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Assertion therapy: Skill training or cognitive restructuring
BEHAVIORTHERAPY 10, 372--388 (1979)
Assertion Therapy: Skill Training or Cognitive Restructuring MARSHA M . L I N E H A N
University of Washington
MARVIN R. G O L D F R I E D AND A N I T A POWERS G O L D F R I E D State University of New York at Stony Brook Seventy-nine women participated in a program designed to compare assertion therapy based on a skill-deficit model with a procedure based on a response inhibition model. Participants were assigned randomly to one of five treatment groups: behavior rehearsal, systematic rational restructuring, behavior rehearsal/ rational restructunng, relationship, and waiting list controls and were also assigned to a male or female therapist. Treatment was carried out at two separate locations resulting in a 2 x 2 x 5 factorial design. Results indicate that the combined behavior rehearsal/rational restructuring therapy was superior; there were few differences among the four contact groups on self-report measures; on both a role-play test and a contrived situational test all three behavioral treatments were equally successful at facilitating women to make a response whereas treatments employing behavior rehearsal were more effective in improving the assertion quality of the response. At follow-up all treatment groups typically maintained or improved on their gains, but failed to differ from each other on a self-report battery. No effect for sex of therapist was obtained. Results were the same at both locations indicating generalizability of results across more than one research setting. The model underlying many studies on assertion training (e.g., McFall & T w e n t y m a n , 1973) is t h a t u n a s s e r t i v e i n d i v i d u a l s h a v e a skill d e f i c i t . T h e p r i m a r y g o a l o f t r a i n i n g , t h e r e f o r e , is t o t e a c h t h e c l i e n t t h e r e q u i s i t e skills. I n t e r v e n t i o n p r o c e d u r e s t y p i c a l l y i n c l u d e b e h a v i o r r e h e a r s a l , The research described in this article was supported in part by Grants MH 26313-01 and MH 24327 from the National Institute of Mental Health. The authors are grateful to: Roger Bartman, Suzanne Bronheim, Anne Byrnes, Karen Haynes, Michael Osarchuk, Jerry Paone, Marilyn Sperling, and Leslie Weinberg who were the therapists in the study, to Gerald C. Davison for his comments on an earlier version of this article, and to Cynthia Pollnow for her invaluable assistance during all phases of this study. Requests for reprints should be sent to: Marsha M. Linehan, Psychology Department (NI-15), University of Washington Seattle, WA 98195. 372 0005-7894/79/030372-17501.00/0 Copyright © 1979 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
ASSERTION~ SKILL OR C O G N I T I V E R E S T R U C T U R I N G
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coaching, modeling, and in vivo practice of overt assertive responses. An alternate model of unassertive behavior assumes that the person has the requisite skills but is inhibited from behaving assertively by conditioned anxiety in assertive situations (Wolpe, 1973; Salter, 1949). Attempts to reduce assertion anxiety directly using systematic desensitization have been somewhat effective in increasing assertive behavior, but not as effective as skills training (Thorpe, 1975; Trower, Yardley, Bryant, & Shaw, 1978). A third model, which is a variation of the anxiety inhibition model, suggests that assertive behavior may be inhibited but that this inhibition is mediated by a person's maladaptive cognitive-evaluative appraisals (Lange & Jackubowski, 1976; Linehan, 1979; Rich & Schroeder, 1976; Schwartz & Gottman, 1976). Thorpe (1975) compared a cognitive procedure with behavior rehearsal and found that the cognitive intervention, designed to reduce maladaptive appraisals, was as effective as skill training procedures in the treatment of unassertive behavior. Wolfe and Fodor (1977) compared a behavior rehearsal approach with a combined behavior rehearsal/cognitive restructuring treatment, finding that the addition of the cognitive component to a skills training package did not increase participants' assertive behavior although it did reduce subjective reports of anxiety while behaving assertively. A major drawback of this study, however, was that the treatment consisted of only two sessions. A problem with these and other studies comparing cognitive interventions with behavioral interventions has been a failure to control for the behavior rehearsal component in the cognitive therapy; while cognitive therapy might have been effective, it is often unclear whether the results were due to the behavior rehearsal component or to the interaction between behavior rehearsal and the cognitive therapy. Even when systematic desensitization has been used alone, there is the likelihood, as Kazdin (1974) suggests, that desensitization may be construed as selfmodeling or covert rehearsal and that the effect may be similar to behavioral rehearsal. A similar problem exists in determining the effective component in the skill training programs. Although the only observable cognitive components in most programs are skill oriented instructions and feedback, it is likely that the client is also learning a new set of cognitive-evaluative appraisals. However, since even the act of accepting a person into an assertion training program is communicating, and thereby perhaps also teaching, an appraisal of the value of assertive behavior, this aspect of the skill training program is potentially inherent in any treatment approach. The primary aim of this study was to compare a therapy designed to modify cognitive appraisals directly (Goldfried, Decenteco, & Weruberg, 1974), controlling for covert behavior rehearsal, with a program designed to teach overt assertion skills. Both treatments were also compared to a treatment combining skill training with cognitive restructuring. While all three behavior therapies utilized rehearsal, modeling, coaching, self-
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statements, and in vivo practice, the target differed----overt behavior, cognitive appraisals, or a combination of the two. A second aim of this research was to study whether therapist gender is an important variable in assertion therapy. To date, little evidence exists demonstrating a differential effectiveness of male or female therapists on treatment outcome (Parloff, Waskow, Wolfe, 1978). Sex of therapist is a particularly relevant issue in the case of the treatment of women clients; questions about the role of therapy in the possible perpetuation of sex-role stereotypes which may be harmful to women are being increasingly raised. METHOD Participants Seventy-nine women, mean age 43.2 years and mean education level 14.5 years, were selected according to the following criteria: (1) a score below zero on the Rathus Assertiveness Inventory (Rathus, 1973), and (2) a score of 3 or above on the Assertion Difficulty Inventory described below. The study was carried out at both The Catholic University of America and the State University of New York at Stony Brook, and a final aim of this research was to demonstrate the feasibility of conducting collaborative outcome research at more than one setting. Although the need for this type of research has generally been agreed upon, the difficulties in standardization have made such ventures relatively rare (Bergin & Strupp, 1970).
Assessment Participant questionnaires. The Rathus Assertiveness Inventory (Rathus, 1973), the Assertion Difficulty Inventory, the S-R Inventory of Anxiousness (Endler, Hunt, & Rosenstein, 1962), and the S-R Inventory of Hostility (Endler & Hunt, 1968) were administered at pretest, posttest, and follow-up measures to all participants. The situations used in the two S-R Inventories as well as the Assertion Difficulty Inventory are described below. Both before and immediately after the first session, participants rated their expectations for therapy success on a 5-point scale ranging from "zero chance of success" (1) to "100% chance of success" (5). Peer questionnaire. Each participant gave the name of a person who she believed knew her well and saw her often enough (generally, at least once a week) to complete a questionnaire at posttest evaluating her assertive behavior. Open-ended questions requested such information as whether changes were observed and the effect of such changes on their relationship. Behavioral role-play test. An extended interaction behavioral roleplaying test was administered at pre- and posttest. A trained male-female assessment team delivered role-play lines verbatim to participants from predetermined scripts. Following a response of the participant, the as-
A S S E R T I O N : S K I L L OR C O G N I T I V E R E S T R U C T U R I N G
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sessors delivered an additional predetermined prompt, and up to five prompts, depending on the point at which the participant gave in or stopped responding. The role-play interactions were tape recorded, and the sex of the assessor was varied across the six situations. The major dependent variables were: assertion content, speech dysfluencies, loudness/affect, eye gazing, number of responses per interaction, and subjective reports of anxiety, guilt, and anger obtained after each of the role-play situations. Assertion content was rated on a 5-point scale from transcriptions of the audio tapes. Speech dysfluencies were scored by counting the number of stammers, blockages, etc. (adapted from Mahl, 1959). The loudness/affect quality of the response was rated from audio tapes (1 = barely audible response to 5 = volume strong, affect does not detract from assertiveness). For these three measures, two separate scores were computed for each situation: a first response only score, and an average situation score. Duration of eye gazing was timed by the unoccupied assessor and a percentage score was obtained by dividing by the total time of the interaction. Number of responses was obtained by counting the number of prompts delivered by the experimenter. Following each role-play situation, participants estimated on a scale of 0 (low) to 100 (high) how much anxiety, guilt, and anger they had experienced during the role-play. A measure of base anxiety was also obtained prior to any of the role play situations, by asking participants to estimate their typical or average level of anxiety in their everyday life. Contrived situational test. While participants were trying to complete a questionnaire at posttest, a female confederate, following a predetermined script, set up six interactions that interfered with the participant's efforts, such that the participant was required either to initiate assertive behavior or exhibit refusal behavior. The confederate delivered up to a total of five prompts (refusals or repeated requests) until the participant stopped responding or gave in. The entire situation was tape recorded, and the dependent variables consisted of assertion content for the first response per interaction, average assertion content per interaction, and number of responses per interaction. Assertion content and number of prompts were scored as in the behavioral role-play test.
Development o f Assessment and Training Situations One hundred eighty situations, collected from previous assertion studies and inventories, were compiled into booklets and distributed to 147 women (mean age, 33 years). Subjects rated on a 6-point scale how difficult it would be to handle each situation in an assertive way and indicated how many times they had encountered each situation in their lifetimes. Twenty-six of the most frequent situations were selected, evenly divided between interactions with both sexes and interactions requiring refusal of an unreasonable request and those requiring initiation of assertive behavior. Since the few items rated as extremely difficult
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were also very low in frequency, most items included were rated as mildly to moderately difficult. Assertion difficulty inventory. An inventory was constructed by rewriting the 26 situations into one-sentence summaries, with instructions to rate each situation on the amount of difficulty one would have in responding assertively in that situation. Ratings varied from easy (1) to extremely difficult (5). Training, role-play, and S - R inventories situations. Situations for training, role-play assessment, and for the S-R Inventories of Anxiousness and Hostility were drawn from the Assertion Difficulty Inventory. Situations required refusal and initiation with both males and females. The six pre and posttest role-play situations were similar in content but not identical, and were matched on rated difficulty and frequency.
Therapists Therapists were four female and four male advanced graduate students and postdoctoral fellows. All therapists had prior training in both behavior and cognitive therapy and received approximately 20 hr of training for this study. Therapists received weekly group supervision from the first two authors during which audio tapes were reviewed to insure that the therapies were being conducted appropriately and progress of each participant was discussed. Treatment Conditions There were a total of five conditions: behavior rehearsal (n = 16), systematic rational restructuring (n = 16), behavior rehearsal/rational restructuring (n = 16), relationship control (n = 16), and a waiting-list control, (n = 15). Treatment was conducted individually in eight sessions over an 8-week period. A within-sample matching technique, based on pretest questionnaire inventory scores, was used to assign participants to the five conditions such that groups were equated on mean scores for each inventory. The overall format for the three behavioral treatment groups was similar: treatment components included coaching, modeling, self-coaching, rehearsal, self-evaluation, feedback, therapist praise, and in vivo practice. Therapy consisted of practicing assertive behaviors, rational restructuring, or a combination of both in 12 training situations, with 4 rehearsal trials per situation. Modeling was faded out over the course of the therapy. The in vivo practice was discussed at the beginning of each session and coaching, feedback, and praise were given as appropriate. Behavioral rehearsal. Training focused on verbal content, nonverbal behaviors, and strategies of assertive behavior. A list summarizing principles of assertive behavior was given to each client. Using a tape recorder, the therapist modeled an assertive response and then the client roleplayed each situation four times with the therapist. The number of predetermined prompts per trial delivered by the therapist increased from one
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to four over the four trials. Before each trial, the client verbalized one or more self-coaching statements (e.g., "Remember, keep good eye contact"). Following each trial the client evaluated her own behavior, using the principles of assertive behavior as criteria, on a 5-point scale, and feedback and coaching were given. Therapists maintained a skill oriented focus to insure that participants did not engage in verbal cognitive restructuring. Clients were instructed to practice and record a description of their assertive behavior at least five times during the week. Systematic rational restructuring. Treatment was a modification of the systematic-rational restructuring procedure proposed by Goldfried et al. (1974). The therapist modeled the cognitive restructuring process and each participant was given a list of assertive beliefs. After the participant verbalized several self-coaching statements (e.g., "Remember, saying no to a friend probably won't make her dislike me forever."), she practiced in her imagination cognitively restructuring the situation read by the therapists over four separate trials. To ensure that participants did not covertly practice assertive responding, they were instructed to verbalize or "think out loud" their self-defeating thoughts and reevaluations immediately following each of the four situation presentations. Therapist prompts ensured that participants focused on their self-statements instead of on what they would do in the situation. Inasmuch as this condition involved no overt behavioral response, prompts were written for trials 2-4 to indicate that the other person in the situation had continued to refuse or persist one or more times. The prompts were taken directly from the script used for the comparable trial in the behavior rehearsal condition. Following each trial, the participant rated her anxiety and anger levels and was given feedback and coaching on her ability to reevaluate the situation. Participants were instructed to practice cognitive restructuring at least five times each week in situations that might call for assertive behavior and to record a discription of the situations and the restructuring process. Behavior rehearsal~rational restructuring. A combined procedure was used and the participant both practiced rational restructuring and behaviorally rehearsed each situation. Homework assignments were a combination of those given to participants in the restructuring and behavioral rehearsal therapies. Relationship Control. This treatment was designed to control for the effects of being in individual treatment for assertion problems and therapist approval and "permission" to behave assertively. Participants were told that assertion problems are due to a lack of self-confidence, which can be overcome by expressing opinions, beliefs and feelings in an accepting and supportive atmosphere. During session 1, the treatment rationale and the participant's assertion problems were discussed. During sessions 2-8, any topic of concern which the participant brought up was discussed. The therapist responded to comments with one or more of the following; attending behavior, reflection of feelings, open-ended questions, and summariza-
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tion of content. Assertion was discussed at least once during each session and therapists generally expressed approval for attempts at behaving assertively. Therapists refrained from giving advice, directions, cognitive restructuring-type comments, and skill training comments. Waiting list. Participants assigned to the waiting-list control were told that because of the large numbers of applicants, there would be a time delay before they would receive treatment. At the end of 8 weeks they were contacted and told they would have to retake the assessment battery before beginning treatment. Participants were then offered treatment and were not included in the follow-up assessment.
RESULTS
Expectancies and Demand Characteristics Separate one-way analyses of variance indicated no significant differences among treatments on estimates of success either prior to or after the first session. The absence of difference after clients had been provided with the therapy rationale and a description of the treatment procedures suggests that the effects of expectancy and demand characteristics, at least at the beginning of treatment, were comparable across treatment conditions. At the follow-up assessment, 8 to 10 weeks after termination, each client confidentially rated her therapist on 7-point scales for a number of different variables (e.g., warmth, comfortableness). Analyses of variance for the average score across all variables indicated no significant differences among treatment conditions.
Location of Therapy Due to the nonrandom assignment to location, any differences at posttest between the participants in Washington, D.C. and Stony Brook (a distant suburb of New York City) would be difficult to interpret. Nonetheless, location was included as one of the factors in the three-way analysis of covariance. The results reflected a main effect for location on only one dependent variable: Washington, D.C. women across all treatment conditions had fewer speech dysfluencies per situation than Stony Brook women (.70 vs .90 respectively, F (1,57) = 3.86, p < .01).
Sex of Therapist There were no main or interaction effects for sex of therapist on any dependent variable used in this study. To assess whether sex of therapist might interact with sex of the other person depicted in the assertion situations used for assessment, the situations in the behavioral roleplaying test and the S - R Inventories of Anxiousness and Hostility were divided into two groups according to sex of the other person in the interaction. Sex of therapist had no effect in any of these analyses. Further, assessment scores on interactions with females were found to be almost identical to scores with males, irrespective of therapist sex.
ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G
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Treatment Effects: Posttesting Inasmuch as no main or interaction effects were found for sex of therapist, and location was significant on only one variable, treatment effects were analysed by one-way analyses of covariance for unequal n values (Winer, 1975). With the one exception, noted below, all regression assumptions were met. Post-hoc comparisons of means were done by Newman-Keuls adjusted for covariance (Dayton, 1970). Questionnaire battery. Tests for differences between adjusted means indicated that participants in the behavior rehearsal/rational restructuring condition showed significantly greater improvement on all questionnaire measures when compared with the waiting-list control (see Table 1). In comparison to those in the waiting-list control, participants in rational restructuring showed greater improvement on the Assertion Difficulty Inventory and the S-R Inventories of Anxiety and Hostility. Participants assigned to behavior rehearsal improved more than waiting-list control on only the Assertion Difficulty Inventory. With the exception of differences on the Assertion Difficulty Inventory, where the combined treatment was superior to the relationship control, there were no significant differences among the four contact groups on questionnaire measures (see Table 1). To focus specifically on the direction of change, analyses of pre-post within-group differences by t tests were computed (see Table 2). Results indicate a significant improvement across all questionnaire measures, except the S-R Inventory of Hostility, for the four treatment contact conditions. Behavioral role-playing test. The performance ratings based on either the transcripts or tape recordings of the participant's response to the role-playing test, were conducted by two or more pairs of judges. On each of the variables, the resulting Pearson product-moment correlation coefficients across all of the data revealed high reliability. For assertion content, reliability was .90 between two raters; for loudness/affect, the average reliability for three pairs of raters was .91 with a range of .86 to .97; for speech dysfluencies, the average reliability for six pairs of raters was .94, with a range of .88 to .96. Since only one assessor recorded eye gazing, it was not possible to calculate reliability. However, during training, reliabilities of .90 and above were obtained with two observers. The unadjusted pre- and posttest means for the variables associated with the role playing assessment are depicted in Fig. 1. The behavior rehearsal/rational restructuring condition and behavior rehearsal alone did not differ from each other on any of the measures, and each was superior to both the relationship and the waiting-list control on measures of assertion content, speech dysfluencies, and total number of responses (see Table 1). In addition, behavior rehearsal/rational restructuring and behavior rehearsal alone were superior to rational restructuring on assertion content and speech dysfluencies. Behavior rehearsal demonstrated significantly greater improvement than waiting-list control on percentage of eye gazing, which was the only significant finding with this measure. All three behavior therapy conditions were comparable on total number of
taJ
37.39 3.01 1.69 7.55 19.02
1 l 3.69 2.23
Behavioral role-play test: performance ratings Assertion Content Speech dysfluencies Loudness/affect Eye gazing (percentage) No. of responses
Behavioral role play test: subjective emotional responses Anxiety Guilt Anger Base anxiety
(4,73) (4,72) (4,69)
(4,72) (4,72) (4,72) (4,69)
(4,73) (4,73) (4,69) (4,72) (4,73)
(4,73) (4,73) (4,73) (4,73)
df
.001 ns ns
ns ns .01 ns
.001 .05 ns .001 .001
.001 .001 .001 .001
p
4.33a 0.72a 3.35a
26.02a 20.48a 25.56a 22.15a
4.21a .38a 3.35a 8lab 4.76a
1.99a 3.54a 206.99a 109.92a
BR/RR
3.72a 1.32a 3.03a
32.02a 20.05a 21.65a 28.52a
3.49b 1.04b 3.03a 74ab 4.57a
2.37ab -5.15ab 199.97a 120.50a
RR
4.29a 0.61a 3.50a
28.43a 19.07a 18.63 a 33.02a
4.27a .53a 3.50a 86a 4.87a
2.48ab - 15.17ab 225.25ab 130.53ab
BR
RC
3.16b 1.26a 3.23a
31.14a 21.69a 35.92a 41.30a
2.80c .82b 3.23a 72ab 3.76b
2.83b -22.98ab 243.43ab 157.16ab
Adjusted treatment means
2.93b 0.88a 2.92a
39.86a 21.80a 38.69a 34.40a
2.50c 1.03b 2.92a 66b 3.46b
3.43c -36.98b 263.79b 172.36b
WL
Note. Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list. Means in the same row with different subscripts differ from each other at least at the .05 level. The lower the score the more positive the self-esteem.
24.02 3.36 1.69
13.25 6.57 6.46 8.32
Questionnaire battery Assertion Difficulty Inventory Rathus Assertiveness Inventory S - R Inventory of Anxiousness S - R Inventory of Hostility
Behavioral role play test: first response Assertion content Speech dysfluencies Loudness/affect
F
Analyses of covariance
1 ANALYSES OF COVAR1ANCE FOR TREATMENT EFFECTS AND ADJUSTED MEANS AT POSTTESTING
Measures
TABLE
381
ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G =-- --e " ~=c ? t-
8R/RR RR 8R RC WAIT
-
BEHAVIOR REHEARSAL/RATIONAL RESTRUCTURING RATIONAL RESTRUCTURING BEHAVIOR REHEARSAL RELATIONSHIP CONTROL WAITING LIST
Assertion Content
50
Number of Responses
30
Percent Eye Gazing
90
o: o 20 (ji
70 15 15
I0 T
I PRE
I POST
6O I
I
5
PRE POST Number of Speech Dysfluencies 1.45;
4
1.15
3
0.85
2
0.55
L~udness/Affect
Roting
~
"T
T
1
PRE
t_
POST
Bose Anxiety 50
3O
\
X.
20 \ W
0.25 1"
!
I
PRE
T
POST
60
60
,.w 5C
I POST
Subjective Guilt
Subjective Anxiety
I PRE
IO T
60
50
50
30
30
i
PRE
i
POST
Subjective Anger
n- 40 3O
2O
2C T
I
PRE
I
POST
T
PRE POST ASSESSMENT PERIOD
20 PRE
POST
FIG. 1. Unadjusted mean scores for behavioral role-play test performance and subjective emotional response measures at pretest and posttest assessment. With the exception of base anxiety, all scores reflect averages across six role-played situations.
responses and superior to both control groups. The only other m e a s u r e on which rational restructuring showed significantly greater i m p r o v e m e n t than control groups was on assertion content. The two control conditions did not differ from each other on any of the p e r f o r m a n c e measures. N o
bo
battery
Inventory
Inventory
S-R
S-R
of Hostifity
of Anxiousness
Inventory
Difficulty Inventory
Rathus Assertiveness
Assertion
Questionnaire
Measures
TABLE
2
-57.50*** -40.87*** 16.63
Pre-follow-up
Post-follow-up
5.07
-40.18"*
-45.25***
0.12
- 76.44* * *
- 61.00" ** 2.44
-76.56***
9.94*
46.76***
36.82* * *
- 0.28"
- 1.57***
- 1.29"**
RR
-63.44"**
Pre-post
Post-follow -up
Pre-follow-up
Pre-post
7.69
52.32***
Post-follow-up
44.63 * **
- 0.11
Post-follow-up
Pre-follow-up
- 1.66"**
Pre-follow-up
Pre-post
- 1.55***
Pre-post
BR/RR
Mean
-0.94
-29.44*
-28.50
- 8.00
- 57.00" **
-49.00**
9.62
36.56***
26.94* **
- 0.37" *
- 1.42***
- 1.05"**
BR
differences
WITHIN-GRouP MEAN DIFFERENCES FROM PRE- TO POSTTESTING~ PRETESTING TO FOLLOW-UP, AND POSTTESTING TO FOLLOW-UP
- 17.37
-33.69**
- 16.32
- 13.31
- 42.69* **
-29.38**
6.70
25.62**
18.62*
- 0.18*
-0.89***
-0.71"**
RC
--
--
2.93
--
--
- 14.67
--
--
4.47
--
--
-0.10
WL
Pre-post Pre-post Pre-post
Assertion content Speech dysfluencies Loudness/affect
1.49"** -0.59* 0.51"
-25.25** - 12.92" - 14.28"* - 16.60"*
1.88"** -0.70** 0.51 * 7* 1.49***
-
0.79*** -0.21 0.21
18.03"* 13.28" 18.68"* 12.92'
1.16"** -0.34 0.21 5 1.47***
1.42"** -0.72** 0.83"*
-20.13" - 16.40"* -23.13"* -3.93
1.99"** -0.61"* 0.83 * * 15"** 1.76***
0.25 -0.20 0.43
-21.35"* - 19.71"** -5.74 0.72
0.49** -0.39 0.43 1 0.63**
0.09 -0.52 0.11
-7.56 - 14.99 -2.13 -7.33
0.22 -0.19 0.11 -6 0.29
Significance of change based on within-group t tests. Follow-up data were based only on questionnaire measures, and were not obtained for the waiting-list control. For the Self-Esteem Scale, the lower the score, the more positive the self-esteem. * p < .05. ** p < .01. *** p < .001.
Note. BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list.
Pre-post Pre-post Pre-post Pre-post
Pre-post Pre-post Pre - p o s t Pre-post Pre-post
Anxiety Guilt Anger Base anxiety Behavioral role play test: first response
Behavioral role play test: subjective emotional response
Behavioral role play test: performance ratings Assertion content Speech dysfluencies Loudne s s/affect Eyegazing (percentage) No. of responses
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LINEHAN, GOLDFRIED, AND GOLDFRIED
significant differences emerged among any of the treatment procedures on loudnes s/affect. The data for the total number of responses should be interpreted in light of the violation of homogeneity of regression assumption on this variable (F (4, 69) = 3.05, p < .02). An examination of the correlations between pretesting and posttesting indicated a positive relationship in the rational restructuring and two control groups, but not in either of the two procedures involving behavior rehearsal, where the correlations approached zero. Within-group mean differences between pre- and posttesting for each of the performance ratings reflect significant improvement on all measures for both the behavior rehearsal/rational restructuring and behavioral rehearsal alone conditions (see Table 2). The results for rational restructuring and the relationship control are comparable in that significant improvement was found for content of assertive responses and and total number of responses. No significant changes were obtained for the waiting-list control. Participants' ratings of their subjective emotional responses showed a main effect of Treatment for anger. Tests for differences between individual adjusted means, however, did not reveal a significant difference between any pair of means. There were no main effects for treatment of subjective measures of anxiety and guilt. Examination of pre- and posttest means and associated t tests (see Table 2) indicated that all three behavioral treatment groups reported less anxiety, guilt, and anger following treatment; the relationship control reported less anxiety and guilt, but no significant change on subjective anger. Once again, there were no pre-post differences on any variable for the waiting-list control. The analyses of covariance did not indicate any significant treatment effect for base anxiety, that is, participants' estimate of their typical level of anxiety (see Table 1). However, within-group t tests between pre- and posttesting indicated significant decrements in base anxiety for those procedures incorporating rational restructuring, either alone or in combination with behavior rehearsal (see Table 2). Behavioral role-play test: First response. Separate analyses were carried out for the first response only on the extended interaction test. Participants in each of three behavioral groups were rated as significantly more assertive on their first responses than those in either of the control conditions (see Table 1). There were no significant treatment effects for speech dysfluencies or loudness/affect. Analysis of the withingroup t test (see Table 2) revealed a pattern similar to that found for the extended interaction analysis. Contrived situational test. The assertive content of each response in the contrived situational test was determined on the basis tf two raters, with an interrater reliability of .88. Inasmuch as the test was administered at posttesting only, a one-way analysis of variance was computed for each variable. A main effect for Treatment condition was found on each measure (see Table 3). Tests between adjusted means indicated that while
ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G
385
TABLE 3 ANALYSES OF VARIANCE FOR TREATMENT EFFECTS." CONTRIVED SITUATIONAL TEST Analyses of variance a Measure Assertion content: across responses Assertion content: first response No. of responses
Treatment means
F
df
p
B1URR
RR
BR
RC
10.28
(4,55)
.001
3.87ab
3.46ac
4.05b
3.20c
3.07c
3.12 3.92
(4,57) (4,49)
.022 .002
4.17ab 4.89a
3.92ab 4.58ab
4.30b 4.92a
3.63a 4.32b
3.79ab 4.44b
WL
Note: Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list. Means in the same row with different subscripts differ from each other at least at the .05 level. a Only the main effects for treatment are presented. The complete three-way table (treatment × location × sex of therapist) may be obtained from the first author.
behavior rehearsal/rational restructuring and behavioral rehearsal alone did not differ from each other, each of these two conditions was superior to both controls on the basis of assertion content across responses and total number of responses. Further superiority for the behavior rehearsal condition was reflected by significantly higher scores than rational restructuring on assertion content score for first response when compared with the relationship control. No other significant differences were found. Peer questionnaire. X2 analyses indicated that when compared with participants in the relationship and waiting-list control groups, clients in the three behavioral treatment groups (behavior rehearsal/rational restructuring, behavior rehearsal, and rational restructuring) were more likely to be seen as easier to get along with (X2 --- 5.8, df = 1,p < .05; 44% for the behavioral conditions vs 17% for the control conditions). There were no differences between individual treatments in either group. Only 11% of the peers in the behavioral treatment conditions and 14% in the two control groups reported more difficulty in relationships.
Treatment Effects: Follow-Up Analyses of covariance were carried out to test whether treatment differences were maintained on the self-report measures at follow-up 8 to 10 weeks after termination. As noted previously, waiting-list participants were not included because of ethical considerations, and instead were offered treatment following the posttesting. Main effects for treatment were found for the Assertion Difficulty Inventory (F (3, 59) = 3.5, p < .02) and the Rathus Assertiveness Inventory ( F (3, 59) = 3.5, p < .02).
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Although the direction of differences was similar to the direction at posttesting, comparisons between adjusted means indicated no significant pair-wise differences. Within-group t tests between pretest and follow-up questionnaire measures revealed a significant improvement for all conditions on all measures (see Table 2). To determine whether the questionnaire changes obtained at posttesting were maintained at follow-up assessment, withingroup t tests were also computed between posttest and follow-up assessment on both the Assertion Difficulty and Rathus Assertiveness Inventories. Participants in both behavior rehearsal and the relationship control also showed continued improvement on the Assertion Difficulty Inventory.
DISCUSSION The findings indicate that a combined intervention procedure, employing both behavioral rehearsal and systematic rational restructuring, was the most effective in increasing assertive behavior and reducing the emotional discomfort associated with such interactions. This superiority, however, was a function of the greater improvement in the combined group relative to the control groups. Participants receiving behavior rehearsal, for the most part, demonstrated gains on self-report measures as well as superiority over participants not receiving the behavioral rehearsal component on qualitative measures of overt assertion. Of particular interest is the finding that behavior rehearsal therapy, in which clients were told to ignore their emotional responses, was effective in reducing a range of maladaptive emotional responses related to assertion in addition to increasing the number and quality of assertive responses. Cognitive therapy alone also showed improvement at posttesting. Although the content of the responses given by participants in rational restructuring was not as assertive as those emitted by individuals in the other two behavioral interventions, it was superior to those given by participants in both control conditions. Our findings lend tentative support to the clinical observations of Lange and Jakubowski (1976), who have suggested that a combination of cognitive restructuring and skill acquisition interventions are the optimal treatment for facilitating assertive behavior. Despite the fact that the relationship control was both not significantly better than the waiting-list control group on any measure used in the study, and significantly less assertive on many performance measures than the behavioral interventions, the participants self-reported the same degree of success in learning to behave assertively and in reducing their problematic emotional responses in assertive situations. These results are comparable to the results of Wolfe and Fodor (1977) who found a similar relationship between their consciousness-raising group and the two behavioral interventions. The subjective experience of benefit reported by the relationship control participants suggests that the very experience of being in therapy may help
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women at least feel better in assertive situations. It is not clear whether this is due to the stated purposes of the treatment (i.e., expressing oneself in a supportive environment), the giving of the permission to behave assertively inherent in any assertion therapy, or any number of other variables that might have been operating. Another major finding of this research was that sex of therapist was not a significant factor in assertion training with our female participants. While our findings are clear, care must be taken as to how they are interpreted. Within the context of the present research, potential bias may have been undercut by virtue of a built-in agreement between client and therapist that the goal was to facilitate assertive behavior. There may be differences in actual clinical settings, particularly in selecting goals and specifying actual behavioral changes needed. In light of the much publicized popular view that assertion training with women may result in increased aggression, hostility, and anger and, thus jeopardize interpersonal relationships, our results are of particular interest and give evidence to the contrary. Across all three behavioral interventions, there was a self-reported decrease, not increase in hostility and anger as a result of treatment. Although retrospective reports on the quality of a relationship must be viewed with caution, the results suggest that relationships were improved as a result of participation in the program. Content of the initial response only for participants in the rational restructuring condition was just as assertive as for those in either behavior rehearsal/rational restructuring or behavior rehearsal alone. When all response associated with the extended interaction are considered, however, rational restructuring participants were not as assertive as either of the other two behavioral conditions. An extended interaction role-playing test may be preferable to use in future outcome research on the grounds that it more closely parallels the nature of an assertion interaction in real life. Although the role-play test may be quite adequate as a measure of the person's assertion capability, this may not reflect the extent of the person's actual assertive responding in the natural envionment. Our finding that a treatment procedure combining both behavior rehearsal and rational restructuring is most effective could be the result of its greater applicability to the range of controlling variables associated with unassertive behavior, rather than evidence of its superiority for use with all unassertive persons. It could be that some of the particip~ :s in the cognitive restructuring therapy might have benefited more t am a behavior rehearsal therapy, and vice versa. A more appropriate methodology in future research would be to carefully assess each participant across each of the assertion response systems, including verbal and nonverbal assertive motor skills, social-evaluative anxiety, and beliefs about both the appropriateness and consequences of assertion; treatment packages, ideographically designed, could then be implemented and compared.
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REFERENCES Bergin, A. E., & Strupp, H. H. New directions in psychotherapy research. Journal of Abnormal Psychology, 1970, 76, 13-26. Dayton, D. M. Design of educational experiments. New York: McGraw-Hill, 1970. Endler, N. S., & Hunt, J. McV. S - R inventories of hostility and comparison of the proportion of variance from persons, responses, and situations for hostility and anxiousness. Journal of Personality and Social Psychology, 1968, 9, 309-315. Endler, M. S., Hunt, J. McV., & Rosenstein, A. J. An S - R inventory of anxiousness. Psychological Monograph. 1962, 76 (17), Whole No. 536. Goldfried, M. R., Decenteceo, E. T., & Weinberg, L. Systematic rational restructuring as a self-control technique. Behavior Therapy, 1974, 5, 247-254. Kazdin, A. E. Effects of covert modeling and model reinforcement on assertive behavior. Journal of Abnormal Psychology, 1974, 83, 240-252. Lange, A. J., & Jackubowski, P. Responsible assertive behavior: Cognitive~behavioral procedures for trainers. Champaign, IL: Research Press, 1976. Linehan, M. Structured cognitive-behavioral treatment of assertion problems. In P. C. Kendall & S. P. Hollon (Eds.), Cognitive-behavioral interventions: Theory, research, and procedures. New York: Academic Press, 1979. Mahl, G. F. Exploring emotional states by content analysis. In I. D. Pool (Ed.), Trends in content analysis. Urbana, IL: Univ. of Illinois Press, 1959. McFall, R. M., & Twentyman, C. T. Four experiments on the relative contributors of rehearsal, modeling, and coaching on assertion training. Journal of Abnormal Psychology, 1973, 81, 199-218. Parloff, M. B., Waskow, I. E., & Wolfe, B. E. Research on therapist variables in relation to process and outcome. In S. L. Garfield & A. E. Bergin (Eds.) Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed.). New York: Wiley, 1978. Rathus, S. A. A 30-item schedule for assessing assertive behavior. Behavior Therapy, 1973, 4, 398-406. Rich, A. R., & Schrueder, H. E. Research issues in assertiveness training. Psychological Bulletin, 1976, 83, 1081-1096. Salter, A. Conditioned reflex therapy. New York: Creative Age, 1949. Schwartz, R. M., & Gottman, J. M. A task analysis approach to clinical problems: A study of assertive behavior: Journal of Consulting and Clinical Psychology, 1976, 44, 910920. Thorpe, G. L. Desensitization, behavior rehearsal, self-instructional training and placebo effects on assertive-refusal behavior. European Journal of Behavioral Analysis and Modification, 1975, 1, 30-44. Trower, P., Yardley, K., Bryant, B. M. & Shaw, P. The treatment of social failure: A comparison of anxiety-reduction and skill-acquisition procedures on two social problems. Behavior Modification, 1978, 2, 41-60. Winer, B. J. Statistical principles in experimental design. New York: McGraw-Hill, 1971. Wolfe, J. L., & Fodor, I. G. Modifying assertive behavior in women: A comparison of three approaches. Behavior Therapy, 1977, 8, 567-574. Wolpe, J. The practice of behavior therapy (2nd ed.). Elmsford, NY: Pergamon, 1973. RECEIVED: May 25, 1978; REVISED: December 1, 1978 FINAL ACCEPTANCE: January 18, 1979
Assertion Therapy: Skill Training or Cognitive Restructuring MARSHA M . L I N E H A N
University of Washington
MARVIN R. G O L D F R I E D AND A N I T A POWERS G O L D F R I E D State University of New York at Stony Brook Seventy-nine women participated in a program designed to compare assertion therapy based on a skill-deficit model with a procedure based on a response inhibition model. Participants were assigned randomly to one of five treatment groups: behavior rehearsal, systematic rational restructuring, behavior rehearsal/ rational restructunng, relationship, and waiting list controls and were also assigned to a male or female therapist. Treatment was carried out at two separate locations resulting in a 2 x 2 x 5 factorial design. Results indicate that the combined behavior rehearsal/rational restructuring therapy was superior; there were few differences among the four contact groups on self-report measures; on both a role-play test and a contrived situational test all three behavioral treatments were equally successful at facilitating women to make a response whereas treatments employing behavior rehearsal were more effective in improving the assertion quality of the response. At follow-up all treatment groups typically maintained or improved on their gains, but failed to differ from each other on a self-report battery. No effect for sex of therapist was obtained. Results were the same at both locations indicating generalizability of results across more than one research setting. The model underlying many studies on assertion training (e.g., McFall & T w e n t y m a n , 1973) is t h a t u n a s s e r t i v e i n d i v i d u a l s h a v e a skill d e f i c i t . T h e p r i m a r y g o a l o f t r a i n i n g , t h e r e f o r e , is t o t e a c h t h e c l i e n t t h e r e q u i s i t e skills. I n t e r v e n t i o n p r o c e d u r e s t y p i c a l l y i n c l u d e b e h a v i o r r e h e a r s a l , The research described in this article was supported in part by Grants MH 26313-01 and MH 24327 from the National Institute of Mental Health. The authors are grateful to: Roger Bartman, Suzanne Bronheim, Anne Byrnes, Karen Haynes, Michael Osarchuk, Jerry Paone, Marilyn Sperling, and Leslie Weinberg who were the therapists in the study, to Gerald C. Davison for his comments on an earlier version of this article, and to Cynthia Pollnow for her invaluable assistance during all phases of this study. Requests for reprints should be sent to: Marsha M. Linehan, Psychology Department (NI-15), University of Washington Seattle, WA 98195. 372 0005-7894/79/030372-17501.00/0 Copyright © 1979 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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coaching, modeling, and in vivo practice of overt assertive responses. An alternate model of unassertive behavior assumes that the person has the requisite skills but is inhibited from behaving assertively by conditioned anxiety in assertive situations (Wolpe, 1973; Salter, 1949). Attempts to reduce assertion anxiety directly using systematic desensitization have been somewhat effective in increasing assertive behavior, but not as effective as skills training (Thorpe, 1975; Trower, Yardley, Bryant, & Shaw, 1978). A third model, which is a variation of the anxiety inhibition model, suggests that assertive behavior may be inhibited but that this inhibition is mediated by a person's maladaptive cognitive-evaluative appraisals (Lange & Jackubowski, 1976; Linehan, 1979; Rich & Schroeder, 1976; Schwartz & Gottman, 1976). Thorpe (1975) compared a cognitive procedure with behavior rehearsal and found that the cognitive intervention, designed to reduce maladaptive appraisals, was as effective as skill training procedures in the treatment of unassertive behavior. Wolfe and Fodor (1977) compared a behavior rehearsal approach with a combined behavior rehearsal/cognitive restructuring treatment, finding that the addition of the cognitive component to a skills training package did not increase participants' assertive behavior although it did reduce subjective reports of anxiety while behaving assertively. A major drawback of this study, however, was that the treatment consisted of only two sessions. A problem with these and other studies comparing cognitive interventions with behavioral interventions has been a failure to control for the behavior rehearsal component in the cognitive therapy; while cognitive therapy might have been effective, it is often unclear whether the results were due to the behavior rehearsal component or to the interaction between behavior rehearsal and the cognitive therapy. Even when systematic desensitization has been used alone, there is the likelihood, as Kazdin (1974) suggests, that desensitization may be construed as selfmodeling or covert rehearsal and that the effect may be similar to behavioral rehearsal. A similar problem exists in determining the effective component in the skill training programs. Although the only observable cognitive components in most programs are skill oriented instructions and feedback, it is likely that the client is also learning a new set of cognitive-evaluative appraisals. However, since even the act of accepting a person into an assertion training program is communicating, and thereby perhaps also teaching, an appraisal of the value of assertive behavior, this aspect of the skill training program is potentially inherent in any treatment approach. The primary aim of this study was to compare a therapy designed to modify cognitive appraisals directly (Goldfried, Decenteco, & Weruberg, 1974), controlling for covert behavior rehearsal, with a program designed to teach overt assertion skills. Both treatments were also compared to a treatment combining skill training with cognitive restructuring. While all three behavior therapies utilized rehearsal, modeling, coaching, self-
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statements, and in vivo practice, the target differed----overt behavior, cognitive appraisals, or a combination of the two. A second aim of this research was to study whether therapist gender is an important variable in assertion therapy. To date, little evidence exists demonstrating a differential effectiveness of male or female therapists on treatment outcome (Parloff, Waskow, Wolfe, 1978). Sex of therapist is a particularly relevant issue in the case of the treatment of women clients; questions about the role of therapy in the possible perpetuation of sex-role stereotypes which may be harmful to women are being increasingly raised. METHOD Participants Seventy-nine women, mean age 43.2 years and mean education level 14.5 years, were selected according to the following criteria: (1) a score below zero on the Rathus Assertiveness Inventory (Rathus, 1973), and (2) a score of 3 or above on the Assertion Difficulty Inventory described below. The study was carried out at both The Catholic University of America and the State University of New York at Stony Brook, and a final aim of this research was to demonstrate the feasibility of conducting collaborative outcome research at more than one setting. Although the need for this type of research has generally been agreed upon, the difficulties in standardization have made such ventures relatively rare (Bergin & Strupp, 1970).
Assessment Participant questionnaires. The Rathus Assertiveness Inventory (Rathus, 1973), the Assertion Difficulty Inventory, the S-R Inventory of Anxiousness (Endler, Hunt, & Rosenstein, 1962), and the S-R Inventory of Hostility (Endler & Hunt, 1968) were administered at pretest, posttest, and follow-up measures to all participants. The situations used in the two S-R Inventories as well as the Assertion Difficulty Inventory are described below. Both before and immediately after the first session, participants rated their expectations for therapy success on a 5-point scale ranging from "zero chance of success" (1) to "100% chance of success" (5). Peer questionnaire. Each participant gave the name of a person who she believed knew her well and saw her often enough (generally, at least once a week) to complete a questionnaire at posttest evaluating her assertive behavior. Open-ended questions requested such information as whether changes were observed and the effect of such changes on their relationship. Behavioral role-play test. An extended interaction behavioral roleplaying test was administered at pre- and posttest. A trained male-female assessment team delivered role-play lines verbatim to participants from predetermined scripts. Following a response of the participant, the as-
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sessors delivered an additional predetermined prompt, and up to five prompts, depending on the point at which the participant gave in or stopped responding. The role-play interactions were tape recorded, and the sex of the assessor was varied across the six situations. The major dependent variables were: assertion content, speech dysfluencies, loudness/affect, eye gazing, number of responses per interaction, and subjective reports of anxiety, guilt, and anger obtained after each of the role-play situations. Assertion content was rated on a 5-point scale from transcriptions of the audio tapes. Speech dysfluencies were scored by counting the number of stammers, blockages, etc. (adapted from Mahl, 1959). The loudness/affect quality of the response was rated from audio tapes (1 = barely audible response to 5 = volume strong, affect does not detract from assertiveness). For these three measures, two separate scores were computed for each situation: a first response only score, and an average situation score. Duration of eye gazing was timed by the unoccupied assessor and a percentage score was obtained by dividing by the total time of the interaction. Number of responses was obtained by counting the number of prompts delivered by the experimenter. Following each role-play situation, participants estimated on a scale of 0 (low) to 100 (high) how much anxiety, guilt, and anger they had experienced during the role-play. A measure of base anxiety was also obtained prior to any of the role play situations, by asking participants to estimate their typical or average level of anxiety in their everyday life. Contrived situational test. While participants were trying to complete a questionnaire at posttest, a female confederate, following a predetermined script, set up six interactions that interfered with the participant's efforts, such that the participant was required either to initiate assertive behavior or exhibit refusal behavior. The confederate delivered up to a total of five prompts (refusals or repeated requests) until the participant stopped responding or gave in. The entire situation was tape recorded, and the dependent variables consisted of assertion content for the first response per interaction, average assertion content per interaction, and number of responses per interaction. Assertion content and number of prompts were scored as in the behavioral role-play test.
Development o f Assessment and Training Situations One hundred eighty situations, collected from previous assertion studies and inventories, were compiled into booklets and distributed to 147 women (mean age, 33 years). Subjects rated on a 6-point scale how difficult it would be to handle each situation in an assertive way and indicated how many times they had encountered each situation in their lifetimes. Twenty-six of the most frequent situations were selected, evenly divided between interactions with both sexes and interactions requiring refusal of an unreasonable request and those requiring initiation of assertive behavior. Since the few items rated as extremely difficult
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were also very low in frequency, most items included were rated as mildly to moderately difficult. Assertion difficulty inventory. An inventory was constructed by rewriting the 26 situations into one-sentence summaries, with instructions to rate each situation on the amount of difficulty one would have in responding assertively in that situation. Ratings varied from easy (1) to extremely difficult (5). Training, role-play, and S - R inventories situations. Situations for training, role-play assessment, and for the S-R Inventories of Anxiousness and Hostility were drawn from the Assertion Difficulty Inventory. Situations required refusal and initiation with both males and females. The six pre and posttest role-play situations were similar in content but not identical, and were matched on rated difficulty and frequency.
Therapists Therapists were four female and four male advanced graduate students and postdoctoral fellows. All therapists had prior training in both behavior and cognitive therapy and received approximately 20 hr of training for this study. Therapists received weekly group supervision from the first two authors during which audio tapes were reviewed to insure that the therapies were being conducted appropriately and progress of each participant was discussed. Treatment Conditions There were a total of five conditions: behavior rehearsal (n = 16), systematic rational restructuring (n = 16), behavior rehearsal/rational restructuring (n = 16), relationship control (n = 16), and a waiting-list control, (n = 15). Treatment was conducted individually in eight sessions over an 8-week period. A within-sample matching technique, based on pretest questionnaire inventory scores, was used to assign participants to the five conditions such that groups were equated on mean scores for each inventory. The overall format for the three behavioral treatment groups was similar: treatment components included coaching, modeling, self-coaching, rehearsal, self-evaluation, feedback, therapist praise, and in vivo practice. Therapy consisted of practicing assertive behaviors, rational restructuring, or a combination of both in 12 training situations, with 4 rehearsal trials per situation. Modeling was faded out over the course of the therapy. The in vivo practice was discussed at the beginning of each session and coaching, feedback, and praise were given as appropriate. Behavioral rehearsal. Training focused on verbal content, nonverbal behaviors, and strategies of assertive behavior. A list summarizing principles of assertive behavior was given to each client. Using a tape recorder, the therapist modeled an assertive response and then the client roleplayed each situation four times with the therapist. The number of predetermined prompts per trial delivered by the therapist increased from one
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to four over the four trials. Before each trial, the client verbalized one or more self-coaching statements (e.g., "Remember, keep good eye contact"). Following each trial the client evaluated her own behavior, using the principles of assertive behavior as criteria, on a 5-point scale, and feedback and coaching were given. Therapists maintained a skill oriented focus to insure that participants did not engage in verbal cognitive restructuring. Clients were instructed to practice and record a description of their assertive behavior at least five times during the week. Systematic rational restructuring. Treatment was a modification of the systematic-rational restructuring procedure proposed by Goldfried et al. (1974). The therapist modeled the cognitive restructuring process and each participant was given a list of assertive beliefs. After the participant verbalized several self-coaching statements (e.g., "Remember, saying no to a friend probably won't make her dislike me forever."), she practiced in her imagination cognitively restructuring the situation read by the therapists over four separate trials. To ensure that participants did not covertly practice assertive responding, they were instructed to verbalize or "think out loud" their self-defeating thoughts and reevaluations immediately following each of the four situation presentations. Therapist prompts ensured that participants focused on their self-statements instead of on what they would do in the situation. Inasmuch as this condition involved no overt behavioral response, prompts were written for trials 2-4 to indicate that the other person in the situation had continued to refuse or persist one or more times. The prompts were taken directly from the script used for the comparable trial in the behavior rehearsal condition. Following each trial, the participant rated her anxiety and anger levels and was given feedback and coaching on her ability to reevaluate the situation. Participants were instructed to practice cognitive restructuring at least five times each week in situations that might call for assertive behavior and to record a discription of the situations and the restructuring process. Behavior rehearsal~rational restructuring. A combined procedure was used and the participant both practiced rational restructuring and behaviorally rehearsed each situation. Homework assignments were a combination of those given to participants in the restructuring and behavioral rehearsal therapies. Relationship Control. This treatment was designed to control for the effects of being in individual treatment for assertion problems and therapist approval and "permission" to behave assertively. Participants were told that assertion problems are due to a lack of self-confidence, which can be overcome by expressing opinions, beliefs and feelings in an accepting and supportive atmosphere. During session 1, the treatment rationale and the participant's assertion problems were discussed. During sessions 2-8, any topic of concern which the participant brought up was discussed. The therapist responded to comments with one or more of the following; attending behavior, reflection of feelings, open-ended questions, and summariza-
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tion of content. Assertion was discussed at least once during each session and therapists generally expressed approval for attempts at behaving assertively. Therapists refrained from giving advice, directions, cognitive restructuring-type comments, and skill training comments. Waiting list. Participants assigned to the waiting-list control were told that because of the large numbers of applicants, there would be a time delay before they would receive treatment. At the end of 8 weeks they were contacted and told they would have to retake the assessment battery before beginning treatment. Participants were then offered treatment and were not included in the follow-up assessment.
RESULTS
Expectancies and Demand Characteristics Separate one-way analyses of variance indicated no significant differences among treatments on estimates of success either prior to or after the first session. The absence of difference after clients had been provided with the therapy rationale and a description of the treatment procedures suggests that the effects of expectancy and demand characteristics, at least at the beginning of treatment, were comparable across treatment conditions. At the follow-up assessment, 8 to 10 weeks after termination, each client confidentially rated her therapist on 7-point scales for a number of different variables (e.g., warmth, comfortableness). Analyses of variance for the average score across all variables indicated no significant differences among treatment conditions.
Location of Therapy Due to the nonrandom assignment to location, any differences at posttest between the participants in Washington, D.C. and Stony Brook (a distant suburb of New York City) would be difficult to interpret. Nonetheless, location was included as one of the factors in the three-way analysis of covariance. The results reflected a main effect for location on only one dependent variable: Washington, D.C. women across all treatment conditions had fewer speech dysfluencies per situation than Stony Brook women (.70 vs .90 respectively, F (1,57) = 3.86, p < .01).
Sex of Therapist There were no main or interaction effects for sex of therapist on any dependent variable used in this study. To assess whether sex of therapist might interact with sex of the other person depicted in the assertion situations used for assessment, the situations in the behavioral roleplaying test and the S - R Inventories of Anxiousness and Hostility were divided into two groups according to sex of the other person in the interaction. Sex of therapist had no effect in any of these analyses. Further, assessment scores on interactions with females were found to be almost identical to scores with males, irrespective of therapist sex.
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Treatment Effects: Posttesting Inasmuch as no main or interaction effects were found for sex of therapist, and location was significant on only one variable, treatment effects were analysed by one-way analyses of covariance for unequal n values (Winer, 1975). With the one exception, noted below, all regression assumptions were met. Post-hoc comparisons of means were done by Newman-Keuls adjusted for covariance (Dayton, 1970). Questionnaire battery. Tests for differences between adjusted means indicated that participants in the behavior rehearsal/rational restructuring condition showed significantly greater improvement on all questionnaire measures when compared with the waiting-list control (see Table 1). In comparison to those in the waiting-list control, participants in rational restructuring showed greater improvement on the Assertion Difficulty Inventory and the S-R Inventories of Anxiety and Hostility. Participants assigned to behavior rehearsal improved more than waiting-list control on only the Assertion Difficulty Inventory. With the exception of differences on the Assertion Difficulty Inventory, where the combined treatment was superior to the relationship control, there were no significant differences among the four contact groups on questionnaire measures (see Table 1). To focus specifically on the direction of change, analyses of pre-post within-group differences by t tests were computed (see Table 2). Results indicate a significant improvement across all questionnaire measures, except the S-R Inventory of Hostility, for the four treatment contact conditions. Behavioral role-playing test. The performance ratings based on either the transcripts or tape recordings of the participant's response to the role-playing test, were conducted by two or more pairs of judges. On each of the variables, the resulting Pearson product-moment correlation coefficients across all of the data revealed high reliability. For assertion content, reliability was .90 between two raters; for loudness/affect, the average reliability for three pairs of raters was .91 with a range of .86 to .97; for speech dysfluencies, the average reliability for six pairs of raters was .94, with a range of .88 to .96. Since only one assessor recorded eye gazing, it was not possible to calculate reliability. However, during training, reliabilities of .90 and above were obtained with two observers. The unadjusted pre- and posttest means for the variables associated with the role playing assessment are depicted in Fig. 1. The behavior rehearsal/rational restructuring condition and behavior rehearsal alone did not differ from each other on any of the measures, and each was superior to both the relationship and the waiting-list control on measures of assertion content, speech dysfluencies, and total number of responses (see Table 1). In addition, behavior rehearsal/rational restructuring and behavior rehearsal alone were superior to rational restructuring on assertion content and speech dysfluencies. Behavior rehearsal demonstrated significantly greater improvement than waiting-list control on percentage of eye gazing, which was the only significant finding with this measure. All three behavior therapy conditions were comparable on total number of
taJ
37.39 3.01 1.69 7.55 19.02
1 l 3.69 2.23
Behavioral role-play test: performance ratings Assertion Content Speech dysfluencies Loudness/affect Eye gazing (percentage) No. of responses
Behavioral role play test: subjective emotional responses Anxiety Guilt Anger Base anxiety
(4,73) (4,72) (4,69)
(4,72) (4,72) (4,72) (4,69)
(4,73) (4,73) (4,69) (4,72) (4,73)
(4,73) (4,73) (4,73) (4,73)
df
.001 ns ns
ns ns .01 ns
.001 .05 ns .001 .001
.001 .001 .001 .001
p
4.33a 0.72a 3.35a
26.02a 20.48a 25.56a 22.15a
4.21a .38a 3.35a 8lab 4.76a
1.99a 3.54a 206.99a 109.92a
BR/RR
3.72a 1.32a 3.03a
32.02a 20.05a 21.65a 28.52a
3.49b 1.04b 3.03a 74ab 4.57a
2.37ab -5.15ab 199.97a 120.50a
RR
4.29a 0.61a 3.50a
28.43a 19.07a 18.63 a 33.02a
4.27a .53a 3.50a 86a 4.87a
2.48ab - 15.17ab 225.25ab 130.53ab
BR
RC
3.16b 1.26a 3.23a
31.14a 21.69a 35.92a 41.30a
2.80c .82b 3.23a 72ab 3.76b
2.83b -22.98ab 243.43ab 157.16ab
Adjusted treatment means
2.93b 0.88a 2.92a
39.86a 21.80a 38.69a 34.40a
2.50c 1.03b 2.92a 66b 3.46b
3.43c -36.98b 263.79b 172.36b
WL
Note. Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list. Means in the same row with different subscripts differ from each other at least at the .05 level. The lower the score the more positive the self-esteem.
24.02 3.36 1.69
13.25 6.57 6.46 8.32
Questionnaire battery Assertion Difficulty Inventory Rathus Assertiveness Inventory S - R Inventory of Anxiousness S - R Inventory of Hostility
Behavioral role play test: first response Assertion content Speech dysfluencies Loudness/affect
F
Analyses of covariance
1 ANALYSES OF COVAR1ANCE FOR TREATMENT EFFECTS AND ADJUSTED MEANS AT POSTTESTING
Measures
TABLE
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ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G =-- --e " ~=c ? t-
8R/RR RR 8R RC WAIT
-
BEHAVIOR REHEARSAL/RATIONAL RESTRUCTURING RATIONAL RESTRUCTURING BEHAVIOR REHEARSAL RELATIONSHIP CONTROL WAITING LIST
Assertion Content
50
Number of Responses
30
Percent Eye Gazing
90
o: o 20 (ji
70 15 15
I0 T
I PRE
I POST
6O I
I
5
PRE POST Number of Speech Dysfluencies 1.45;
4
1.15
3
0.85
2
0.55
L~udness/Affect
Roting
~
"T
T
1
PRE
t_
POST
Bose Anxiety 50
3O
\
X.
20 \ W
0.25 1"
!
I
PRE
T
POST
60
60
,.w 5C
I POST
Subjective Guilt
Subjective Anxiety
I PRE
IO T
60
50
50
30
30
i
PRE
i
POST
Subjective Anger
n- 40 3O
2O
2C T
I
PRE
I
POST
T
PRE POST ASSESSMENT PERIOD
20 PRE
POST
FIG. 1. Unadjusted mean scores for behavioral role-play test performance and subjective emotional response measures at pretest and posttest assessment. With the exception of base anxiety, all scores reflect averages across six role-played situations.
responses and superior to both control groups. The only other m e a s u r e on which rational restructuring showed significantly greater i m p r o v e m e n t than control groups was on assertion content. The two control conditions did not differ from each other on any of the p e r f o r m a n c e measures. N o
bo
battery
Inventory
Inventory
S-R
S-R
of Hostifity
of Anxiousness
Inventory
Difficulty Inventory
Rathus Assertiveness
Assertion
Questionnaire
Measures
TABLE
2
-57.50*** -40.87*** 16.63
Pre-follow-up
Post-follow-up
5.07
-40.18"*
-45.25***
0.12
- 76.44* * *
- 61.00" ** 2.44
-76.56***
9.94*
46.76***
36.82* * *
- 0.28"
- 1.57***
- 1.29"**
RR
-63.44"**
Pre-post
Post-follow -up
Pre-follow-up
Pre-post
7.69
52.32***
Post-follow-up
44.63 * **
- 0.11
Post-follow-up
Pre-follow-up
- 1.66"**
Pre-follow-up
Pre-post
- 1.55***
Pre-post
BR/RR
Mean
-0.94
-29.44*
-28.50
- 8.00
- 57.00" **
-49.00**
9.62
36.56***
26.94* **
- 0.37" *
- 1.42***
- 1.05"**
BR
differences
WITHIN-GRouP MEAN DIFFERENCES FROM PRE- TO POSTTESTING~ PRETESTING TO FOLLOW-UP, AND POSTTESTING TO FOLLOW-UP
- 17.37
-33.69**
- 16.32
- 13.31
- 42.69* **
-29.38**
6.70
25.62**
18.62*
- 0.18*
-0.89***
-0.71"**
RC
--
--
2.93
--
--
- 14.67
--
--
4.47
--
--
-0.10
WL
Pre-post Pre-post Pre-post
Assertion content Speech dysfluencies Loudness/affect
1.49"** -0.59* 0.51"
-25.25** - 12.92" - 14.28"* - 16.60"*
1.88"** -0.70** 0.51 * 7* 1.49***
-
0.79*** -0.21 0.21
18.03"* 13.28" 18.68"* 12.92'
1.16"** -0.34 0.21 5 1.47***
1.42"** -0.72** 0.83"*
-20.13" - 16.40"* -23.13"* -3.93
1.99"** -0.61"* 0.83 * * 15"** 1.76***
0.25 -0.20 0.43
-21.35"* - 19.71"** -5.74 0.72
0.49** -0.39 0.43 1 0.63**
0.09 -0.52 0.11
-7.56 - 14.99 -2.13 -7.33
0.22 -0.19 0.11 -6 0.29
Significance of change based on within-group t tests. Follow-up data were based only on questionnaire measures, and were not obtained for the waiting-list control. For the Self-Esteem Scale, the lower the score, the more positive the self-esteem. * p < .05. ** p < .01. *** p < .001.
Note. BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list.
Pre-post Pre-post Pre-post Pre-post
Pre-post Pre-post Pre - p o s t Pre-post Pre-post
Anxiety Guilt Anger Base anxiety Behavioral role play test: first response
Behavioral role play test: subjective emotional response
Behavioral role play test: performance ratings Assertion content Speech dysfluencies Loudne s s/affect Eyegazing (percentage) No. of responses
384
LINEHAN, GOLDFRIED, AND GOLDFRIED
significant differences emerged among any of the treatment procedures on loudnes s/affect. The data for the total number of responses should be interpreted in light of the violation of homogeneity of regression assumption on this variable (F (4, 69) = 3.05, p < .02). An examination of the correlations between pretesting and posttesting indicated a positive relationship in the rational restructuring and two control groups, but not in either of the two procedures involving behavior rehearsal, where the correlations approached zero. Within-group mean differences between pre- and posttesting for each of the performance ratings reflect significant improvement on all measures for both the behavior rehearsal/rational restructuring and behavioral rehearsal alone conditions (see Table 2). The results for rational restructuring and the relationship control are comparable in that significant improvement was found for content of assertive responses and and total number of responses. No significant changes were obtained for the waiting-list control. Participants' ratings of their subjective emotional responses showed a main effect of Treatment for anger. Tests for differences between individual adjusted means, however, did not reveal a significant difference between any pair of means. There were no main effects for treatment of subjective measures of anxiety and guilt. Examination of pre- and posttest means and associated t tests (see Table 2) indicated that all three behavioral treatment groups reported less anxiety, guilt, and anger following treatment; the relationship control reported less anxiety and guilt, but no significant change on subjective anger. Once again, there were no pre-post differences on any variable for the waiting-list control. The analyses of covariance did not indicate any significant treatment effect for base anxiety, that is, participants' estimate of their typical level of anxiety (see Table 1). However, within-group t tests between pre- and posttesting indicated significant decrements in base anxiety for those procedures incorporating rational restructuring, either alone or in combination with behavior rehearsal (see Table 2). Behavioral role-play test: First response. Separate analyses were carried out for the first response only on the extended interaction test. Participants in each of three behavioral groups were rated as significantly more assertive on their first responses than those in either of the control conditions (see Table 1). There were no significant treatment effects for speech dysfluencies or loudness/affect. Analysis of the withingroup t test (see Table 2) revealed a pattern similar to that found for the extended interaction analysis. Contrived situational test. The assertive content of each response in the contrived situational test was determined on the basis tf two raters, with an interrater reliability of .88. Inasmuch as the test was administered at posttesting only, a one-way analysis of variance was computed for each variable. A main effect for Treatment condition was found on each measure (see Table 3). Tests between adjusted means indicated that while
ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G
385
TABLE 3 ANALYSES OF VARIANCE FOR TREATMENT EFFECTS." CONTRIVED SITUATIONAL TEST Analyses of variance a Measure Assertion content: across responses Assertion content: first response No. of responses
Treatment means
F
df
p
B1URR
RR
BR
RC
10.28
(4,55)
.001
3.87ab
3.46ac
4.05b
3.20c
3.07c
3.12 3.92
(4,57) (4,49)
.022 .002
4.17ab 4.89a
3.92ab 4.58ab
4.30b 4.92a
3.63a 4.32b
3.79ab 4.44b
WL
Note: Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list. Means in the same row with different subscripts differ from each other at least at the .05 level. a Only the main effects for treatment are presented. The complete three-way table (treatment × location × sex of therapist) may be obtained from the first author.
behavior rehearsal/rational restructuring and behavioral rehearsal alone did not differ from each other, each of these two conditions was superior to both controls on the basis of assertion content across responses and total number of responses. Further superiority for the behavior rehearsal condition was reflected by significantly higher scores than rational restructuring on assertion content score for first response when compared with the relationship control. No other significant differences were found. Peer questionnaire. X2 analyses indicated that when compared with participants in the relationship and waiting-list control groups, clients in the three behavioral treatment groups (behavior rehearsal/rational restructuring, behavior rehearsal, and rational restructuring) were more likely to be seen as easier to get along with (X2 --- 5.8, df = 1,p < .05; 44% for the behavioral conditions vs 17% for the control conditions). There were no differences between individual treatments in either group. Only 11% of the peers in the behavioral treatment conditions and 14% in the two control groups reported more difficulty in relationships.
Treatment Effects: Follow-Up Analyses of covariance were carried out to test whether treatment differences were maintained on the self-report measures at follow-up 8 to 10 weeks after termination. As noted previously, waiting-list participants were not included because of ethical considerations, and instead were offered treatment following the posttesting. Main effects for treatment were found for the Assertion Difficulty Inventory (F (3, 59) = 3.5, p < .02) and the Rathus Assertiveness Inventory ( F (3, 59) = 3.5, p < .02).
386
LINEHAN, GOLDFRIED, AND GOLDFRIED
Although the direction of differences was similar to the direction at posttesting, comparisons between adjusted means indicated no significant pair-wise differences. Within-group t tests between pretest and follow-up questionnaire measures revealed a significant improvement for all conditions on all measures (see Table 2). To determine whether the questionnaire changes obtained at posttesting were maintained at follow-up assessment, withingroup t tests were also computed between posttest and follow-up assessment on both the Assertion Difficulty and Rathus Assertiveness Inventories. Participants in both behavior rehearsal and the relationship control also showed continued improvement on the Assertion Difficulty Inventory.
DISCUSSION The findings indicate that a combined intervention procedure, employing both behavioral rehearsal and systematic rational restructuring, was the most effective in increasing assertive behavior and reducing the emotional discomfort associated with such interactions. This superiority, however, was a function of the greater improvement in the combined group relative to the control groups. Participants receiving behavior rehearsal, for the most part, demonstrated gains on self-report measures as well as superiority over participants not receiving the behavioral rehearsal component on qualitative measures of overt assertion. Of particular interest is the finding that behavior rehearsal therapy, in which clients were told to ignore their emotional responses, was effective in reducing a range of maladaptive emotional responses related to assertion in addition to increasing the number and quality of assertive responses. Cognitive therapy alone also showed improvement at posttesting. Although the content of the responses given by participants in rational restructuring was not as assertive as those emitted by individuals in the other two behavioral interventions, it was superior to those given by participants in both control conditions. Our findings lend tentative support to the clinical observations of Lange and Jakubowski (1976), who have suggested that a combination of cognitive restructuring and skill acquisition interventions are the optimal treatment for facilitating assertive behavior. Despite the fact that the relationship control was both not significantly better than the waiting-list control group on any measure used in the study, and significantly less assertive on many performance measures than the behavioral interventions, the participants self-reported the same degree of success in learning to behave assertively and in reducing their problematic emotional responses in assertive situations. These results are comparable to the results of Wolfe and Fodor (1977) who found a similar relationship between their consciousness-raising group and the two behavioral interventions. The subjective experience of benefit reported by the relationship control participants suggests that the very experience of being in therapy may help
A S S E R T I O N : SKILL OR C O G N I T I V E R E S T R U C T U R I N G
387
women at least feel better in assertive situations. It is not clear whether this is due to the stated purposes of the treatment (i.e., expressing oneself in a supportive environment), the giving of the permission to behave assertively inherent in any assertion therapy, or any number of other variables that might have been operating. Another major finding of this research was that sex of therapist was not a significant factor in assertion training with our female participants. While our findings are clear, care must be taken as to how they are interpreted. Within the context of the present research, potential bias may have been undercut by virtue of a built-in agreement between client and therapist that the goal was to facilitate assertive behavior. There may be differences in actual clinical settings, particularly in selecting goals and specifying actual behavioral changes needed. In light of the much publicized popular view that assertion training with women may result in increased aggression, hostility, and anger and, thus jeopardize interpersonal relationships, our results are of particular interest and give evidence to the contrary. Across all three behavioral interventions, there was a self-reported decrease, not increase in hostility and anger as a result of treatment. Although retrospective reports on the quality of a relationship must be viewed with caution, the results suggest that relationships were improved as a result of participation in the program. Content of the initial response only for participants in the rational restructuring condition was just as assertive as for those in either behavior rehearsal/rational restructuring or behavior rehearsal alone. When all response associated with the extended interaction are considered, however, rational restructuring participants were not as assertive as either of the other two behavioral conditions. An extended interaction role-playing test may be preferable to use in future outcome research on the grounds that it more closely parallels the nature of an assertion interaction in real life. Although the role-play test may be quite adequate as a measure of the person's assertion capability, this may not reflect the extent of the person's actual assertive responding in the natural envionment. Our finding that a treatment procedure combining both behavior rehearsal and rational restructuring is most effective could be the result of its greater applicability to the range of controlling variables associated with unassertive behavior, rather than evidence of its superiority for use with all unassertive persons. It could be that some of the particip~ :s in the cognitive restructuring therapy might have benefited more t am a behavior rehearsal therapy, and vice versa. A more appropriate methodology in future research would be to carefully assess each participant across each of the assertion response systems, including verbal and nonverbal assertive motor skills, social-evaluative anxiety, and beliefs about both the appropriateness and consequences of assertion; treatment packages, ideographically designed, could then be implemented and compared.
388
LINEHAN, GOLDFRIED, AND GOLDFRIED
REFERENCES Bergin, A. E., & Strupp, H. H. New directions in psychotherapy research. Journal of Abnormal Psychology, 1970, 76, 13-26. Dayton, D. M. Design of educational experiments. New York: McGraw-Hill, 1970. Endler, N. S., & Hunt, J. McV. S - R inventories of hostility and comparison of the proportion of variance from persons, responses, and situations for hostility and anxiousness. Journal of Personality and Social Psychology, 1968, 9, 309-315. Endler, M. S., Hunt, J. McV., & Rosenstein, A. J. An S - R inventory of anxiousness. Psychological Monograph. 1962, 76 (17), Whole No. 536. Goldfried, M. R., Decenteceo, E. T., & Weinberg, L. Systematic rational restructuring as a self-control technique. Behavior Therapy, 1974, 5, 247-254. Kazdin, A. E. Effects of covert modeling and model reinforcement on assertive behavior. Journal of Abnormal Psychology, 1974, 83, 240-252. Lange, A. J., & Jackubowski, P. Responsible assertive behavior: Cognitive~behavioral procedures for trainers. Champaign, IL: Research Press, 1976. Linehan, M. Structured cognitive-behavioral treatment of assertion problems. In P. C. Kendall & S. P. Hollon (Eds.), Cognitive-behavioral interventions: Theory, research, and procedures. New York: Academic Press, 1979. Mahl, G. F. Exploring emotional states by content analysis. In I. D. Pool (Ed.), Trends in content analysis. Urbana, IL: Univ. of Illinois Press, 1959. McFall, R. M., & Twentyman, C. T. Four experiments on the relative contributors of rehearsal, modeling, and coaching on assertion training. Journal of Abnormal Psychology, 1973, 81, 199-218. Parloff, M. B., Waskow, I. E., & Wolfe, B. E. Research on therapist variables in relation to process and outcome. In S. L. Garfield & A. E. Bergin (Eds.) Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed.). New York: Wiley, 1978. Rathus, S. A. A 30-item schedule for assessing assertive behavior. Behavior Therapy, 1973, 4, 398-406. Rich, A. R., & Schrueder, H. E. Research issues in assertiveness training. Psychological Bulletin, 1976, 83, 1081-1096. Salter, A. Conditioned reflex therapy. New York: Creative Age, 1949. Schwartz, R. M., & Gottman, J. M. A task analysis approach to clinical problems: A study of assertive behavior: Journal of Consulting and Clinical Psychology, 1976, 44, 910920. Thorpe, G. L. Desensitization, behavior rehearsal, self-instructional training and placebo effects on assertive-refusal behavior. European Journal of Behavioral Analysis and Modification, 1975, 1, 30-44. Trower, P., Yardley, K., Bryant, B. M. & Shaw, P. The treatment of social failure: A comparison of anxiety-reduction and skill-acquisition procedures on two social problems. Behavior Modification, 1978, 2, 41-60. Winer, B. J. Statistical principles in experimental design. New York: McGraw-Hill, 1971. Wolfe, J. L., & Fodor, I. G. Modifying assertive behavior in women: A comparison of three approaches. Behavior Therapy, 1977, 8, 567-574. Wolpe, J. The practice of behavior therapy (2nd ed.). Elmsford, NY: Pergamon, 1973. RECEIVED: May 25, 1978; REVISED: December 1, 1978 FINAL ACCEPTANCE: January 18, 1979