Some people are shy, timid, unsure of themselves, or introverted to the extent that they don't speak up when it would be in their best interest to do so--for example, when a manager is looking for someone to take on a high-profile assignment, or when a patient doesn't ask the busy doctor for clarification on a diagnosis. Learning to be assertive is essential for success in all aspects of life, from relationships to careers to personal happiness.

Assertiveness training is a useful type of behavioral therapy I use with such people, and it can make an enormous difference for them.

Let's look at the case of a 30-year-old 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 the initial visit to which his mother accompanied him--it became clear to both of us that he had been brought up with tender loving care, which translated, in this case, to having most things done for him. Pop psychology calls this "helicopter parenting."

The parents' hovering had backfired for Anthony, resulting in a learning pattern that left him feeling as if he could not do things very well. Ultimately, the misguided TLC, coupled with feelings of not being capable or competent, appeared to become dominant themes in Anthony's life.

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 and he clearly functioned in society.

But he was suffering and wanted more out of life. As he described his life at work and outside of it, he was able to admit that he annoyed some coworkers with his frequent requests for computer and copy manchine help. Also, he wanted vacation time but felt unable to ask for it. Finally, his social life was poor, and he had difficulty getting up the nerve to ask women for dates. At times he was angry and upset with himself for his lack of assertiveness.

The therapeutic model I used with this patient was a behavioral approach involving assertiveness therapy and training. First, I asked Anthony about his willingness to learn new coping styles. He was agreeable to my approach and felt reasonably certain 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. For assertiveness training, back-and-forth dialogue, partnering with the patient, and patient involvement in the process are all very important and necessary. Informing the patient and explaining what you are doing as you enlist his cooperation are also critical aspects of behavioral therapy.

In assertiveness training, you certainly do not want to encourage outright forceful or confrontational behaviors that would be counterproductive. Rather, what you are working toward 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 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.

A working combination of therapeutic interaction and a behavioral approach--with therapeutic goals that are specific, timely, and measurable--seems to work best. It is important to provide a time frame for evaluating results. That is the best way to avoid the open-ended, no-end-in-sight approach to therapy, which often leads patients to feel discouraged and unmotivated.

With his cooperation and clear understanding of a treatment plan, we began to address Anthony's three spheres of problems that he wanted to face and resolve:

• How to overcome his dependence on coworkers.

• How to learn to ask for work-related needs, such as vacation time.

• How to establish a fresh approach to dating women.

Anthony usually asked coworkers for help with the computer and copy machine, and this habit proved bothersome after his last five years at the job. Also, 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.

We determined that a new and nonthreatening approach to computers and lunches was for him to become the initiator, or the assertive one.

First, Anthony agreed to get computer instruction outside of work from a local community college. After he had learned the programs, he might even offer to tutor others, such as new hires, who were having similar difficulty.

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. These two new strategies initially appeared alien to Anthony. But they were nonthreatening and put him in no psychological jeopardy. The approaches worked. He reported a significant difference in coworkers' attitudes toward him within weeks after he had taken the computer class and started trying out the new behaviors.

When it came to asking his manager for vacation time, 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 in which he challenged negative responses, substituting a wider range of positive options. We discussed how routine and normal it is, in the corporate workplace, for managers and bosses to field requests for vacation time. Anthony actually believed that he would be reprimanded for making such a request. His manager was a fair and understanding person who also took vacations, and even though Anthony intellectually understood this, he seemed unable to integrate this concept into his behavior.

We worked on getting Anthony to see that stepping up and being assertive in one's own service is an acceptable model when asking for vacation time. The earth won't split open, so why not make it happen? He finally took the bold step, and for his boss this was a nonevent. The boss said yes on the spot, which surprised and delighted Anthony.

Finally, in Anthony's social life, it became clear to him that he was sabotaging his success with women by being tentative in his requests for a date. When we role-played, 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 ways 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'd like to get know you better, so let's have dinner Saturday." Anthony had reasonable success using this new, more confident style.

Integrated in the treatment plan for Anthony were some guided imagery techniques I taught him. We'll look at these techniques and how they helped Anthony in Part II of this blog.

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. 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's 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.

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.

In my next blog, I will discuss how to use two more techniques--guided imagery and systematic desensitization--to help patients like Anthony become more assertive.

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This blog aims to present psychiatric/psychological information to a general readership, offering insights into a variety of emotional disorders, as well as social issues that affect our emotional well-being. It includes the ideas and opinions of Dr. London and other leading experts. This blog does not provide psychotherapy or personal advice, which should only be done by a mental health care professional during a personal evaluation.

About the Author

Robert London, M.D.

Robert London, M.D., has been a practicing physician/psychiatrist for more than three decades.

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