Whatever Happened to Assertiveness Training?

Therapists teach distress tolerance skills instead of problem-solving skills

Posted Sep 28, 2015

My fellow blogger over at BehaveNet had an interesting entry in May of this year about a consultant coming in to talk to a psychiatric hospital staff about "physician burnout." The consultant suggested that the psychiatric staff consider using mindfulness techniques to basically chill out about all the stresses they are under.

I have said before that mindfulness techniques can be very helpful in learning to stay relaxed when one is subjected to either common, everyday types of stress, or stressful environmental contingencies over which one has no possible control or has no hope of changing or correcting.

Physician burnout, however, is usually not one of those occasions. It has been occurring with greater and greater frequency because doctors are being driven mad by managed care insurance companies and business types. These folks, who have no medical or psychiatric expertise, are constantly telling doctors what they can or cannot do, and making their professional (and sometimes personal) lives miserable.

What the consultant in the BehaveNet post was recommending was something that is definitely not called for in this type of situation: passivity. 

Insurance companies and business people need doctors more than we need them. We need to get them out of the way so we true professionals can render effective patient treatment and also have a reasonable schedule so we can lead normal and balanced lives. (As an aside, for a group of intelligent and educated people, physicians seem to be surprisingly passive and unwilling to fight for both themselves and for their patients.)

The blogger hit the nail on the head: "The Doctors' prescription of mindfulness to address the problem suggests to me a strategy to get physicians to devote adequate time to contemplation of our navels so we will learn to tolerate even more abuse and exploitation with a smile and a 'Yessuh, Massah.'" He suggests that instead of that, doctors should push back, refuse, resign, set limits, make demands, and maybe even disrupt things.

Analogously, the current psychotherapy craze of teaching mindfulness to patients with major family issues so that they might learn to tolerate their stressful family and relationship lives with more equanimity is an abomination. As I mentioned in my previous post on mindfulness, it's a bit like giving an opiate to people who are being followed around by someone who is continually stabbing them in the shoulder with a pen knife.

Therapists should instead be teaching their patients techniques for accomplishing the goal of fixing the situations creating their interpersonal stress in the first place.

I am not saying, by the way, that the patients' own behavior does not contribute to the dysfunctional family patterns of which they are a part. Clearly it does. But that just means that they have to change their own behavior in reaction to the abuse, distancing, and conflicting messages which they often receive on a daily basis from their family systems — as a strategy for stopping these patterns, not for merely tolerating them better.

Cognitive behavior (CBT) therapists have of late seemed to be the biggest champions of using mindfulness for patients with these personality/family problems. This is ironic because back in the 1970's those very same CBT therapists were the very ones who labeled being passive as a form of psychopathology. As also mentioned in the BehaveNet blog post, they advocated something called assertiveness training.

Basically, in discussing the range of responses to mistreatment by someone else, assertiveness training posited one helpful response pattern and three dysfunctional ones. The dysfunctional ones were labeled passive (just sit there, take it, and do nothing about it), aggressive (attack the other person verbally or even physically), and passive-aggressive (Are you mad at your husband? Burn his toast).

The healthy response was called assertiveness — that meant speaking up for yourself and demanding respect from others without trying to bring the other party down, casting aspersions on them, or in some other way attacking them.

CBT assertiveness trainers followed the two "Bibles" of assertiveness training: Your Perfect Right by Alberti and Emmons and The Assertive Woman by Phelps and Austin.

After a while of teaching these assertiveness skills, however, CBT therapists began to back down. They were forced to admit that the "healthy" response might in some situations get you beat up or even killed, so it might be best to let some offenses go without any response. If you speak up when someone cuts in front of you in line these days, for example, the other person may go ballistic and hit you or even pull out a gun. This really doesn't happen very often if a person is assertive and not aggressive. It's in fact so unusual it often makes the evening news, which then makes everyone think it's way more common that it actually is. But it is a risk.

Nowadays, assertiveness training is discussed by CBT therapists far less if at all. It is telling that the initial editions of Your Perfect Right had one section for all readers and another section specifically written for therapists to teach them how to teach assertiveness skills to their clients. In later editions the self-help part was retained, but the part for therapists was eliminated completely.

Now it is true, I have found, that with ongoing repetitive family problems, the sort of generic assertiveness skills taught by CBT therapists in the past often just did not work. However, that was because family members often develop a whole repertoire of counter-moves that scream to the member attempting to be assertive, "You are wrong, change back." Some of these counter strikes are quite frightening. (I described many of them in a previous post.) All involve the person who is trying to be assertive getting invalidated in some way, and made to feel small for daring to speak up.

 "Help is at hand" by Angus Fraser CC By 2.0
Source: Source: "Help is at hand" by Angus Fraser CC By 2.0

This does not mean that the proper strategy for handling these problems is passivity. What I discovered is that the assertiveness training techniques that used to be taught had to be modified to fit the sensitivities and histories of each of the other family members being addressed.

Furthermore, these modifications were different for every family, and they therefore had to be tailored specifically to each one. There was no way to know in advance which strategy might work best, but there was almost always one that could be devised that could help diffuse the family drama significantly for any patient.

In therapy, I have my patients role play the other relatives to show me what they are up against, and I try out a variety of different strategies and counter-strategies to see which ones work the best.

Many of the different possible strategies were discussed in my earlier series of posts on responding to provocations from people with borderline traits, and another series about family meta-communication and intimate conversations. These strategies are just initial suggestions for how to respond, and as such, they may or may not work.

So the CBT therapists had the right idea about assertiveness training before they more or less gave up on it and resorted to the "distress tolerance skills" that are part and parcel of what they used to label dysfunctional passivity. They should have listened to some of the ideas from family systems therapists in order to improve their therapeutic assertiveness techniques.