ASSERTIVENESS

Having just commemorated a local hero, Terry Fox, last month here in Canada, I was interested to see if his campaign was heard internationally. It turns out that the annual Terry Fox Run, first held in 1981, has grown to involve millions of participants in over 60 countries and is now the world’s largest one-day fundraiser for cancer research having raised over $750 million as of January 2018 (The Terry Fox foundation).

What started out as a 22-year-old cancer patient’s 143 days and 5,373 kilometres race to jumpstart his rebuttal to osteoscarcoma would go on to win the admiration and support of  the entire world. Annually, people run in Vietnam, Brazil, St. Maarten, Dubai, Croatia, India, China and many other countries to keep the spirit of Terry’s message alive: that you can take our limbs but we will keep running towards a cure. 

Assertiveness is not about winning and losing; it’s about how you play the game. It’s a culture that allows you keep your head held up high in the face of adversity. It empowers you with a response even against the most formidable of opponents. I doubt that he would have thought that here in Canada, 38 years after his passing, his name would be more widely known than osteosarcoma.

President Abraham Lincoln made famous the saying “You’re right to swing your fist ends where my nose begins!”.

This embodies the spirit of assertiveness. Assertiveness is all about balancing the scales; making things more equal; leveling the playing field; respecting everyone’s right to choose their course and their response. It’s chess; the better you play it, the more you will relish the game

A comprehensive definition:

• Assertive self-expression is direct, firm, positive – and, when necessary, persistent – action intended to promote equality in person-to-person relationships. Assertiveness enables us to act in our own best interests, to stand up for ourselves without undue anxiety, to exercise personal rights without denying the rights of others and to express our feelings and needs (affection, love, friendship, disappointment, annoyance, anger, regret, sorrow) honestly and comfortably (Alberti & Emmons, 2008).

Every day people make a run on our sense of self-efficacy in the pursuit of their own interests in many different contexts: home, job, school, financial transactions, services, club meetings, religious places, etc. Not every challenge has to be a life-threatening one like that of Terry Fox. And you may decide not to deal with every situation assertively, and that may be the best decision for you; but are you making that decision consciously? Many feel that the every day stressors can have a cumulative effect that is more deleterious than one big stressor. Common situations with which can chip away at our sense of control over lives:

• Feeling pressure to oblige a request for a favour that you would prefer to decline
• Telephone sales pitch at dinner time
• A coworker put you down in front of your work group
• Your spouse gives you a dirty look
• A neighbour blasts his music until 3 am
• One of your kids snaps at you

There is no one right way to handle the above. But ultimately you have the choice to make the play you choose. Which one is more likely to be successful in increasing your sense of self-efficacy and self-confidence? Which one will empower you in the short- and long-run? Can you aware of the emotional and psychological situations above have on you? Do you have the skills to express your position in respectful and assertive manner? Or do you resort to aggression and passivity, which usually have poorer long-term prognosis?

Assertiveness is not just for confrontational situations. Some shirk away from expressing themselves in positive situations. Do you have the confidence to express yourself in a relationship? To show appreciation? Gratitude?

Assertive individuals are said to possess four abilities (Lazurus, 1973):

1. the ability to openly communicate about one’s own desires and needs;
2. the ability to say no;
3. the ability to openly communicate about one’s own positive and negative feelings; and
4. the ability to establish context and to begin, maintain, and end conversations.

• Relate to others with less conflict
• More relaxed around others
• Focus on the present situation
• Retain self-respect without stepping on another’s toes or even getting your way
• Increase self-confidence
• We regain control over our lives
• Allows us to be “fully” in a relationship

As communication – both internal talk and external communication – serves as our “operating system”, optimizing the same can improve performance and satisfaction. There are 11 key points that have been attributed to assertive behaviour and communication (Alberti and Emmons, 2008):

1. Self-expressive;
2. Respectful of the rights of others;
3. Honest;
4. Direct and firm;
5. Equalizing, benefiting both parties in a relationship;
6. Assertive language and nonverbal style to communication;
7. Applicable to positive – expressing affection, praise and appreciation – and negative situations – expressing limits, anger and criticism;
8. Person and situation-dependent to some extent. For example, some situations are fragile enough that adding assertiveness to the mix may not benefit anyone. Or in dealing with certain individuals, because of their local/international status (e.g., prime minister, the pope, Dalai Lama, Queen of England, Dean of your university, etc.) may require a modified approach;
9. Socially responsible;
10. Both inborn – some people have some inherited traits that may make assertiveness more “natural” –  and learned – it can be trained;
11. As persistent as is necessary to achieve one’s goals without violating the 10 points above.

Although, assertiveness was made popular by many David and Goliath-like events like Terry’s, Rosa Parks civil “disobedience”, Gandhi’s satyagraha (truth insistence), it does not have to involve martyrdom. It can be 2019 Raptors running the Golden State Warriors off the court simply by out playing them. Or it can involve you telling your neighbour that you are not okay with him putting his stones on your property; or maybe you are okay with it, but because you consciously choose that option rather than feeling pressured into going along with his request. Although the stones will end up on your property, when forced to go along with it, you feel more helpless, whereas when you consciously consent to allow it, you maintain your sense of propriety.

Ultimately, assertiveness is a tool  to strengthen your internal locus of control.

People who base their success on their own work and believe they control their life have an internal locus of control. In contrast, people who attribute their success or failure to outside influences have an external locus of control. Sometimes people who have an internal locus of control can be too hard on themselves (i.e., blame themselves and only their selves when things turn out differently than initially desired) but can accomplish great things (i.e., vzv. tenacity, resourcefulness, self-efficacy). Sometimes, people with a strong external locus of control are too quick to “throw in the towel” or feel helpless but can be good supporting players on a team, being ready to give up the reigns to another.

Ultimately, one has to pick their battles and make their strategies. The more tools you have in your toolbox, and the better understanding you have of the pros and cons of each tool, the better you can play the game (of life) consciously and on your own terms.

Rather than being submissive or aggressive, the goal of assertiveness training is to help patients become better able to openly verbalize what they want in various life situations. Assertiveness training, which uses a variety of cognitive behavioural techniques, can be conceptualized as a component of social skills training, which broadly aims to help individuals reduce any anxiety-based inhibitions and learn specific skills to develop more competent social functioning (Speed et al., 2017).

Within this framework, unassertiveness may result from genuine skills deficit (e.g., inability to understand and effectively communicate wants/needs), performance deficits, possibly due to anxiety, or both (Heimberg & Becker, 1981). Therefore, assertiveness training involves cognitive and behavioural techniques aimed at increasing patient expressiveness, including cognitive restructuring of negative thoughts about asserting oneself, and behavioural rehearsal, role playing, and modeling to reduce anxiety. It also includes teaching communication skills and enhancing self-efficacy (Speed et al., 2017).

As communication is a significant neurophysiological function that not only affects our relationship with others, but also our relationship with ourselves, its effect can be felt internally. As such, assertiveness is considered a stand-alone, transdiagnostic (i.e., meaning, it can be used for many different diagnosis) intervention.

There exists considerable basic research evidence linking unassertiveness to specific clinical problems, as well as findings from outcome research indicating that assertiveness training can improve various clinical symptoms above and beyond assertive behaviour.

Anxiety

Socially anxious patients often display difficulties in assertiveness through submissive or avoidance (Walters & Hope, 1998). There is evidence that social anxiety is positively associated with anger and hostility, therefore indicating that assertiveness may be beneficial in reducing anger in these patient (Allan & Gilbert, 2002). Many studies have shown that assertiveness training, group and individual assertiveness training, result in significantly reduced depression and anxiety symptoms and decreased clinical symptoms (Lomont et al., 1969; Linehan et al., 1979; Hammen et al., 1980).

Depression

There are some professionals that purport that depressed patients have social skill deficits, resulting in interactions that are unlikely to be reinforcing and are more likely to highlight perceived deficits in social support (Windle, 1992). Those at higher risk of developing depression may experience higher rates of depression in part due to an interaction between experiencing more negative events and engaging in dysfunctional cognitive styles (Hankin & Abramson, 2001).  One study found that the type of assertiveness problem varies between genders; depression is positively associated with hostility in men and agreeableness in women (Maier et al., 2009). Furthermore, low assertiveness may be an indicator of poor prognosis for women if unaddressed (Bouhuys et al., 1999). There is evidence that low assertiveness is predictive of increases in depression symptoms or disorder onset (Ball et al., 1994).

Many studies have shown that group assertiveness training helped depressed women become significantly more assertive and that these gains are enduring for longer than the termination of the training (Hayman & Cope, 1980). Assertiveness group therapy was found to increase patients’ comfort with assertiveness and increase their likelihood of engaging in assertive behaviour. Assertiveness training resulted in significantly less depressive symptoms and patients displayed more rational thinking and acceptance, and were significantly less likely to seek out further treatment at follow-up (Sanchez et al., 1980).

Self-esteem

Assertiveness has been positively correlated with measures of self-esteem (Riggio et al., 1990). Assertiveness training improves general self-esteem, self-concept, and internal locus of control (Hammen et al., 1980). As individuals become less worried about the opinion of others and become more comfortable in asserting themselves, they seem to become more self-confident in the legitimacy of what they want, think and feel.

Relationships

Unassertiveness in either partner (in a couple) was found to be associated with negative outcomes for the couple, including hostility in the husband and increased guilt and anxiety in the wife (Hafner & Spence, 1988). When either individual men or women from a couple participated in assertiveness training, self-reported levels of trust and intimacy improved (Gordon & Waldo, 1984).

Assertiveness was a very popular form of therapy in the 70’s and 80’s. As discussed above, it has shown merit as a stand-alone therapy for many different types of symptoms and conditions (i.e., transdiagnostic). In fact, it can be used just to get more out of life and enhance performance.

Then a shift came about where professional became more concerned about making manualized treatment interventions for specific DSM diagnoses that could then be marketed.

Things are starting to come back full circle where people are starting to care to know about the root cause of their problems (i.e., etiology at a behavioural and cognitive level) so that they can discover the mechanism of their problems and then improve their habits (cognitions, behaviours, etc.) to result in better outcomes.

There are also some other popular forms of psychotherapy that may “compete” for the therapists attention. For example, CBT is said to have had 3 “waves” (i.e., generations):

1. Behavioural therapy, which focused on operant conditioning;
2. Cognitive interventions were incorporated in behavioural therapy;
3. Focus on acceptance and mindfulness, which has taken off in recent years.

“Novel” therapies (mindfulness is really an old intervention but has been marketed anew) have taken a leading role in modern psychotherapeutic interventions; the 3rd wave may have been seen as “washing away” the previous 2 waves, practically-speaking (Goldfried et al., 2000; Dimidjian et al., 2016).

1. Reliance on a different style of communication: passive, aggressive, passive-aggressive.

• Depending on the situation, many of us may flip-flop from one style to another although most of us have a preferred, baseline style, kind of like our “default mode” style of communication.
• For each style of communication, there may be logical explanations for why that patient developed a reliance on a specific style.
  • For example, people who rely on the passive style may have had:
    • a passive role model (e.g., parent);
    • or overly “considerate” parents who didn’t want to bother the child so the child never learned to say “no”;
    • or an aggressive parent who always knocked down any bold initiative the child had, so the child just learned helplessness;
    • or abuse.

2. Having negative core beliefs (these may be subconscious)

• Others are more important than me
• Others are entitled to have control over their lives, I’m not
• They can do things effectively. I can’t.
• My role in life is to be the servant

3. Lack of awareness of a better method of communication (i.e., assertiveness)

• Sometimes patients get anxious, angry or caught up in the moment that they don’t catch themselves being creatures of habit rather than living consciously.
• This can be trained and may involve mindfulness, self-regulation techniques (e.g., biofeedback-based methods), etc.
• Many people have assertive communications skills but lack awareness in certain contexts (e.g., a common situation in professional, middle-aged women that deal with anxiety-driven performance overstriving).

4. Lack of assertive communication skills

• This can also be trained and when learned, can increase one’s sense of self-efficacy.

5. Anxiety

• Sometimes, there is a fear of a backlash to an assertive communications style.

Alberti, Robert; Emmons, Michael. Your Perfect Right: Assertiveness and Equality in Your Life and Relationships. Impact; 9th Edition (May 21, 2008).

Allan, S., & Gilbert, P. (2002). Anger and anger expression in relation to perceptions of social rank, entrapment and depressive symptoms. Personality and Individual Differences, 32, 551–565. https://doi.org/10.1016/S0191-8869(01) 00057-5.

Ball, S. G., Otto, M. W., Pollack, M. H., & Rosenbaum, J. F. (1994). Predicting prospective episodes of depression in patients with panic disorder: A longitudinal study. Journal of Consulting and Clinical Psychology, 62, 359–365. https://doi. org/10.1037/0022-006X.62.2.359.

Bouhuys, A. L., Geerts, E., & Gordijn, M. C. (1999). Gender-specific mechanisms associated with outcome of depression: Perception of emotions, coping and
interpersonal functioning. Psychiatry Research, 85, 247–261. https://doi.org/10.1016/S0165-1781(99)00003-7.

Dimidjian, S., Arch, J. J., Schneider, R. L., Desormeau, P., Felder, J. N., & Segal, Z. V. (2016). Considering metaanalysis, meaning, and metaphor: A systematic review and critical examination of “third wave” cognitive and behavioral therapies. Behavior Therapy, 47, 886–905. https://doi.org/10.1016/j.beth.2016.07.002.

Goldfried, M. R. (2000). Consensus in psychotherapy research and practice: Where have all the findings gone? Psychotherapy Research, 10, 1–16. https://doi.org/10.1093/ptr/10.1.1.

Gordon, S., & Waldo, M. (1984). The effects of assertiveness training on couples’ relationships. American Journal of Family Therapy, 12(1), 73–77. https://doi.org/10.1080/01926188408250160.

Hafner, R. J., & Spence, N. S. (1988). Marriage duration, marital adjustment and psychological symptoms: A crosssectional study. Journal of Clinical Psychology, 44, 309–316. https://doi.org/10.1002/1097-4679(198805)44:3<309: AID-JCLP2270440302>3.0.CO;2-W.

Hammen, C. L., Jacobs, M., Mayol, A., & Cochran, S. D. (1980). Dysfunctional cognitions and the effectiveness of skills and cognitive behavioral assertion training. Journal of Consulting and Clinical Psychology, 48, 685–695. https://doi. org/10.1037/0022-006X.48.6.685.

Hankin, B. L., & Abramson, L. Y. (2001). Development of gender differences in depression: An elaborated cognitive vulnerability–transactional stress theory. Psychological Bulletin, 127, 773–796. https://doi.org/10.1037/0033- 2909.127.6.773.

Hayman, P. M., & Cope, C. S. (1980). Effects of assertion training on depression. Journal of Clinical Psychology, 36, 534–543. https://doi.org/10.1002/jclp.
6120360226.

Heimberg, R. G., & Becker, R. E. (1981). Cognitive and behavioral models of assertive behavior: Review, analysis and integration. Clinical Psychology Review, 1, 353–373. https://doi.org/10.1177/01454455860103003.

Lazarus, A. A. (1973). On assertive behavior: A brief note. Behavior Therapy, 4, 697–699. https://doi.org/10.1016/S0005-7894(73)80161-3.

Linehan, M., Goldfried, M. R., & Goldfried, A. P. (1979). Assertion training: Skill acquisition or cognitive restructuring. Behavior Therapy, 10, 372–388. https://doi. org/10.1016/S0005-7894(79)80026-X.

Lomont, J. F., Gilner, F. H., Spector, N. J., & Skinner, K. K. (1969). Group assertion training and group insight therapies. Psychological Reports, 25, 463–470. https://doi. org/10.2466/pr0.1969.25.2.463.

Maier, K. J., Goble, L. A., Neumann, S. A., Giggey, P. P., Suarez, E. C., & Waldstein, S. R. (2009). Dimensions across measures of dispositional hostility, expressive style, and depression show some variation by race/ethnicity and gender in young adults. Journal of Social and Clinical Psychology, 28, 1199–1225. https://doi.org/10.1521/jscp. 2009.28.10.1199.

Riggio, R. E., Throckmorton, B., & DePaola, S. (1990). Social skills and self-esteem. Personality and Individual Differences, 11, 799–804. https://doi.org/10.1016/0191-8869(90)90188-W.

Sanchez, V. C., Lewinsohn, P. M., & Larson, D. W. (1980). Assertion training: Effectiveness in the treatment of depression. Journal of Clinical Psychology, 36(2), 526–529. https://doi.org/10.1002/jclp.6120360224.

Speed, Brittany & Goldstein, Brandon & Goldfried, Marvin. (2017). Assertiveness Training: A Forgotten Evidence-Based Treatment. Clinical Psychology: Science and Practice. 25. 10.1111/cpsp.12216.

“Terry’s Story”. The Terry Fox Foundation. Retrieved January 29, 2018.

Walters, K. S., & Hope, D. A. (1998). Analysis of social behavior in individuals with social phobia and nonanxious participants using a psychobiological model. Behavior Therapy, 29, 387–407. https://doi.org/10.1016/S0005- 7894(98)80039-7.

Windle, M. (1992). Temperament and social support in adolescence: Interrelations with depressive symptoms and delinquent behaviors. Journal of Youth and Adolescence, 21, 1–21. https://doi.org/10.1007/BF01536980.