- Email: [email protected]
Assertive behavior of alcoholics: A descriptive analysis
BEHAVIOR THERAPY 8, 146-149 (1977)
Assertive Behavior of Alcoholics: A Descriptive Analysis PETER
M. M I L L E R
Hilton Head Hospital Hilton Head Island, South Carolina AND RICHARD M. EISLER
University o f Mississippi Medical Center Alcoholic and nonalcoholic psychiatric patients were c o m p a r e d on selfreported a s s e r t i v e n e s s a n d behavioral a s s e r t i v e n e s s . In addition, the relationship b e t w e e n the a s s e r t i v e n e s s of alcoholics and their alcohol drinking behavior was a s s e s s e d . Results indicated that, while alcoholics reported t h e m s e l v e s to be more assertive than nonalcoholics, both groups were equally nonassertive on behavioral tests m e a s u r i n g negative assertion (expression of a n g e r or irritation). H o w e v e r , alcoholics performed significantly better than nonalcoholics on positive a s s e r t i v e n e s s (expression of positive feelings or complimentary remarks). A negative correlation was found b e t w e e n negative a s s e r t i v e n e s s and alcohol c o n s u m p tion.
Clinical and experimental studies on alcoholism have indicated that interpersonal situations which require assertive responses are stressful for alcoholics and frequently set the occasion for excessive drinking. Using an operant analog drinking task, Miller, Hersen, Eisler, and Hilsman (1974) exposed both alcoholics and social drinkers to interpersonal encounters requiring assertiveness. While both groups were stressed equally in terms of autonomic arousal, alcoholics significantly increased their operant drinking subsequent to these situations whereas social drinkers did not. In a similar study, Marlatt, Kosturn, and Lang (1975) deliberately angered heavy drinking college students and observed the effects on their drinking via a laboratory taste rating task. The results indicated that subjects who were allowed to retaliate against the source of their arousal drank significantly less than those who were prevented from doing so. The authors hypothesized that alcoholics who do not respond to interpersonal conflict (possibly because of deficits in assertion skills) would also drink to excess in response to similar situations. The present study further evaluated these issues with particular referR e q u e s t s for reprints should be sent to Peter M. Miller, D e p a r t m e n t of Psychiatry, University of Mississippi Medical Center, J a c k s o n , MS 39216. 146 Copyright @ 1977by the Associationfor Advancementof Behavior Therapy. All rights of reproduction in any form reserved.
ISSN 0005-7894
A S S E R T I V E B E H A V I O R OF A L C O H O L I C S
e n c e t o (1) t h e r e l a t i o n s h i p b e t w e e n
147
alcoholics' self-report of their asser-
t i v e n e s s c o m p a r e d w i t h t h e i r a c t u a l b e h a v i o r , (2) t h e r e l a t i o n s h i p b e t w e e n a l c o h o l i c s ' a s s e r t i v e r e s p o n d i n g a n d t h e i r d r i n k i n g b e h a v i o r , a n d (3) t h e assertive behavior of alcoholic patients as compared to patients receiving psychiatric treatment for other disorders.
METHOD Data were obtained from a previous study by Eisler, Hersen, Miller, and Blanchard (1975). From their total of 60 male psychiatric patients, 10 alcoholics and 10 nonalcoholics (nonpsychotics) were chosen at random. The alcoholics were characterized by numerous past hospitalizations, loss of employment, and loss of family due to their excessive drinking. The remaining 10 subjects were psychiatric patients who had been diagnosed as either character disorders, neurotics, or adult situational reactions. On the basis of medical records and family information, none of the psychiatric patients had a history of abusive drinking. Mean age and education for the alcoholics were 46.1 and 12.5 years, respectively, as compared to 45.7 and 12.4 years for the nonalcoholic group. Procedure. All subjects had been administered the Wolpe-Lazarus (1966) inventory as a measure of self-reported assertiveness. Thirty-two assertive situations were role-played and recorded on videotape. Role-played situations included scenes requiring both positive (e.g., expressing warm feelings or complimentary remarks) and negative (e.g., expressing feelings of irritation or disapproval) assertiveness. All scenes were role-played in a simulated living room containing a portable television camera and a two-way intercom system. Subjects' responses were observed and recorded via a television monitor and equipment in an adjoining room. Subjects were told that the role playing was a means of assessing their reactions to everyday situations with other people. Each subject was then seated next to the role model (research assistant) and each scene was described via an intercom from the adjacent room. After each narration, the role model delivered a prearranged verbal prompt to which the subjects were expected to respond. An example scene follows: You go to a ballgame with reserved seat tickets. When you arrive you find that someone has put his coat on the seat that you have reserved. You ask him to remove it. He tells you that he's saving it for a friend. He says, " I ' m sorry, but this seat is saved!" For a more detailed description of the role-played situations and procedures, see Eisler, Hersen, Miller, and Blanchard (1975). All videotaped responses were subsequently rated independently by two judges. Percentage of agreement exceeded 95% for all dependent measures. While a variety of verbal and nonverbal components of assertiveness were rated (Eisler, Miller, & Hersen, 1973), the present analysis utilized only a composite overall assertiveness rating. This measure was based on the ratings of two research assistants who rated the subjects' videotaped responses on a five-point overall assertiveness scale from 1 to 5. A score of 1 indicated "very unassertive" and a score of 5 indicated "very assertive." These raters were provided with Wolpe's (1969) definitions of "hostile" and "commendatory" assertiveness prior to independently rating the videotapes. On the three consecutive days following the administration of the assertiveness measures, the drinking behavior of subjects in the alcoholic group was assessed via a daily session on an operant drinking apparatus. This requires subjects to press a lever for a 10-min interval to obtain alcohol (dispensed into a shot glass) on an FR50 reinforcement schedule (Miller, Hersen, & Eisler, 1974; Miller, Hersen, Eisler, & Elkin, 1974). Subjects were instructed to press on the lever as many or as few times as they wished and to drink the alcohol that was dispensed.
148
MILLER AND EISLER TABLE 1 MEAN BEHAVIORAL ASSERTIVENESS RATINGS FOR ALCOHOLICS AND NONALCOHOLICS
Self-reports ( W o l p e - L a z a r u s ) Positive assertion Negative assertion
Alcoholics
Nonalcoholics
t
20.3 2.98 2.55
14.3 2.44 2.31
3.17 (p < .01) 2.50 (p < .05) 1.13 (N.S.)
The drinking task was not administered to nonalcoholic subjects since this study w a s designed primarily to evaluate a s s e r t i v e n e s s rather t h a n drinking behavior per se. Drinking data were obtained on alcoholic subjects as part of a regular overall behavioral a s s e s s m e n t prior to treatment.
RESU kTS Self-report of assertiveness as measured by the Wolpe-Lazarus inventory was compared for both alcoholics and nonalcoholics. The maximum possible assertiveness score on this inventory is 30. The alcoholics scored significantly higher on this measure than did the nonalcoholics. Both alcoholics and nonalcoholics scored equally low in their ability to express negative feelings. Differences were found, however, when the groups were compared on expression of positive assertiveness. The alcoholics scored significantly higher on this measure than the nonalcoholics. There was no significant correlation between positive assertion and drinking. However, the correlation of -.63 between negative assertion and operant drinking is significant (p < .05). Thus, the less assertive an alcoholic was behaviorally, the more alcohol he was likely to consume. DISCUSSION Alcoholics perceive themselves as being more assertive than other psychiatric patients on self-report measures. Behaviorally, however, these groups were both equally unassertive when expressing feelings of anger or irritation. In addition, the inability to express feelings was demonstrated to be positively related to the amount of alcohol ingested. Alcoholics did perform significantly better than other patients in situations requiring the ability to express positive and complimentary feelings. Clinically, this analysis appears to have two implications. First, clinicians must be wary of exaggerated self-reports of assertiveness by alcoholics and check the accuracy of these reports via direct behavioral observations or reports from others. Also, in addition to teaching an alcoholic appropriate assertive responses, clinicians may be required to increase the accuracy of the alcoholic's self-observation of his interactive behavior in order to elicit the patient's cooperation with training. Second, training alcoholics to express negative feelings may be more essential to
ASSERTIVE
BEHAVIOR
OF ALCOHOLICS
149
therapeutic success than teaching positive assertiveness. In general, these results emphasize the importance of teaching appropriate assertive skills to alcoholics as part of their total treatment program. REFERENCES Eisler, R. M., Hersen, M., Miller, P. M., & Blanchard, E. B. Situational determinants of and Clinical Psychology, 1975,43,330-340. assertive behaviors. Journal of Consulting Eisler, R. M., Miller, P. M., & Hersen, M. Components of assertive behavior. Journal of Clinical Psychology, 1973, 29, 295-299. Marlatt, G. A., Kosturn, C. F., & Lang, A. R. Provocation to anger and opportunity for retaliation as determinants of alcohol consumption in social drinkers. Journal ofAbnormal Psychology, 1975, 84, 652-659. Miller, P. M., Hersen, M., & Eisler, R. M. Relative effectiveness of instructions, agreements, and reinforcement in behavioral contracts with alcoholics. Journal of Abnormal
Psychology,
1974,
83, 548-553.
Miller, P. M., Hersen, M., Eisler, R. M., & Elkin, T. E. A retrospective analysis of alcohol Reconsumption on laboratory tasks as related to therapeutic outcome. Behaviour search
and
Therapy,
1974,
12, 73-76.
Miller, P. M., Hersen, M., Eisler, R. M., & H&man, G. Effects of social stress on operant drinking of alcoholics and social drinkers. Behaviour Research and Therapy, 1974, 12, 67-72. therapy techniques. New York: Pergamon Press, Wolpe, J., & Lazarus, A. A. Behavior 1966. RECEIVED: FINAL
September 5, 1975 April 30, 1976
ACCEPTANCE:
Assertive Behavior of Alcoholics: A Descriptive Analysis PETER
M. M I L L E R
Hilton Head Hospital Hilton Head Island, South Carolina AND RICHARD M. EISLER
University o f Mississippi Medical Center Alcoholic and nonalcoholic psychiatric patients were c o m p a r e d on selfreported a s s e r t i v e n e s s a n d behavioral a s s e r t i v e n e s s . In addition, the relationship b e t w e e n the a s s e r t i v e n e s s of alcoholics and their alcohol drinking behavior was a s s e s s e d . Results indicated that, while alcoholics reported t h e m s e l v e s to be more assertive than nonalcoholics, both groups were equally nonassertive on behavioral tests m e a s u r i n g negative assertion (expression of a n g e r or irritation). H o w e v e r , alcoholics performed significantly better than nonalcoholics on positive a s s e r t i v e n e s s (expression of positive feelings or complimentary remarks). A negative correlation was found b e t w e e n negative a s s e r t i v e n e s s and alcohol c o n s u m p tion.
Clinical and experimental studies on alcoholism have indicated that interpersonal situations which require assertive responses are stressful for alcoholics and frequently set the occasion for excessive drinking. Using an operant analog drinking task, Miller, Hersen, Eisler, and Hilsman (1974) exposed both alcoholics and social drinkers to interpersonal encounters requiring assertiveness. While both groups were stressed equally in terms of autonomic arousal, alcoholics significantly increased their operant drinking subsequent to these situations whereas social drinkers did not. In a similar study, Marlatt, Kosturn, and Lang (1975) deliberately angered heavy drinking college students and observed the effects on their drinking via a laboratory taste rating task. The results indicated that subjects who were allowed to retaliate against the source of their arousal drank significantly less than those who were prevented from doing so. The authors hypothesized that alcoholics who do not respond to interpersonal conflict (possibly because of deficits in assertion skills) would also drink to excess in response to similar situations. The present study further evaluated these issues with particular referR e q u e s t s for reprints should be sent to Peter M. Miller, D e p a r t m e n t of Psychiatry, University of Mississippi Medical Center, J a c k s o n , MS 39216. 146 Copyright @ 1977by the Associationfor Advancementof Behavior Therapy. All rights of reproduction in any form reserved.
ISSN 0005-7894
A S S E R T I V E B E H A V I O R OF A L C O H O L I C S
e n c e t o (1) t h e r e l a t i o n s h i p b e t w e e n
147
alcoholics' self-report of their asser-
t i v e n e s s c o m p a r e d w i t h t h e i r a c t u a l b e h a v i o r , (2) t h e r e l a t i o n s h i p b e t w e e n a l c o h o l i c s ' a s s e r t i v e r e s p o n d i n g a n d t h e i r d r i n k i n g b e h a v i o r , a n d (3) t h e assertive behavior of alcoholic patients as compared to patients receiving psychiatric treatment for other disorders.
METHOD Data were obtained from a previous study by Eisler, Hersen, Miller, and Blanchard (1975). From their total of 60 male psychiatric patients, 10 alcoholics and 10 nonalcoholics (nonpsychotics) were chosen at random. The alcoholics were characterized by numerous past hospitalizations, loss of employment, and loss of family due to their excessive drinking. The remaining 10 subjects were psychiatric patients who had been diagnosed as either character disorders, neurotics, or adult situational reactions. On the basis of medical records and family information, none of the psychiatric patients had a history of abusive drinking. Mean age and education for the alcoholics were 46.1 and 12.5 years, respectively, as compared to 45.7 and 12.4 years for the nonalcoholic group. Procedure. All subjects had been administered the Wolpe-Lazarus (1966) inventory as a measure of self-reported assertiveness. Thirty-two assertive situations were role-played and recorded on videotape. Role-played situations included scenes requiring both positive (e.g., expressing warm feelings or complimentary remarks) and negative (e.g., expressing feelings of irritation or disapproval) assertiveness. All scenes were role-played in a simulated living room containing a portable television camera and a two-way intercom system. Subjects' responses were observed and recorded via a television monitor and equipment in an adjoining room. Subjects were told that the role playing was a means of assessing their reactions to everyday situations with other people. Each subject was then seated next to the role model (research assistant) and each scene was described via an intercom from the adjacent room. After each narration, the role model delivered a prearranged verbal prompt to which the subjects were expected to respond. An example scene follows: You go to a ballgame with reserved seat tickets. When you arrive you find that someone has put his coat on the seat that you have reserved. You ask him to remove it. He tells you that he's saving it for a friend. He says, " I ' m sorry, but this seat is saved!" For a more detailed description of the role-played situations and procedures, see Eisler, Hersen, Miller, and Blanchard (1975). All videotaped responses were subsequently rated independently by two judges. Percentage of agreement exceeded 95% for all dependent measures. While a variety of verbal and nonverbal components of assertiveness were rated (Eisler, Miller, & Hersen, 1973), the present analysis utilized only a composite overall assertiveness rating. This measure was based on the ratings of two research assistants who rated the subjects' videotaped responses on a five-point overall assertiveness scale from 1 to 5. A score of 1 indicated "very unassertive" and a score of 5 indicated "very assertive." These raters were provided with Wolpe's (1969) definitions of "hostile" and "commendatory" assertiveness prior to independently rating the videotapes. On the three consecutive days following the administration of the assertiveness measures, the drinking behavior of subjects in the alcoholic group was assessed via a daily session on an operant drinking apparatus. This requires subjects to press a lever for a 10-min interval to obtain alcohol (dispensed into a shot glass) on an FR50 reinforcement schedule (Miller, Hersen, & Eisler, 1974; Miller, Hersen, Eisler, & Elkin, 1974). Subjects were instructed to press on the lever as many or as few times as they wished and to drink the alcohol that was dispensed.
148
MILLER AND EISLER TABLE 1 MEAN BEHAVIORAL ASSERTIVENESS RATINGS FOR ALCOHOLICS AND NONALCOHOLICS
Self-reports ( W o l p e - L a z a r u s ) Positive assertion Negative assertion
Alcoholics
Nonalcoholics
t
20.3 2.98 2.55
14.3 2.44 2.31
3.17 (p < .01) 2.50 (p < .05) 1.13 (N.S.)
The drinking task was not administered to nonalcoholic subjects since this study w a s designed primarily to evaluate a s s e r t i v e n e s s rather t h a n drinking behavior per se. Drinking data were obtained on alcoholic subjects as part of a regular overall behavioral a s s e s s m e n t prior to treatment.
RESU kTS Self-report of assertiveness as measured by the Wolpe-Lazarus inventory was compared for both alcoholics and nonalcoholics. The maximum possible assertiveness score on this inventory is 30. The alcoholics scored significantly higher on this measure than did the nonalcoholics. Both alcoholics and nonalcoholics scored equally low in their ability to express negative feelings. Differences were found, however, when the groups were compared on expression of positive assertiveness. The alcoholics scored significantly higher on this measure than the nonalcoholics. There was no significant correlation between positive assertion and drinking. However, the correlation of -.63 between negative assertion and operant drinking is significant (p < .05). Thus, the less assertive an alcoholic was behaviorally, the more alcohol he was likely to consume. DISCUSSION Alcoholics perceive themselves as being more assertive than other psychiatric patients on self-report measures. Behaviorally, however, these groups were both equally unassertive when expressing feelings of anger or irritation. In addition, the inability to express feelings was demonstrated to be positively related to the amount of alcohol ingested. Alcoholics did perform significantly better than other patients in situations requiring the ability to express positive and complimentary feelings. Clinically, this analysis appears to have two implications. First, clinicians must be wary of exaggerated self-reports of assertiveness by alcoholics and check the accuracy of these reports via direct behavioral observations or reports from others. Also, in addition to teaching an alcoholic appropriate assertive responses, clinicians may be required to increase the accuracy of the alcoholic's self-observation of his interactive behavior in order to elicit the patient's cooperation with training. Second, training alcoholics to express negative feelings may be more essential to
ASSERTIVE
BEHAVIOR
OF ALCOHOLICS
149
therapeutic success than teaching positive assertiveness. In general, these results emphasize the importance of teaching appropriate assertive skills to alcoholics as part of their total treatment program. REFERENCES Eisler, R. M., Hersen, M., Miller, P. M., & Blanchard, E. B. Situational determinants of and Clinical Psychology, 1975,43,330-340. assertive behaviors. Journal of Consulting Eisler, R. M., Miller, P. M., & Hersen, M. Components of assertive behavior. Journal of Clinical Psychology, 1973, 29, 295-299. Marlatt, G. A., Kosturn, C. F., & Lang, A. R. Provocation to anger and opportunity for retaliation as determinants of alcohol consumption in social drinkers. Journal ofAbnormal Psychology, 1975, 84, 652-659. Miller, P. M., Hersen, M., & Eisler, R. M. Relative effectiveness of instructions, agreements, and reinforcement in behavioral contracts with alcoholics. Journal of Abnormal
Psychology,
1974,
83, 548-553.
Miller, P. M., Hersen, M., Eisler, R. M., & Elkin, T. E. A retrospective analysis of alcohol Reconsumption on laboratory tasks as related to therapeutic outcome. Behaviour search
and
Therapy,
1974,
12, 73-76.
Miller, P. M., Hersen, M., Eisler, R. M., & H&man, G. Effects of social stress on operant drinking of alcoholics and social drinkers. Behaviour Research and Therapy, 1974, 12, 67-72. therapy techniques. New York: Pergamon Press, Wolpe, J., & Lazarus, A. A. Behavior 1966. RECEIVED: FINAL
September 5, 1975 April 30, 1976
ACCEPTANCE: