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Modifying assertive behavior in women: A comparison of three approaches
BEHAVIOR THERAPY 8, 567-574 (1977)
Modifying Assertive Behavior in Women: A Comparison of Three Approaches JANET L . W O L F E
Institute for Advanced Study in Rational Psychotherapy AND
IRIS G . FODOR
New York University Modeling-plus-behavior rehearsal (BT), modeling-plus-behavior rehearsalplus-rational therapy (RBT), a consciousness-raising group (CR), and a notreatment waiting list control (WL) were compared in the treatment of assertion difficulties in 64 women in an outpatient clinical setting. Both BT and RBT showed significant improvement on the content and paralinguistic scales of the behavioral measure on treated situations. These effects also generalized to nontreated situations. Only RBT showed reduction in situational anxiety. CR proved to be ineffective.
Difficulties in self-assertion in women appear related to differential sex role socialization, which trains them to be passive, nurturant, and dependent (Block, 1973; Fodor, 1974). Attention has been drawn to the ways in which therapists have inhibited assertive strivings in women (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970; Chesler, 1972). As women begin to develop new assertive behaviors, increased anxiety frequently results (Jakubowski-Spector, 1973; Wolfe & Fodor, 1975). Lange and Jakubowski (1976) and Lazarus and Fay (1975) describe a cognitive behavioral program that not only trains people to behave more assertively, but also helps them (following Ellis, 1962, 1974) to deal with their anxiety about change by identifying and challenging their irrational belief systems. In spite of the wide interest in such cognitive-behavioral This paper is based on the senior author's Ph.D. thesis. Requests for reprints should be addressed to Janet Wolfe at the Institute for Advanced Study in Rational Psychotherapy, 45 East 65th Street, New York, NY 10021. 567 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
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WOLFE AND FODOR
approaches to the modification of assertive behavior in women, there is a paucity of supportive research. Most of the reported assertiveness training programs have emphasized direct behavioral training utilizing variants of the clinical modeling and behavior rehearsal procedures developed by Wolpe and Lazarus (1966). Attempts to incorporate cognitive features into behavior training programs by means of instructions and feedback have been largely elaborations of a basically behaviorally oriented, skills-deficit approach; for example, the client is instructed to raise her voice, make "I-statements," or not to be so apologetic. For the most part, research in assertion training has ignored cognitive factors which deal with the clients' internal appraisals (thoughts about themselves and their behavior and evaluations of the consequences of their assertive behavior) and particularly the self-statements that may be associated with anxiety about self-assertion. Schwartz and Gottman (Note 4) found that low assertive subjects may know what to say in certain situations but are inhibited from emitting this response due to anxiety, and Goldfried (Note 2) suggests that it may be more appropriate to view unassertive behavior in part as a form of social evaluative anxiety and, as such, amenable to cognitive intervention procedures specifically designed to reduce anxiety. Rational-emotive therapy (RET) has been found effective in the treatment of speech anxiety (Meichenbaum, Gilmore, & Fedoravicius, 1971; Trexler & Karst, 1972), in the reduction of interpersonal anxiety (DiLoreto, 1970; Kanter, Note 3), in reducing anxiety (Burkhead, Note 1), and in treating rat phobias (D'Zurilla, Wilson, & Nelson, 1973). Extending cognitive restructuring research into the area of assertiveness deficits, Thorpe (1975) found that both self-instructional training (a procedure modeled on rational-emotive therapy) and modeling-plus-behavior rehearsal emerged superior to controls on self-report and behavioral measures. The present study compared three approaches: behavioral, behavioral/cognitive restructuring, and consciousness raising, a group process developed by the women's movement (Kirsch, 1974). It was hypothesized that the behavioral and cognitive/behavioral treatments would be more effective than consciousness-raising in modifying assertive behavior and that the combined cognitive/behavioral treatment would be the most effective in reducing anxiety accompanying assertive behavior. The group procedures were developed as therapy analog sufficiently controlled to lend themselves to outcome research and yet (with slight modification) also viable as short-term therapy programs suitable for groups of women in actual clinical settings.
ASSERTIVE BEHAVIOR IN WOMEN
569
METHOD Subjects Sixty-four women, aged 20 to 29 years, recruited through notices at an outpatient psychotherapy clinic calling for women experiencing difficulties in asserting themselves, were selected according to the following criteria: (1) a rating of 4 or less on a Global Self-Rating of Assertiveness which ranged from 1 ("extremely unassertive") to 6 ("extremely assertive"); and (2) a score not more than one and one-half standard deviations above or below the mean on the Rathus Assertiveness Schedule (Rathus, 1973).
Measures Behavioral measures. All subjects were asked to respond aloud to 11 situations described on the videotape by a narrator and enacted by an actor or actress. The pretest was individually administered to all subjects approximately I0 days before treatment, and the posttest was individually administered approximately 1 week following treatment. All responses were tape-recorded. The items represented called for a variety of assertive behaviors, including refusal behavior, expression of negative feelings, and initiation of social contact. Two uninformed trained graduate students rated the tape-recorded responses in random order. Two 5-point rating scales were used: one to assess the assertive content, the other to assess such paralinguistic factors as firmness of voice and appropriateness .of affect. The scoring system was derived in part from McFall and Lillesand's (1971) rating scale but was amplified to include items not dealing with refusal behavior and modified so that it differentiated between assertive and aggressive responses, according to Alberti and Emmons' (1970) criteria. Possible scores on each of the two scales (Content and Paralinguistic) ranged from 1 to 55. The average interrater reliability for both scales exceeded .95 on both pre and postassessment. Self-report measures. The Rathus Assertiveness Schedule (Raihus, 1973), the Social Avoidance and Distress Scale, and the Fear of Negative Evaluation Scale (Watson & Friend, 1969) were administered as pre and posttest measures to all subjects. Following each of their responses to the 11 behavioral test stimulus situations, subjects rated the amount of anxiety experienced on a 4-point scale similar to Walk's (1956) "fear thermometer." Posttreatment data sheets. At the end of the second treatment session, all subjects filled out a posttreatment Rating Form, rating their therapist in terms of competence, likability, and other factors on a 6-point Likert-type scale. A Postexperimental Questionnaire, assessing reactions to the treatment, was completed by each subject after the posttest session. Treatment Procedures Following the behavioral preassessment, the 64 subjects were assigned to matched treatment or control groups, with Rathus means and ages roughly comparable in each group. The groups were randomly assigned to one of three treatment conditions and to one of the two therapists, or to the waiting list control. The six treatment groups, behavior therapy (BT), rational therapy plus behavior therapy (RBT), and consciousness-raising (CR), each met for two 2-hr sessions I week apart; the 16 WL subjects were told that treatment would be delayed 3 weeks. Behavior therapy: Modeling-plus-behavior rehearsal (BT) (modeled after the assertion training procedures of Lazarus, 1971, and McFall and Lillesand, 1971). The treatment rationale given was that people could be helped to become more assertive by learning what constituted an appropriate assertive response and by practicing and receiving feedback on
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WOLFE AND FODOR
their assertive behavior. A brief talk, designed to teach discrimination between assertive, nonassertive, and aggressive behavior, was followed by a 15-rain videotape which reviewed definitions and showed three different female models responding to three different situations calling for assertiveness: a secretary dealing with an overly critical boss, a woman confronting her lover about his frequent last-minute date cancellations, and a student dealing with her mother's attempted interference in her life. The remainder of session one was devoted to role-playing three of the I 1 behavioral test situations, with three subjects consecutively role-playing responses to each situation, followed by therapist and group feedback and the therapist's modeling of an appropriate response. Finally, the three subjects were given a second opportunity to role-play the situation, The same procedure was followed with three different subjects for each of two other stimulus situations. At the end of the first session, subjects were given the homework assignment of observing their own and others' responses in situations calling for assertiveness. During the second treatment session 30 min of discussion of homework was followed by role-playing of three more situations from the behavioral assessment, each by three new group members, according to the same format as the first session.
Rational~Behavior therapy: Modeling-plus-behavior rehearsal-plus rational therapy (RBT). This technique was designed to determine the extent to which the addition of a cognitive component, in the form of rational therapy, to the behavior therapy assertiveness training "'package" would enhance its effectiveness. Procedures were similar to those employed in the BT group, with the following revisions and additions: The treatment retionale was described to group members as one in which they would learn what constitutes an appropriate assertive response, practice assertive behavior, and identify and counteract assertion-impeding beliefs. In the first session, subjects were given the same introduction as the BT group, with the following addition: Several irrational beliefs or self-statements, explained as being related to assertiveness difficulties in women, were listed. These self-statements, adapted from Ellis' 12 Irrational Ideas (Ellis, 1962), included the belief that it is awful to hurt other people or make them angry and that it is awful to make a "fool" of oneself or to be rejected. It was explained that by learning to challenge some of these irrational self-statements, a good deal of the anxiety associated with assertiveness difficulties could be eradicated, Videotapes identical to those used in the BT group were then shown; these tapes had edited onto them, however, the model's voice-over maladaptire and adaptive (irrational and rational) self-verbalizations that preceded or followed each of their responses, following the "coping model" advocated by Meichenbaum (1971). The BT narration was amplified to include an explanation of the role of these self-verbalizations in impeding and facilitating effective assertion. Role-playing procedures employed the same three situations used in the BT sessions. In addition, subjects were instructed, as they performed the role-playing, to "'try to identify some of the ideas that were going through your head as you attempted to respond." During the feedback phase of the behavior rehearsal, group members were encouraged to counteract dysfunctional beliefs by formulating effective "'challenges" to them: for example, "So what if I say this to him and he thinks I'm a castrating bitch. I'd rather not live like a doormat the rest of my life. And if worst comes to worst, I can still lead a happy existence, even without him." The homework assignment given at the end of session one and discussed at the beginning of session two was to take notes on irrational beliefs or self-statements which subjects observed themselves making during the week in situations calling for assertiveness. Consciousness-raising. The treatment rationale which followed the introduction of group members was that women receive considerable help in the area of assertiveness by discussing and sharing with other women some of their common problems in this area and by learning about the influence of past experiences and early sex role conditioning. An approx-
ASSERTIVE BEHAVIOR IN WOMEN
571
imately 15-rain videotape was shown of a group of women discussing their assertion difficulties and appearing to gain considerable relief from doing so. For the remainder of session one, a "go-around" format typical of a consciousness-raising group was followed, with each woman having approximately 10 min to discuss in detail the history and nature of her major assertion difficulties. The other subjects were permitted to respond briefly and share similar experiences. The leader's role was carefully restricted to (I) facilitating group interaction, (2) probing further for historical roots of the problems, and (3) making generalizations about sex role conditioning and early learning. Group members were given the homework assignment of thinking back to other early experiences that may have contributed to their assertion problems. As with the BT and RBT groups, the first 30 min of the second session were devoted to a discussion of the homework; the remainder of the session followed the same discussion format as in session one. Waiting list control (WL). Following the behavioral assessment, WL subjects were told that it would be necessary to postpone therapy for approximately 3 weeks because of scheduling problems. It was stated that another behavioral assessment would be required at that time, for the purpose of judging subjects' level of assertiveness at the time treatment began. Approximately I week following the second behavioral assessment, all subjects in the waiting list control were given assertion training similar to that in the RBT or BT group.
RESULTS Premeasure analyses of variance revealed no initial pretreatment difference between groups, and a 2 × 4 factor analysis of variance indicated no significant difference between therapists. Behavioral Measures Tape recordings from the pre and posttreatment behavioral assessments were given to the two raters in random order, with no identification as to pre or posttests. An analysis of change scores (difference between pre and postscores) revealed highly significant~differences between treatment groups in the Assertive Content Scale [F (3, 56) = 16.22, p < .01]. Multiple comparisons between means using the Duncan Multiple Range test (Edwards, 1968) showed that both the BT and RBT groups performed significantly better than CR and WL (p < .01) but that there was no significance between CR and WL. Significant differences between groups on Paralinguistic Scale ratings were also found [F (3, 56) = 8.43, p < .01]. Further analysis revealed that (a) BT and RBT improved significantly over WL (p < .01); (b) CR also improved significantly more than WL, though less than the BT and RBT groups (p < .05); and (c) BT improved significantly more than CR (p < .05). Separate analyses of the five Behavioral Assessment items that were not used in the treatment revealed differential treatment effects [Content F (3, 56) = 4.10, p < .05; Paralinguistic F (3, 56) = 6.87, p < .01], demonstrating that a transfer of training did indeed occur in the BT and RBT groups (p < .01 and p < .05, respectively).
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W O L F E AND F O D O R
Self-Report Scales An analysis of variance of change scores indicated no significant F-ratio on the Rathus Assertiveness Schedule. No treatment effect was found on the Social Avoidance and Distress and the Fear of Negative Evaluation scales.
Self-Reported Anxiety Significant treatment differences were obtained on subjects' ratings of the degree of anxiety experienced while responding to the 11 Behavioral Test items, as measured by a 4-point "fear thermometer" IF (3, 56) = 4.27, p < .01]. When investigated by means of the Duncan test, the BT, CR, and WL groups did not improve differentially; only the RBT group showed significant reduction on this situational measure of anxiety (p < .01).
Questionnaire Measures Inconsistencies appeared between CR subjects' self-reports of improvement on the post-therapy questionnaire and actual improvement as measured on the more objective behavioral measure. Despite the fact that CR did not improve significantly more than WL controls on the two behavioral scales and the anxiety thermometer, they reported the same degree of success in learning to behave more assertively as did BT and RBT. The high pretest correlations between both the Content and Paralinguistic rating scales of the authors' behavioral test and the two other measures of assertiveness (Rathus Assertiveness Schedule and self-rated assertiveness) appear to be a fairly strong indicator of the behavioral measures' construct validity. They are similarly highly correlated with the other situational measure, the anxiety self-rating.
DISCUSSION This study offers support for the efficacy of BT and RBT in the treatment of assertiveness difficulties in women. Although brief, consisting of two 2-hr sessions, BT and RBT improved significantly on the major measure, the ratings of responses to a laboratory behavioral test. Moreover, the training effects generalized to nonpracticed scenes. While there appears to be little evidence that the rational therapy component produced significantly greater generalization than the largely behavioral (BT) approach, some partial support seems to be given to the therapeutic potential of a procedure combining behavior rehearsal with rational psychotherapy (the significant reduction in situational anxiety was demonstrated only in the RBT group). A major limitation is the brevity of the treatment. This may have
ASSERTIVE BEHAVIOR IN WOMEN
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particularly handicapped the RBT group who had the same amount of time as members of the BT group not only to do the behavior rehearsal, but also to elicit and challenge maladaptive self-statements. Ideally, more time is needed to explore the irrational ideas and to give subjects sufficient practice in constructing more facilitative self-statements. Despite CR's failure to differ significantly from WL controls on all but one dependent measure, the subjective experience of benefit reported by CR subjects on the posttherapy questionnaire was equivalent to that of the other two experimental groups. While possibly deriving, at least in part, from the demand characteristics of the assessment situation, there is some suggestion of "relief," if not overt behavioral change, accruing to participation in women's consciousness-raising groups, a finding previously suggested by Kirsch (1974) and Micossi (1970). One could hypothesize that, as subjects talked about anxiety-producing material within the relaxed, nonthreatening atmosphere of the CR group, there would be some extinction or counterconditioning of anxiety related to interpersonal performance. However, the CR group did not significantly decrease their anxiety during the behavioral assessment over WL controls. The only measure on which CR improved significantly was the Paralinguistic behavioral measure, suggesting, again, that participants sound better (more confident, less hesitant), while not significantly improving the content of their assertive responses. The present results provide some empirical support for the growing discontent on the part of many women with CR groups, which provide insight and sharing of experiences but often fail to provide actual tools for behavior change. REFERENCE NOTES 1. Burkhead, D. The reduction of negative affect in human subjects: A laboratory investigation of rational-emotive psychotherapy. Unpublished doctoral dissertation, Western Michigan University, 1970. 2. Goldfried, M. Outcome studies on social evaluative anxiety and assertive behavior. Paper presented at the First National Conference on Cognitive Behavior Therapy Research, New York City, 1976. 3. Kanter, N. A comparison of self-control, desensitization and systematic rational restructuring Jor the reduction of interpersonal anxiety. Unpublished doctoral dissertation. SUNY at Stony Brook, 1975. 4. Schwartz, R., & Gottman, J. A task analysis approach to clinical problems: A study of assertive behavior. Unpublished manuscript, Indiana University, 1974.
REFERENCES Alberti, R. E., & Emmons, M. L. Yourperfect right:A guide to assertive behavior. San Luis Obispo, CA: Impact, 1970. Block, J. H. Conceptions of sex role: Some cross-cultural and longitudinal perspectives. American Psychologist, 1973, 28, 512-526.
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Broverman, 1., Broverman. D., Clarkson, F.. Rosenkrantz, P., & Vogel, S. Sex role stereotypes and clinical judgments of mental health. Journal of Consulting and Clinical Psychology, 1970, 34, 1-7. Chesler, P. Women and madness. Garden City, New York: Doubleday. 1972. DiLoreto, A. A comparison of the relative effectiveness of systematic desensitization, rational-emotive and client-centered group therapy in the reduction of interpersonal anxiety in introverts and extroverts (Doctoral dissertation, Michigan State University). Ann Arbor, Michigan: University Microfilms, 1970, No. 70-9521. D'Zurilla, T. J., Wilson, G. T., & Nelson, R. A comparative study of systematic desensitization, prolonged imagery, and cognitive restructuring. Behavior Therapy, 1973, 4, 672685. Edwards, A. L. Experimental design in psychological research. New York: Holt, Rinehart & Winston, 1968. Ellis, A. Reason and emotion in psychotherapy. New York: Lyle Stuart, 1962. Ellis, A. Humanistic" psychotherapy: The rational-emotive approach. New York: Julian Press and McGraw-Hill Paperbacks, 1974. Fodor, I. G. Sex role conflict and symptom formation in women: Can behavior therapy help? Psychotherapy: Theory, Research and Practice, 1974, 2, 22-29. Jakubowski-Spector, P. Facilitating the growth of women through assertive training. The Counseling Psychologist, 1973, 4, 75-86. Kirsch, B. Consciousness-raising groups as therapy for women. In V. Franks & V. Burtle (Eds.), Women in therapy. New York: Brunner/Mazel, 1974. Lange, A., & Jakubowski, P. Responsible assertive behavior. Champaign, IL: Research Press, 1976. Lazarus, A. A. Behavior therapy and beyond. New York: McGraw-Hill, 1971. Lazarus, A. A., & Fay, A. 1 can i f l want to. New York: Morrow, 1975. McFall, R. M., & Lillesand, D. B. Behavior rehearsal with modeling and coaching in assertive training. Journal of Abnormal Psychology, 1971, 77, 313-323. Meichenbaum, D. H. Examination of model characteristics in reducing avoidance behavior. Journal of Persona6ty and Social Psychology, 1971, 17, 298-307. Meichenbaum, D. H., Gilmore, J. B., & Fedoravicius, A. Group insight versus group desensitization in treating speech anxiety. Journal of Consulting and Clinical Psychology, 1971, 36, 410-421. Micossi, A. L. Conversion to women's lib. Trans-Action, 1970, 8, 82-90. Rathus, S. A. A 30-item schedule for assessing assertive behavior. Behavior Therapy, 1973, 4, 398-406. Thorpe, G. L. Short-term effectiveness of systematic desensitization, modeling and behavior rehearsal, and self-instructional training in facilitating assertive-refusal behavior. European Journal of Behaviour Analysis and Modification, 1975, 1, 30-44. Trexler, L., & Karst, T. Rational-emotive therapy, placebo, and no-treatment effects on public speaking anxiety. Journal of Abnormal Psychology, 1972, 79, 60-67. Walk, R. D. Self-ratings of fear in a fear-invoking situation. Journal of Abnormal and Social Psychology, 1956, 52, 171-178. Watson, D., & Friend, R. Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 1969, 33, 448-457. Wolfe, J. L., & Fodor, I. G. A cognitive behavioral approach to modifying assertive behavior in women. The Counseling Psychologist, 1975, 5, 45-52. Wolpe, J., & Lazarus, A. A. Behavior therapy techniques: A guide to the treatment of neuroses. New York: Pergamon, 1966.
RECEIVED: February 2, 1976; REVISED: March 26, 1976 FINAL ACCEPTANCE: July 10, 1976
Modifying Assertive Behavior in Women: A Comparison of Three Approaches JANET L . W O L F E
Institute for Advanced Study in Rational Psychotherapy AND
IRIS G . FODOR
New York University Modeling-plus-behavior rehearsal (BT), modeling-plus-behavior rehearsalplus-rational therapy (RBT), a consciousness-raising group (CR), and a notreatment waiting list control (WL) were compared in the treatment of assertion difficulties in 64 women in an outpatient clinical setting. Both BT and RBT showed significant improvement on the content and paralinguistic scales of the behavioral measure on treated situations. These effects also generalized to nontreated situations. Only RBT showed reduction in situational anxiety. CR proved to be ineffective.
Difficulties in self-assertion in women appear related to differential sex role socialization, which trains them to be passive, nurturant, and dependent (Block, 1973; Fodor, 1974). Attention has been drawn to the ways in which therapists have inhibited assertive strivings in women (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970; Chesler, 1972). As women begin to develop new assertive behaviors, increased anxiety frequently results (Jakubowski-Spector, 1973; Wolfe & Fodor, 1975). Lange and Jakubowski (1976) and Lazarus and Fay (1975) describe a cognitive behavioral program that not only trains people to behave more assertively, but also helps them (following Ellis, 1962, 1974) to deal with their anxiety about change by identifying and challenging their irrational belief systems. In spite of the wide interest in such cognitive-behavioral This paper is based on the senior author's Ph.D. thesis. Requests for reprints should be addressed to Janet Wolfe at the Institute for Advanced Study in Rational Psychotherapy, 45 East 65th Street, New York, NY 10021. 567 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
568
WOLFE AND FODOR
approaches to the modification of assertive behavior in women, there is a paucity of supportive research. Most of the reported assertiveness training programs have emphasized direct behavioral training utilizing variants of the clinical modeling and behavior rehearsal procedures developed by Wolpe and Lazarus (1966). Attempts to incorporate cognitive features into behavior training programs by means of instructions and feedback have been largely elaborations of a basically behaviorally oriented, skills-deficit approach; for example, the client is instructed to raise her voice, make "I-statements," or not to be so apologetic. For the most part, research in assertion training has ignored cognitive factors which deal with the clients' internal appraisals (thoughts about themselves and their behavior and evaluations of the consequences of their assertive behavior) and particularly the self-statements that may be associated with anxiety about self-assertion. Schwartz and Gottman (Note 4) found that low assertive subjects may know what to say in certain situations but are inhibited from emitting this response due to anxiety, and Goldfried (Note 2) suggests that it may be more appropriate to view unassertive behavior in part as a form of social evaluative anxiety and, as such, amenable to cognitive intervention procedures specifically designed to reduce anxiety. Rational-emotive therapy (RET) has been found effective in the treatment of speech anxiety (Meichenbaum, Gilmore, & Fedoravicius, 1971; Trexler & Karst, 1972), in the reduction of interpersonal anxiety (DiLoreto, 1970; Kanter, Note 3), in reducing anxiety (Burkhead, Note 1), and in treating rat phobias (D'Zurilla, Wilson, & Nelson, 1973). Extending cognitive restructuring research into the area of assertiveness deficits, Thorpe (1975) found that both self-instructional training (a procedure modeled on rational-emotive therapy) and modeling-plus-behavior rehearsal emerged superior to controls on self-report and behavioral measures. The present study compared three approaches: behavioral, behavioral/cognitive restructuring, and consciousness raising, a group process developed by the women's movement (Kirsch, 1974). It was hypothesized that the behavioral and cognitive/behavioral treatments would be more effective than consciousness-raising in modifying assertive behavior and that the combined cognitive/behavioral treatment would be the most effective in reducing anxiety accompanying assertive behavior. The group procedures were developed as therapy analog sufficiently controlled to lend themselves to outcome research and yet (with slight modification) also viable as short-term therapy programs suitable for groups of women in actual clinical settings.
ASSERTIVE BEHAVIOR IN WOMEN
569
METHOD Subjects Sixty-four women, aged 20 to 29 years, recruited through notices at an outpatient psychotherapy clinic calling for women experiencing difficulties in asserting themselves, were selected according to the following criteria: (1) a rating of 4 or less on a Global Self-Rating of Assertiveness which ranged from 1 ("extremely unassertive") to 6 ("extremely assertive"); and (2) a score not more than one and one-half standard deviations above or below the mean on the Rathus Assertiveness Schedule (Rathus, 1973).
Measures Behavioral measures. All subjects were asked to respond aloud to 11 situations described on the videotape by a narrator and enacted by an actor or actress. The pretest was individually administered to all subjects approximately I0 days before treatment, and the posttest was individually administered approximately 1 week following treatment. All responses were tape-recorded. The items represented called for a variety of assertive behaviors, including refusal behavior, expression of negative feelings, and initiation of social contact. Two uninformed trained graduate students rated the tape-recorded responses in random order. Two 5-point rating scales were used: one to assess the assertive content, the other to assess such paralinguistic factors as firmness of voice and appropriateness .of affect. The scoring system was derived in part from McFall and Lillesand's (1971) rating scale but was amplified to include items not dealing with refusal behavior and modified so that it differentiated between assertive and aggressive responses, according to Alberti and Emmons' (1970) criteria. Possible scores on each of the two scales (Content and Paralinguistic) ranged from 1 to 55. The average interrater reliability for both scales exceeded .95 on both pre and postassessment. Self-report measures. The Rathus Assertiveness Schedule (Raihus, 1973), the Social Avoidance and Distress Scale, and the Fear of Negative Evaluation Scale (Watson & Friend, 1969) were administered as pre and posttest measures to all subjects. Following each of their responses to the 11 behavioral test stimulus situations, subjects rated the amount of anxiety experienced on a 4-point scale similar to Walk's (1956) "fear thermometer." Posttreatment data sheets. At the end of the second treatment session, all subjects filled out a posttreatment Rating Form, rating their therapist in terms of competence, likability, and other factors on a 6-point Likert-type scale. A Postexperimental Questionnaire, assessing reactions to the treatment, was completed by each subject after the posttest session. Treatment Procedures Following the behavioral preassessment, the 64 subjects were assigned to matched treatment or control groups, with Rathus means and ages roughly comparable in each group. The groups were randomly assigned to one of three treatment conditions and to one of the two therapists, or to the waiting list control. The six treatment groups, behavior therapy (BT), rational therapy plus behavior therapy (RBT), and consciousness-raising (CR), each met for two 2-hr sessions I week apart; the 16 WL subjects were told that treatment would be delayed 3 weeks. Behavior therapy: Modeling-plus-behavior rehearsal (BT) (modeled after the assertion training procedures of Lazarus, 1971, and McFall and Lillesand, 1971). The treatment rationale given was that people could be helped to become more assertive by learning what constituted an appropriate assertive response and by practicing and receiving feedback on
570
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their assertive behavior. A brief talk, designed to teach discrimination between assertive, nonassertive, and aggressive behavior, was followed by a 15-rain videotape which reviewed definitions and showed three different female models responding to three different situations calling for assertiveness: a secretary dealing with an overly critical boss, a woman confronting her lover about his frequent last-minute date cancellations, and a student dealing with her mother's attempted interference in her life. The remainder of session one was devoted to role-playing three of the I 1 behavioral test situations, with three subjects consecutively role-playing responses to each situation, followed by therapist and group feedback and the therapist's modeling of an appropriate response. Finally, the three subjects were given a second opportunity to role-play the situation, The same procedure was followed with three different subjects for each of two other stimulus situations. At the end of the first session, subjects were given the homework assignment of observing their own and others' responses in situations calling for assertiveness. During the second treatment session 30 min of discussion of homework was followed by role-playing of three more situations from the behavioral assessment, each by three new group members, according to the same format as the first session.
Rational~Behavior therapy: Modeling-plus-behavior rehearsal-plus rational therapy (RBT). This technique was designed to determine the extent to which the addition of a cognitive component, in the form of rational therapy, to the behavior therapy assertiveness training "'package" would enhance its effectiveness. Procedures were similar to those employed in the BT group, with the following revisions and additions: The treatment retionale was described to group members as one in which they would learn what constitutes an appropriate assertive response, practice assertive behavior, and identify and counteract assertion-impeding beliefs. In the first session, subjects were given the same introduction as the BT group, with the following addition: Several irrational beliefs or self-statements, explained as being related to assertiveness difficulties in women, were listed. These self-statements, adapted from Ellis' 12 Irrational Ideas (Ellis, 1962), included the belief that it is awful to hurt other people or make them angry and that it is awful to make a "fool" of oneself or to be rejected. It was explained that by learning to challenge some of these irrational self-statements, a good deal of the anxiety associated with assertiveness difficulties could be eradicated, Videotapes identical to those used in the BT group were then shown; these tapes had edited onto them, however, the model's voice-over maladaptire and adaptive (irrational and rational) self-verbalizations that preceded or followed each of their responses, following the "coping model" advocated by Meichenbaum (1971). The BT narration was amplified to include an explanation of the role of these self-verbalizations in impeding and facilitating effective assertion. Role-playing procedures employed the same three situations used in the BT sessions. In addition, subjects were instructed, as they performed the role-playing, to "'try to identify some of the ideas that were going through your head as you attempted to respond." During the feedback phase of the behavior rehearsal, group members were encouraged to counteract dysfunctional beliefs by formulating effective "'challenges" to them: for example, "So what if I say this to him and he thinks I'm a castrating bitch. I'd rather not live like a doormat the rest of my life. And if worst comes to worst, I can still lead a happy existence, even without him." The homework assignment given at the end of session one and discussed at the beginning of session two was to take notes on irrational beliefs or self-statements which subjects observed themselves making during the week in situations calling for assertiveness. Consciousness-raising. The treatment rationale which followed the introduction of group members was that women receive considerable help in the area of assertiveness by discussing and sharing with other women some of their common problems in this area and by learning about the influence of past experiences and early sex role conditioning. An approx-
ASSERTIVE BEHAVIOR IN WOMEN
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imately 15-rain videotape was shown of a group of women discussing their assertion difficulties and appearing to gain considerable relief from doing so. For the remainder of session one, a "go-around" format typical of a consciousness-raising group was followed, with each woman having approximately 10 min to discuss in detail the history and nature of her major assertion difficulties. The other subjects were permitted to respond briefly and share similar experiences. The leader's role was carefully restricted to (I) facilitating group interaction, (2) probing further for historical roots of the problems, and (3) making generalizations about sex role conditioning and early learning. Group members were given the homework assignment of thinking back to other early experiences that may have contributed to their assertion problems. As with the BT and RBT groups, the first 30 min of the second session were devoted to a discussion of the homework; the remainder of the session followed the same discussion format as in session one. Waiting list control (WL). Following the behavioral assessment, WL subjects were told that it would be necessary to postpone therapy for approximately 3 weeks because of scheduling problems. It was stated that another behavioral assessment would be required at that time, for the purpose of judging subjects' level of assertiveness at the time treatment began. Approximately I week following the second behavioral assessment, all subjects in the waiting list control were given assertion training similar to that in the RBT or BT group.
RESULTS Premeasure analyses of variance revealed no initial pretreatment difference between groups, and a 2 × 4 factor analysis of variance indicated no significant difference between therapists. Behavioral Measures Tape recordings from the pre and posttreatment behavioral assessments were given to the two raters in random order, with no identification as to pre or posttests. An analysis of change scores (difference between pre and postscores) revealed highly significant~differences between treatment groups in the Assertive Content Scale [F (3, 56) = 16.22, p < .01]. Multiple comparisons between means using the Duncan Multiple Range test (Edwards, 1968) showed that both the BT and RBT groups performed significantly better than CR and WL (p < .01) but that there was no significance between CR and WL. Significant differences between groups on Paralinguistic Scale ratings were also found [F (3, 56) = 8.43, p < .01]. Further analysis revealed that (a) BT and RBT improved significantly over WL (p < .01); (b) CR also improved significantly more than WL, though less than the BT and RBT groups (p < .05); and (c) BT improved significantly more than CR (p < .05). Separate analyses of the five Behavioral Assessment items that were not used in the treatment revealed differential treatment effects [Content F (3, 56) = 4.10, p < .05; Paralinguistic F (3, 56) = 6.87, p < .01], demonstrating that a transfer of training did indeed occur in the BT and RBT groups (p < .01 and p < .05, respectively).
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Self-Report Scales An analysis of variance of change scores indicated no significant F-ratio on the Rathus Assertiveness Schedule. No treatment effect was found on the Social Avoidance and Distress and the Fear of Negative Evaluation scales.
Self-Reported Anxiety Significant treatment differences were obtained on subjects' ratings of the degree of anxiety experienced while responding to the 11 Behavioral Test items, as measured by a 4-point "fear thermometer" IF (3, 56) = 4.27, p < .01]. When investigated by means of the Duncan test, the BT, CR, and WL groups did not improve differentially; only the RBT group showed significant reduction on this situational measure of anxiety (p < .01).
Questionnaire Measures Inconsistencies appeared between CR subjects' self-reports of improvement on the post-therapy questionnaire and actual improvement as measured on the more objective behavioral measure. Despite the fact that CR did not improve significantly more than WL controls on the two behavioral scales and the anxiety thermometer, they reported the same degree of success in learning to behave more assertively as did BT and RBT. The high pretest correlations between both the Content and Paralinguistic rating scales of the authors' behavioral test and the two other measures of assertiveness (Rathus Assertiveness Schedule and self-rated assertiveness) appear to be a fairly strong indicator of the behavioral measures' construct validity. They are similarly highly correlated with the other situational measure, the anxiety self-rating.
DISCUSSION This study offers support for the efficacy of BT and RBT in the treatment of assertiveness difficulties in women. Although brief, consisting of two 2-hr sessions, BT and RBT improved significantly on the major measure, the ratings of responses to a laboratory behavioral test. Moreover, the training effects generalized to nonpracticed scenes. While there appears to be little evidence that the rational therapy component produced significantly greater generalization than the largely behavioral (BT) approach, some partial support seems to be given to the therapeutic potential of a procedure combining behavior rehearsal with rational psychotherapy (the significant reduction in situational anxiety was demonstrated only in the RBT group). A major limitation is the brevity of the treatment. This may have
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particularly handicapped the RBT group who had the same amount of time as members of the BT group not only to do the behavior rehearsal, but also to elicit and challenge maladaptive self-statements. Ideally, more time is needed to explore the irrational ideas and to give subjects sufficient practice in constructing more facilitative self-statements. Despite CR's failure to differ significantly from WL controls on all but one dependent measure, the subjective experience of benefit reported by CR subjects on the posttherapy questionnaire was equivalent to that of the other two experimental groups. While possibly deriving, at least in part, from the demand characteristics of the assessment situation, there is some suggestion of "relief," if not overt behavioral change, accruing to participation in women's consciousness-raising groups, a finding previously suggested by Kirsch (1974) and Micossi (1970). One could hypothesize that, as subjects talked about anxiety-producing material within the relaxed, nonthreatening atmosphere of the CR group, there would be some extinction or counterconditioning of anxiety related to interpersonal performance. However, the CR group did not significantly decrease their anxiety during the behavioral assessment over WL controls. The only measure on which CR improved significantly was the Paralinguistic behavioral measure, suggesting, again, that participants sound better (more confident, less hesitant), while not significantly improving the content of their assertive responses. The present results provide some empirical support for the growing discontent on the part of many women with CR groups, which provide insight and sharing of experiences but often fail to provide actual tools for behavior change. REFERENCE NOTES 1. Burkhead, D. The reduction of negative affect in human subjects: A laboratory investigation of rational-emotive psychotherapy. Unpublished doctoral dissertation, Western Michigan University, 1970. 2. Goldfried, M. Outcome studies on social evaluative anxiety and assertive behavior. Paper presented at the First National Conference on Cognitive Behavior Therapy Research, New York City, 1976. 3. Kanter, N. A comparison of self-control, desensitization and systematic rational restructuring Jor the reduction of interpersonal anxiety. Unpublished doctoral dissertation. SUNY at Stony Brook, 1975. 4. Schwartz, R., & Gottman, J. A task analysis approach to clinical problems: A study of assertive behavior. Unpublished manuscript, Indiana University, 1974.
REFERENCES Alberti, R. E., & Emmons, M. L. Yourperfect right:A guide to assertive behavior. San Luis Obispo, CA: Impact, 1970. Block, J. H. Conceptions of sex role: Some cross-cultural and longitudinal perspectives. American Psychologist, 1973, 28, 512-526.
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Broverman, 1., Broverman. D., Clarkson, F.. Rosenkrantz, P., & Vogel, S. Sex role stereotypes and clinical judgments of mental health. Journal of Consulting and Clinical Psychology, 1970, 34, 1-7. Chesler, P. Women and madness. Garden City, New York: Doubleday. 1972. DiLoreto, A. A comparison of the relative effectiveness of systematic desensitization, rational-emotive and client-centered group therapy in the reduction of interpersonal anxiety in introverts and extroverts (Doctoral dissertation, Michigan State University). Ann Arbor, Michigan: University Microfilms, 1970, No. 70-9521. D'Zurilla, T. J., Wilson, G. T., & Nelson, R. A comparative study of systematic desensitization, prolonged imagery, and cognitive restructuring. Behavior Therapy, 1973, 4, 672685. Edwards, A. L. Experimental design in psychological research. New York: Holt, Rinehart & Winston, 1968. Ellis, A. Reason and emotion in psychotherapy. New York: Lyle Stuart, 1962. Ellis, A. Humanistic" psychotherapy: The rational-emotive approach. New York: Julian Press and McGraw-Hill Paperbacks, 1974. Fodor, I. G. Sex role conflict and symptom formation in women: Can behavior therapy help? Psychotherapy: Theory, Research and Practice, 1974, 2, 22-29. Jakubowski-Spector, P. Facilitating the growth of women through assertive training. The Counseling Psychologist, 1973, 4, 75-86. Kirsch, B. Consciousness-raising groups as therapy for women. In V. Franks & V. Burtle (Eds.), Women in therapy. New York: Brunner/Mazel, 1974. Lange, A., & Jakubowski, P. Responsible assertive behavior. Champaign, IL: Research Press, 1976. Lazarus, A. A. Behavior therapy and beyond. New York: McGraw-Hill, 1971. Lazarus, A. A., & Fay, A. 1 can i f l want to. New York: Morrow, 1975. McFall, R. M., & Lillesand, D. B. Behavior rehearsal with modeling and coaching in assertive training. Journal of Abnormal Psychology, 1971, 77, 313-323. Meichenbaum, D. H. Examination of model characteristics in reducing avoidance behavior. Journal of Persona6ty and Social Psychology, 1971, 17, 298-307. Meichenbaum, D. H., Gilmore, J. B., & Fedoravicius, A. Group insight versus group desensitization in treating speech anxiety. Journal of Consulting and Clinical Psychology, 1971, 36, 410-421. Micossi, A. L. Conversion to women's lib. Trans-Action, 1970, 8, 82-90. Rathus, S. A. A 30-item schedule for assessing assertive behavior. Behavior Therapy, 1973, 4, 398-406. Thorpe, G. L. Short-term effectiveness of systematic desensitization, modeling and behavior rehearsal, and self-instructional training in facilitating assertive-refusal behavior. European Journal of Behaviour Analysis and Modification, 1975, 1, 30-44. Trexler, L., & Karst, T. Rational-emotive therapy, placebo, and no-treatment effects on public speaking anxiety. Journal of Abnormal Psychology, 1972, 79, 60-67. Walk, R. D. Self-ratings of fear in a fear-invoking situation. Journal of Abnormal and Social Psychology, 1956, 52, 171-178. Watson, D., & Friend, R. Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 1969, 33, 448-457. Wolfe, J. L., & Fodor, I. G. A cognitive behavioral approach to modifying assertive behavior in women. The Counseling Psychologist, 1975, 5, 45-52. Wolpe, J., & Lazarus, A. A. Behavior therapy techniques: A guide to the treatment of neuroses. New York: Pergamon, 1966.
RECEIVED: February 2, 1976; REVISED: March 26, 1976 FINAL ACCEPTANCE: July 10, 1976