Dr Robert London

Rebooting the Brain for Assertiveness

Clinical Psychiatry News - Volume 36, Issue 10, Page 25 (October 2008)

Last month, I spelled out specific methodology and behavioral therapies aimed at dealing with an anxiety ridden disorder (“Systematic Desensitization in 10 Steps,” September 2008, p. 23). However, anxiety disorders are not the only problems that respond to structured behavioral techniques. Many problems—disorders if you will—can be successfully treated with relearning or behavioral therapies. Another form of behavioral treatment is assertiveness training.

Let's take the case of a patient I'll call Anthony. He sought help at the suggestion of his mother because, as she kept pointing out, he seemed so unhappy. She thought he also seemed frustrated and angry at times, because his life was not going the way he wanted. He agreed.

After two visits with Anthony, including some direct questioning about what bothered him, it became clear to both of us that he had been brought up with tender loving care—in that most things were done for him—if you call that TLC.

Furthermore, a learning pattern was in place that made him think that he could not do things very well. So the TLC resulted in misunderstandings and things getting misplaced.

Ultimately, the misguided TLC, coupled with the feelings of not being capable or competent, appeared to become dominant themes in Anthony's life.

His mother accompanied him to the first visit—to make sure he'd be OK. Talk about dependency in a 30-year-old! Yes, Anthony was a dependent person, or as the DSM would suggest, he had a dependent personality. Anthony, a stock analyst, always showed up for work and did a good job when he got there. But he was constantly asking for help and seemed unable to speak up for himself at work or in his social life. In his free time, he liked going to the movies. So clearly, he functioned in society.

But Anthony was unhappy; he was suffering and wanted more out of life. As he described his life at work and outside of it, he was able to recall the extent to which he annoyed some coworkers, regularly asking them for help. He wanted vacation time and seemed unable to ask for it.

In addition, his social life was poor, and he had difficulty asking for a date. He at times was angry and upset with himself for his lack of assertiveness. Even though there was an anxiety component to his personality, most of his story could be traced more to dependency and a lack of healthy assertiveness.

The therapeutic model I used with this patient was a behavioral approach involving assertiveness therapy and training. To do this, I asked the patient about his willingness to learn new coping styles. Then I moved forward in this model, rather than engaging in a lengthy exploration of interpersonal and intrapsychic conflicts consistent with those “archaeological digs,” that so often pass for the only kind of therapy there is.

He was clearly agreeable to my approach and felt pretty sure that exploring family conflicts and stressors was not where he wanted to go. His main goal was to improve his functioning and to feel better at work and in his social life. Unlike the clear cut hierarchies developed for certain anxiety disorders described in last month's column, with assertiveness training, I believe, more dialogue and patient involvement are very important and necessary. Informing the patient and explaining what you are doing as you enlist his cooperation are critical aspects of behavioral therapy.

In fact, partnering with the patient in this way is a part of good health care, regardless of what the dysfunction or illness might be. The theory underlying this approach is unlike many of the “master-knows-best theories” that so dominate talk psychotherapy. As a good friend once said to me, “You go for help with a problem and, not only do they burn the house down, they burn down the whole town down.”

In assertiveness training, you certainly do not want to encourage outright forceful or confrontational behaviors that would be counterproductive. What is necessary is a motivated, active, and enthusiastic commitment, coupled with an understanding that as new approaches are learned and employed, a sense of anxiety and even fear may be present. However, as these new approaches bear fruit, and the patient sees results, these new behaviors get positively reinforced and become more permanently integrated into the patient's personality structure.

Therefore, a working combination of therapeutic interaction and a behavioral approach seems to work best, and it is important to provide a time frame for evaluating results.

That is the best way to avoid that open-ended, no-end-in-sight approach.

Talking with many therapists, as I do, has led me to believe that many do use assertiveness techniques in a less-formal manner. For example, they offer suggestions and plans of action that differ from their patients’ everyday styles.

For Anthony, I was able to offer a clearer understanding about hierarchical methods aimed at helping him achieve his therapeutic goals in a specific, timely, and measurable way.

With his cooperation and clear understanding of a treatment plan, we began to address three spheres of problems that he wanted to face and resolve:
1.His dependence on coworkers.

2.His inability to ask for work-related needs, such as vacation time.

3.How to establish a fresh approach to dating women.

Anthony usually asked coworkers for help with the copy machines, and this habit proved bothersome after his last 5 years at the job. He never made any suggestions for going out to lunch but would often ask to come along. Or he would get his colleagues to bring food back for him.

A new and nonthreatening approach to copy machines and lunches was to be the starter-upper, or to become the assertive one.

First, Anthony could get the instructions for the copy machine, learn them, use them, and at times, offer to make copies for others.

Second, Anthony could start suggesting a place for lunch or even offer to bring food in for his team—especially on days when the weather was bad. Those two new approaches at first appeared alien to Anthony. But they were nonthreatening and put him in no psychological jeopardy. These approaches worked.

When it came to asking for a vacation, Anthony simply got angry and frustrated, because it was beyond his ability to ask for time off even though it was part of his job. He felt he would be rejected or chastised for asking his manager.

Again, with Anthony's cooperation, we attempted to assess the results of asking forthrightly for vacation time. We evaluated many options in a cognitive-behavioral model with a challenge to negative responses, substituting a wider range of options, especially including the normal requests for vacation time in the corporate workplace. Anthony actually believed that he would be reprimanded for making such a request. We came to understand that the manager was a fair and understanding person who also took vacations and that Anthony understood this but without help seemed unable to integrate this into his behavior.

Stepping up and being assertive in your own service is an acceptable model when asking for vacation time. The earth won't split open, so why not make it happen? The thing is, in Anthony's experience, things did just happen under misguided TLC and the early family dynamic of having things done for him.

In the social world, a more difficult area in which to navigate, it became clear that Anthony would sabotage himself with his lack of assertiveness by being tentative in his requests for a date. We role-played, and his first question to a woman in asking her out was, “If you're free on the weekend and have nothing to do, maybe you want to go to dinner?” Now that seems nice enough, but is it really asking someone on a date?

We rehearsed some conversations on how to present himself in a more assertive and meaningful way with good success. Even if his offer was not accepted, his message would be clear. For example, we arrived at, “I would like to get know you better, so let's have dinner on Saturday evening.”

Integrated in the treatment plan for Anthony were some guided imagery techniques, which I taught him. Those techniques enabled Anthony to learn to visualize new approaches to situations where he wanted to be more assertive. He saw himself in those situations and noted whether anxiety occurred.

This approach allowed him to link these new approaches to pleasant experiences of his choosing, therefore incorporating a reciprocal inhibition and desensitization process.

Assertiveness training is not for everyone, nor is it all or nothing. A person might be assertive in some areas of life and not so in others.

Anthony was able to ask for money back at a movie theater if, at the onset, he didn't like the film. He also had no problem not leaving a tip in a restaurant if the service was poor.

Assertiveness training is not an aggressive approach to situations in which a person is not able to express himself clearly or differently.

It's a teaching and relearning technique in which cognitive challenges, role-playing, and imagery occur, and new and different perspectives are offered to replace the old set of problems. It is goal oriented and focused. It's an agreement about what the therapist and patient can do together, with the therapist integrating assertiveness within the structure of cognitive challenges and relearning, offering new ideas and perspectives.

Hierarchies of desensitization may be developed in the desensitization process, but it is less formal and more in the way of a dialogue, with emphasis on what the patient feels comfortable with.

One thing Anthony realized without guidance from me was that he didn't need his mother to accompany him to a doctor's office. An equally positive result was that the mother benefited from his new independence and had no interest in holding him back. That's not always the case.

The entire therapeutic relationship with Anthony lasted about 10 months. That time period allowed us to achieve solid results that pleased the patient.

Let me know your thoughts and experiences in using behavioral therapies aimed at helping people overcome difficulties in vocational and social adjustments with more meaningfully and valuable behaviors.

PII: S0270-6644(08)70707-0


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