.
Women in the experimental group changed significantly on the HSCL
dimension of anxiety in the direction of less anxiety. This measure
includes general indicators of anxiety such as restlessness

122
and nervousness as well as some somatic signs, e.g. trembling. This
dimension is composed of six items, with possible scores from 6 to 24.
The adjusted mean of 11.31 for the experimental group suggests that
anxiety might have been more of a problem for the women than the other
symptom dimensions. However, it is still not high enough to suggest
a serious problem.
Eleven items make up the dimension of depression. They include
complaints such as withdrawal of interest in activities, lack of
motivation, lack of energy and feelings of hopelessness and futility.
Possible scores range from 11 to 44. There was no significant change
on this dimension. This could be attributable to the fact that two
experimental subjects reported experiencing a state of personal depres¬
sion at the time of posttesting. Their scores on the depression scale
at posttesting reflected this state.
Imp!ications
Several factors seem to be especially significant in discussing
why women are anxious. Stresses arising from potentially conflicting
social roles can create problems for women that lead to anxiety.
Women today are also caught between conforming to existing standards
or role definitions and exploring the promise of new alternatives.
Often, as women assess their individual potentials for self-growth,
they notice inadequacies in their abilities to fulfill their aspirations.
Anxiety often inhibits their trying out new roles and seeking new
relationships. Thus, many women are caught in the paradoxical situation

123
of experiencing anxiety within their existing situations or roles
(trait anxiety) and at the same time experiencing anxiety (state
anxiety) as they try out new behaviors which might alleviate those
anxieties.
Anxiety can be treated. As discussed in Chapter 1, since many
individuals first manifest anxiety symptomatically, they often approach
their physician for help. Medical treatment often takes the form of
drug therapy which can be expensive and in some cases debilitating.
Moreover, treating the symptom or somatic manifestation of the anxiety
does not help the patient identify and learn to cope with the anxiety-
provoking situation.
The psychological treatment of anxiety has traditionally involved
extended and intensive psychotherapeutic relationships. Such methods
can be expensive and time-consuming and are frequently not available
to the vast majority of people. Also, 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.
This study shows that assertion training is an effective treatment
for reducing women's anxiety. The training is based upon the principle
of increasing women's adaptive behaviors and helping them focus their
emotional energy on alleviating specific difficulties or problems.
Along with this lessening of anxiety, the assertion training also
precipitated a reduction in the level and intensity of the women's
symptomatic manifestations of that anxiety. Since this particular

124
technique does in fact significantly increase assertion and decrease
anxiety and symptomization, it can be stated that we have an effec¬
tive methodology that is (1) socially acceptable, (2) easily taught
and (3) relatively easy for participants to understand and learn.
Thus, an important implication of this study is that we have a method¬
ology which is a viable alternative to the use of either medical
intervention or extended psychotherapeutic relationships for the
treatment of anxiety and its consequent symptomization.
Along with this implication for practice are two other consid¬
erations. The first has to do with counselor training. Assertion
training has been shown to be a methodology which is helpful to a
group of women who represent a large segment of our population -
namely, those women who are afflicted with anxiety, who exhibit
symptoms of that anxiety and who report these symptoms to their
physicians. As such, it should be an important part of training
programs for counselors since it provides them with another technique
to use.
Secondly, these findings have an important implication for
future research. Assertion training has been shown to be effective
in reducing women's anxiety and symptomization. It remains to be
shown exactly why the training works. Future research might explore
what it is specifically that makes it effective, e.g. the particular
leadership style, attendance or specific activities.

APPENDICES

APPENDIX A
Doctor's Letter
February 2, 1978
Dear Doctor:
For my doctoral dissertation I am studying the effect of a psycho¬
logical treatment program on anxious women. I am interested in in¬
volving women who periodically experience stress induced symptoms
and who come to their physician for treatment. This program will be
offered only as an adjunct to the individual’s physician's prescribed
treatment plan. It is psychological in nature but primarily involves
the building of new interpersonal skills rather than indepth personal
exploration or therapy.
I am writing to request your assistance in referring patients to
my study. I am interested in women ranging in age from 20 to 65 who,
in your estimation, are experiencing one or more of the following
symptoms as a consequence of anxiety:
1. Somatic Complaints: e.g. headaches, gastro-intestinal
distress, muscle soreness, chest pain, faintness or
dizziness;
2. Interpersonal Hypersensitivity: e.g. feeling critical of
others, easily annoyed or irritated; experiencing temper
outbursts or feelings of inferiority;
3. Depression: e.g. loss of sexual interest or pleasure, poor
appetite, crying easily, feeling blue or worrying or stewing
about things; or
4. Anxiety: e.g. feeling fearful, nervous, shaky, tense or
keyed up or heart pounding or racing.
126

127
These women may be receiving psychotherapeutic drug therapy, but that
is not a necessary criterion for referral. Patients with evidence of
organicity, psychosis, addictive disorder or sociopathy will be ex¬
cluded.
The program will be offered free of charge. It will involve
seven weeks of group experience to take place during February, March
and April, 1978. I have had extensive experience in conducting groups
of this nature, and I will be doing all of the training. My vita is
enclosed. The research part of the study will involve the adminis¬
tration of three psychological inventories before and after the
training. I will be glad to report back to you about your patient's
progress at the end of the training.
I would appreciate your mentioning this opportunity to your
patients who meet these criteria. I have included several copies of
a letter to your patients with cards for them to return to me if
they are interested in the training. I will get in touch with you
soon to answer any questions you might have and to find out if you
need more letters. Dr. Wilmer Coggins, a faculty member in the
Department of Community Health and Family Medicine, is providing
medical sponsorship for this project. All patients will remain
under your direct management, but he has agreed to answer any
questions you might wish to address to a physician.
Thank you for your consideration.
Sincerely yours,
Trudy Gies Little, M.Ed.,
Ed.S.
1719-PHF MW 23 Avenue
Gainesville, FL 32605
Telephone: 378-5000 or
376-2672

APPENDIX B
PERSONAL
Home Address:
Telephone:
Date of Birth:
Place of Birth:
Marital Status:
Gertrude Gies Little
Personal and Professional Data
1719-PHF NW 23 Avenue, Gainesville, Florida 32605
(904) 378-5000
February 14, 1947
Erie, Pennsylvania
Married
PROFESSIONAL PREPARATION
Ph.D.
Counselor Education, University of Florida
(expected August, 1978)
Ed. S.
1971
Counselor Education, University of Florida
M. Ed.
1971
Counselor Education, University of Florida
B. A.
1968
Philosophy, St. Marys College, Notre Dame, Indiana
PROFESSIONAL EXPERIENCE
March 1974
to December 1977
Instructor, Assertiveness Training for Women,
Santa Fe Community College, Gainesville, Florida
September 1971
to March 1975
Instructor, Department of Behavioral Studies,
University of Florida
September
to August
1971
1974
Assistant to the Coordinator of Practicum and Intern¬
ship, Department of Counselor Education, University of
Florida
September 1969
to June 1971
Resident Advisor, University of Florida residence halls
Two years of supervised counseling experience in place¬
ments such as Lowell Prison, Santa Fe Community College
and the University of Florida Office for Student
Development
PROFESSIONAL AFFILIATIONS
American Personnel and Guidance Association
American College Personnel Association
128

APPENDIX C
Patient's Letter
Hello!
Your doctor has suggested that you might benefit from working
with me in a program I am currently conducting. I have asked him(her)
to give you this letter, so that I could tell you a little more about
the experience I am offering. This program is designed for women.
It is intended to help women become more effective in their inter¬
personal relationships. What it will involve for you is meeting in
a group with several other women and receiving some interpersonal
skills training. I have had extensive experience in conducting
groups of this nature, and I will be doing all of the training.
At the end of the program I will be glad to give both you and your
doctor feedback about your progress.
There will be no charge for the program. Each group will meet
for two hours once a week for seven weeks at a time which is con¬
venient for the members. Some women will begin the training in
February, others in April. You will also be asked to fill out
several questionnaires to help me evaluate the effectiveness of
the training.
If you decide to participate in the program you should plan
to attend all the sessions, since the training can be effective
only if you are there. The time periods are listed on the attached
card. Please indicate your first three preferences. I will make
every effort to accommodate you.
If you are interested, or if you would like more information,
just drop the card in the mail. I will be glad to answer any of
your questions. I look forv/ard to meeting you.
Sincerely yours,
Trudy Gies Little
1719-PHF MW 23 Avenue
Gainesville, FL 32605
Telephone: 376-2672 (an
answering service will take a
message and I will call you
back)
129

APPENDIX D
Postcard
NAME PHONE
ADDRESS
Please call as I need more information
Yes, I want to participate and have indicated at least
three (3) times I am available.
Please check three times you could attend
Times MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SAT
10:00-12:00
1:00-3:00
3:00-5:00
7:00-9:00
130

APPENDIX E
Personal Data Sheet
Name
Age Race
Marital Status
Number of Years in Present Marriage
Number of Children
Highest Grade Completed in School
Are you employed?
131

APPENDIX F
Evaluation Form
Name
The researcher would appreciate your taking time to fill out this
evaluation of the training program. Please circle the letter of the
proper answer.
1.
I thought the training program was:
a.
excellent b.
very good c.
good
d.
fair e.
poor
2.
The
ideas and material presented by the leader
were:
a.
excellent b.
very good c.
good
d.
fair e.
poor
3.
The
way the material
was presented
was:
a.
excellent b.
very good c.
good
d.
fair e.
poor
4.
The
behavior rehearsal experiences
were:
a.
excellent b.
very good c.
good
c.
fair e.
poor
5.
The help I received
from the group
leader
was:
a.
excellent b.
very good c.
good
c.
fair e.
poor
6.
The
help I received
from other members of
the group was:
a.
excellent b.
very good c.
good
c.
fair e.
poor
Please write any comments you wish to make about the experience below
(use back if necessary).
132

APPENDIX G
Treatment Procedures
First Session (one hour)
I.Introduction and welcome
A. Leader introduces self briefly
B. Group members introduce selves and share something about
their background
II.Short background and history of assertive training
III.Why assertive training for women
A. burgeoning interest in self-fulfillment and in self¬
actual ization
B. new options for women and flexible opportunities
C. women's movement - new permission to be strong and effective
IV.Brief explanation of assertive training procedure and goals
V.Establish certain ground rules
A. confidentiality - everything disclosed within the group
is not to be discussed outside of the group
B. explanation of the participants' responsibility to each
other - their need to help others and receive help from
others
133

134
C. passing - each person must feel free to refuse to partici¬
pate
D. discomfort - if a participant is unhappy with the way
things are going it is her responsibility to express this
to the group
VI. Go over dates and times of sessions and the importance of their
participation in each session
VII. Assignment: Participants are not to try to change their be¬
havior but rather to observe
A. How do you handle conflict
1. How do you get what you want without directly asking
(e.g. flirting, whinning)?
2. What message did your parents give you about handling
conflict (e.g. children should be seen and not heard)?
B. Try to identify during the week times their needs are not
being met
Second Session (two hours)
I. Comparison of nonassertive, assertive and aggressive behavior
(Alberti S Emmons, 1974).
A. Use of blackboard and member participation in discussing
1. characteristics of the behavior
2. your feelings during the behavior
3. other person's feelings about self at time
other person's feelings about you
4.

135
B. Define nonassertion, direct and indirect aggression,
assertion
C. Talk about projection
II. Discuss needs
A. Identification of needs
B. Expression of your needs to others
C. Last weeks' assignment - what they noticed
C. Nonassertive circle (engage in behavior to protect a
relationship; build up resentment and end up hurting the
relationship)
E. Hidden bargain (I've struck a bargain with you that you
don't know anything about)
III. Identify interpersonal rights and responsibilities
A. Discuss refusal rights and responsibilities
B. Have group brainstorm their own list of basic rights
(e.g. right to feel and express anger, right to have one's
needs be as important as the needs of other people)
C. Rights without guilt
D. Limitations and responsibilities
1. have refusal rights even if the other person badly
wants the request, is emotionally sick or an authority
figure - a limitation would be a prior commitment
2. have right to express needs even if the other person
doesn't want to hear them - a limitation would be the
responsibility not to use other people

136
3. role of compromise
IV. Assignment: Participants are encouraged not to try to change
their behavior but rather to observe times during the week that
they are assertive, nonassertive or aggressive. Notice
A. When does each happen, e.g. time of day
B. Does a particular behavior evidence itself most frequently
with a particular person, e.g. spouse, boss, children
C. Do certain situations provoke certain behaviors e.g. are
you assertive at home but never at work
D. Participants are asked to write down their observations
to refresh their memories at the next class
Third Session (two hours)
I.Discuss assignment from previous week
II.Discuss positive or soft assertions: giving and receiving
compliments
A. Rationale
1. expressing positive, caring feelings frequently more
difficult than "standing up" behaviors due to a fear
of embarassment or ridicule
2. people learning to express negative feelings should also
be able to express positive feelings
B. Explain how such behaviors also require assertiveness
C. Distinguishbetween healthy self-pride and egotism
III.Exercises for soft assertions
A. Group members describe or act out ways in which persons
respond to compliments that would make the giver unlikely
to offer another compliment

137
1. denying shyly (Oh gosh, who me?)
2. returning the focus at once (Oh, I like your blouse
a lot, too)
3. rejecting (This old rag, I've had it for years)
B. Group members act out negative ways of giving a compliment
1. self-deprecating (I'm not a very good mother but you're
so great)
2. sarcastic (Those pants really do fit well, don't they!)
3. crooked (Most people don't like you but I do)
C. Each person gives a compliment to the person on their right
and that person responds; they interact briefly; then the
receiver turns to compliment the person on her right. Then
each giver expresses to the receiver something she liked
about how the receiver responded to her compliment
IV. Discuss components of assertive behavior (Alberti & Emmons,
1974)
A.
eye contact
B.
body posture
C.
gestures
d.
facial expression
e.
voice tone, inflection,
volume
f.
timing
g-
content of what you are
saying

138
V. Assignment: participants are asked to
A. Give three compliments during the following week and assess
how comfortable and how direct they are
B. Observe how they react when the receive compliments and
assess how comfortable they are and how assertively they
respond
C. Make several positive self-statements
D. Note which components of assertive behavior they have
trouble with
E. Write down their observations to refresh their memories
at the next class
F. Start identifying situations in their everyday lives that
they might work on in class
Fourth Session (two hours)
I. Leader clarifies types of assertive responses
A. Simple assertion - uncomplex, simple statements
B. Empathic assertion - includes recognition of the other
person's state or situation
1. explain reflection
2. differentiates between reflection of feeling and
reflection of content
C. Assertions which include expression of your own feelings
in a situation (either positive or negative)

139
1. discuss the importance of identifying and owning your
own feelings
2. suggest as a model the formula I feel (feeling) when
(situation or behavior) because (effect on your life in
concrete way). I'd prefer (what behavior you would
prefer).
II.Distinguish between proactive and reactive assertion
III.Begin behavior rehearsal of situations the participants wish to
work on. Group members should be encouraged to become familiar
with the process involved
A. Clarify the situation
1. what is your goal for this assertive interaction
2. is your goal reasonable
B. Behavior rehearsal offers participants a chance to practice
assertion in a safe setting and lets group members learn by
watching each other
1. a group member plays herself, the leader plays other
person; the interaction is taped
2. the recording of the interaction is played back and
the group member involved receives feedback from the
leader and other group members
3. the client then plays the other person while the leader
plays the client and models good assertive responses;
the interaction is taped

140
4. the tape is played back, feedback is given and roles
are reversed again
5. the client plays herself and the leader plays the other;
the leader makes responses which make it increasingly
difficult for the client to handle
C. Stress the importance of positive feedback and support from
group members; feedback should be specific about verbal and
nonverbal behavior
IV. Assignment: Group members are encouraged to practice making the
three basic types of assertive responses. They are to keep
track of their eye contact, gestures, etc.
Fifth Session (two hours)
I.Discuss assignment from previous week. Allow an opportunity to
rehearse in class those situations which members found difficult
II.Discuss irrational beliefs which might inhibit assertion
A. Individuals frequently focus on only one outcome, e.g., the
worst possible one
B. Participants are encouraged to think of all possible outcomes
C. Brainstorm irrational beliefs
D. Discuss concept of escalation
III.Class does an exercise geared to helping participants recognize
and cope with negative responses often incurred while making
and/or refusing requests

141
A. Four class members form a line
B. The person at the top of the line goes through the line and
either makes a request of or refuses a request from each
person in the line
C. Individuals react by ignoring or by trying to make the
person going through the line feel guilty, or by getting
angry
IV. In refusing a request group members should be encouraged to
A. Assess whether the request is reasonable
B. Practice saying no without long winded statements of excuses,
justifications or rationalizations
C. Drop the use of disclaimers, e.g., "I'm sorry but"
D. Most importantly think over the decision before responding
1. do I really want to do it
2. if I decide to do it will it be rewarding now and later
V. Assignment: class is encouraged to find a partner outside of
class to rehearse new behaviors with. They are given the fol¬
lowing guidelines
A. Basic rules to follow
1. keep scenes simple and specific
2. use scenes from real life
3. give partner specific instructions about how to play
the role you want him/her to play

142
4. start with easy situations and work up to more difficult
ones
5. try to become aware of stimuli which causes you diffi¬
culty e.g.,a frown, tone of voice and add them to the
scene
B. Under content they are encouraged to look at the following
factors
1. did I face the real problem
2. does my solution resolve the problem
3. did I communicate what I wanted to communicate
4. did I avoid being compliant
5. did I clearly request a new behavior from the other
person
C. Under mode of expression
1. was my voice sufficiently loud and firm
2. did I talk too long and overexplain
3. did I talk long enough to make myself understood
4. did my voice, expression and gestures communicate
what I felt
Sixth Session (two hours)
I. Discussion of assignment from previous week. Allow an oppor¬
tunity to rehearse in class those situations which members
bring in.
II. Discuss potential adverse reactions to assertive behavior
(Alberti & Emmons, 1974); rehearse coping strategies

143
A. backbiting
B. aggression
C. temper tantrums
D. psychosomatic reactions
E. overapologizing
F. revenge
III. Assignment: same as for Session Five
Seventh Session (one hour)
I.Discussion of assignment from previous week. Short rehearsal
of problem situations
II.Discuss specific times women might choose to not assert them¬
selves (Alberti & Emmons, 1974).
1. redundancy
2. being understanding
3. when you are wrong
III.Discuss with the group members
1. what they will continue to work on
2. what methods will I use
3. contracting

APPENDIX H
Consent Form
You are being asked to participate in a research project that has
been designed to study the effectiveness of assertiveness training in
helping women feel better about themselves. Individuals generally find
that they benefit from the training.
All participants will be asked to fill out a personal data sheet and
three paper and pencil inventories before and after the treatment period.
There will also be a brief evaluation form to fill out after the training
program. Your name will be coded so your identity and responses will re¬
main anonymous. Only this experimenter will have access to the data; she
will destroy it after she has analyzed it for research purposes.
Your participation in this project is completely voluntary. You have
the right to withdraw at any time. You also have the right to ask questions
of the experimenter either now or at any time during the study.
I have read and I understand the procedure described above and I agree
to participate in the procedure. I have received a copy of this description.
Name
Date
Researcher's Name
Date
144

APPENDIX I
Second Doctor's Letter
April 14, 1978
Dear Doctor,
I am writing to thank all of you who have referred patients to
my study about women who receive assertiveness training. I also
wanted to tell you that I will be accepting referrals for this
project only until Friday, April 21.
At present there are 72 women involved in the program. I
anticipate that all of the training and the analysis of the data
will be completed by August 1. When I have the results I shall
send you a report of my findings.
Once again thank you very much for your attention.
Sincerely,
Trudy Gies Little
1719-PHF NW 23 Avenue
Gainesville, FL 32605
376-2672 (answering
service)
378-5000 (home)
145

APPENDIX J
Experimental Group Members' Comments
Group I
-I am very happy I participated. I have learned a tremendous
amount of valuable information not only about myself but about
others. I feel able to communicate more effectively, to listen
better and to feel good!
-I am very sorry the group is over. I feel like it has helped
reinforce the positive areas in my life which has made me able
to accept and work on the negative areas. I was having a hard
time even looking at the positive side much less work on the
negative areas. Thanks.
Group II
-During this difficult period of my life, this program was a
really terrific experience. If I haven't learned but one thing
it is that I have rights as a person. Thank you.
-I have recommended this class to friends and I hope they will
participate and gain as much as I have.
-Interaction of women in assertiveness training is beneficial
at all ages and in all walks of life. It is training which
should be continued and refreshed throughout a woman's life.
146

147
Group III
-Very enjoyable. Would like to do further work.
-Guess I expected problems would diminish. Found, even though
problems increased, ability to cope and "say my piece" also
increased.
-How simple it was to solve a problem I had had for almost a
year! Rehearsing on tape was very good. The next day, when I
talked to the person I work with, I could not believe how calm
my voice was and that I did not feel guilty for telling it like
it was.
Group IV
-There were a lot of concepts I have been developing (ways to
communicate effectively) that were reinforced by the class
sessions. I appreciated the opportunity to write down and think
and talk about various situations that I was confronted with.
There were times when I felt bored and exasperated when concepts
were not grasped by others. I felt uncomfortable expressing these
feelings directly at the times because I was not in a "group"
that was revealing feelings to each other - perhaps a different
group could have been more so. I also knew that someone else
may need to learn the concepts I felt so bored by. Anyway, on
the whole I know that I am now thinking a lot more about being
honest, open and direct as opposed to my easier more sarcastic
modes. I am also feeling more confidence within myself which is
a nice feeling. Thanks for your time and efforts.

148
-I feel it might have been better if it were at all possible -
to have grouped similar people together with as much similar
situation. It was hard or more difficult to relate to a group
mostly composed of middle-aged nonworking wifes and mothers when
I am a student divorced and going through experiences from the
viewpoint of a totally different lifestyle and attitudes. I
think maybe it would've been more fulfilling to be able to be
in a group of women that have or are in similar circumstances -
that way I think the group idea - of helping one another -
learning from each other's experiences, etc. can be maximized.
However, the group was very enjoyable and I learned a lot from
the other women's experiences as well. I learned a lot of
behavior patterns that were indicative of unassertive behavior -
behavior which I had rationalized about before. I do not mean
to put down the other ladies in the group at all - in fact I found
most of them to be very nice. Sometimes it just helps to feel
that other people are in similar situations and can feel the same
way e.g. dating, problems of being on your own, etc. which
these ladies don't have. It was however a very enjoyable class
and I admire your efforts.
Group V
-I feel I have learned to know who I am once again and where I'm
heading. This helps me cope with small problems as they come
and not let them become big and out of hand.

149
-I would like to see this taught in the elementary schools. I
feel it is important to a feeling of self-worth as well as harmony
among groups of people.
-I really enjoyed the class because now I feel like I can cope with
different situations assertively and not keep putting off people.
-I feel more at ease in my everyday situations because I am more
aware of my feelings and better able to express them to myself
and others.
-Though somewhat apprehensive the first two meetings, I have learned
to be a little more open in stating my needs. I am a happier
and more relaxed person now. You have helped me to be more
careful with my assertions, that is less aggressive.
-This has helped me think more of myself and to let others know
my true feelings.
Group VI
-Need more reinforcement to change habits. Do the wrong thing
before I think of what I should have done.
-I have enjoyed this class and feel that I have learned from
it.
-I have enjoyed this course very much. At times I felt we spent
too much time in discussing personal problems. We tended to
try solving others problems instead of dealing with assertive
behaviors. However, I realize that this all helped us to relate
to how assertiveness effects our own personal lives. I hope I
am able to consistently use the techniques I have learned.

150
-I found the training helpful to me especially in this period
of transition from marriage to single parent. The ideas and
material were presented in a practical manner so that I felt
comfortable in trying to apply them to my new home situation
in relationships of total responsibility for children. In
addition I began work after an interim as a homemaker. I was
more readily able to assimilate myself into a different working
environment. Thank you for your helpful suggestions, challenging
“homework" assignments and opportunities to practice assertions
in class. I am very grateful for your knowledge and your
time.

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BIOGRAPHICAL SKETCH
Gertrude Gies Little was born on February 14, 1947 in Erie,
Pennsylvania. She was raised in St. Marys, Pennsylvania. On June
12, 1975 she married George Walton Little, M.D. She now resides
in Gainesville, Florida.
Ms. Little was graduated from the Grier School in Tyrone,
Pennsylvania in May, 1964. In May, 1968 she received the Bachelor
of Arts degree in Philosophy from St. Marys College in Notre Dame,
Indiana. She began her graduate study in the Department of Counselor
Education at the University of Florida the following September. She
received her Master of Education and Specialist in Education degrees
in 1971.
During her graduate work Ms. Little served as a resident assis¬
tant in the University of Florida residence halls and as a graduate
assistant in both the Department of Counselor Education and the
Department of Behavioral Studies at the University of Florida. She
has taught Assertiveness Training from Women in the Community Edu¬
cation program at Sante Fe Community College for four years.
Ms. Little is a member of the American Personnel and Guidance
Association and the American College Personnel Association.
160

I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is fully
adequate, in scope and quality, as a dissertation for the degree of
Doctor of Philosophy.
Counselor Education
I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is fully
adequate, in scope and quality, as a dissertation for the degree of
Doctor of Philosophy.
David Lane
Professor Emeritus, Department of
Counselor Education
I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is fully
adequate, in scope and quality, as a dissertation for the degree of
Doctor of Philosophy.
This dissertation was submitted to the Graduate Faculty of the Department
of Counselor Education in the College of Education and to the Graduate
Council, and was accepted as partial fulfillment of the requirements for
the degree of Doctor of Philosophy.
August, 1978
Dean, Graduate School

UNIVERSITY OF FLORIDA