BEHAVIORTHERAPY 10, 372--388 (1979)

Assertion Therapy: Skill Training or

Cognitive Restructuring
MARSHA M . L I N E H A N

University of Washington

MARVIN R. G O L D F R I E D AND A N I T A POWERS G O L D F R I E D

State University of New York at Stony Brook
Seventy-nine women participated in a program designed to compare assertion
therapy based on a skill-deficit model with a procedure based on a response
inhibition model. Participants were assigned randomly to one of five treatment
groups: behavior rehearsal, systematic rational restructuring, behavior rehearsal/
rational restructunng, relationship, and waiting list controls and were also assigned
to a male or female therapist. Treatment was carried out at two separate locations
resulting in a 2 x 2 x 5 factorial design. Results indicate that the combined behavior
rehearsal/rational restructuring therapy was superior; there were few differences
among the four contact groups on self-report measures; on both a role-play test and
a contrived situational test all three behavioral treatments were equally successful
at facilitating women to make a response whereas treatments employing behavior
rehearsal were more effective in improving the assertion quality of the response. At
follow-up all treatment groups typically maintained or improved on their gains, but
failed to differ from each other on a self-report battery. No effect for sex of therapist
was obtained. Results were the same at both locations indicating generalizability of
results across more than one research setting.
The model underlying many studies on assertion training (e.g., McFall
& T w e n t y m a n , 1973) is t h a t u n a s s e r t i v e i n d i v i d u a l s h a v e a skill d e f i c i t .
T h e p r i m a r y g o a l o f t r a i n i n g , t h e r e f o r e , is t o t e a c h t h e c l i e n t t h e r e q u i s i t e
skills. I n t e r v e n t i o n p r o c e d u r e s t y p i c a l l y i n c l u d e b e h a v i o r r e h e a r s a l ,
The research described in this article was supported in part by Grants MH 26313-01 and
MH 24327 from the National Institute of Mental Health. The authors are grateful to: Roger
Bartman, Suzanne Bronheim, Anne Byrnes, Karen Haynes, Michael Osarchuk, Jerry
Paone, Marilyn Sperling, and Leslie Weinberg who were the therapists in the study, to
Gerald C. Davison for his comments on an earlier version of this article, and to Cynthia
Pollnow for her invaluable assistance during all phases of this study. Requests for reprints
should be sent to: Marsha M. Linehan, Psychology Department (NI-15), University of
Washington Seattle, WA 98195.
372
0005-7894/79/030372-17501.00/0
Copyright 1979 by Association for Advancement of Behavior Therapy
All rights of reproduction in any form reserved.

ASSERTION~ SKILL OR C O G N I T I V E R E S T R U C T U R I N G

373

coaching, modeling, and in vivo practice of overt assertive responses. An

alternate model of unassertive behavior assumes that the person has the
requisite skills but is inhibited from behaving assertively by conditioned
anxiety in assertive situations (Wolpe, 1973; Salter, 1949). Attempts to
reduce assertion anxiety directly using systematic desensitization have
been somewhat effective in increasing assertive behavior, but not as
effective as skills training (Thorpe, 1975; Trower, Yardley, Bryant, &
Shaw, 1978).
A third model, which is a variation of the anxiety inhibition model,
suggests that assertive behavior may be inhibited but that this inhibition is
mediated by a person's maladaptive cognitive-evaluative appraisals
(Lange & Jackubowski, 1976; Linehan, 1979; Rich & Schroeder, 1976;
Schwartz & Gottman, 1976). Thorpe (1975) compared a cognitive procedure with behavior rehearsal and found that the cognitive intervention,
designed to reduce maladaptive appraisals, was as effective as skill training procedures in the treatment of unassertive behavior. Wolfe and Fodor
(1977) compared a behavior rehearsal approach with a combined behavior
rehearsal/cognitive restructuring treatment, finding that the addition of the
cognitive component to a skills training package did not increase participants' assertive behavior although it did reduce subjective reports of anxiety while behaving assertively. A major drawback of this study, however,
was that the treatment consisted of only two sessions.
A problem with these and other studies comparing cognitive interventions with behavioral interventions has been a failure to control for the
behavior rehearsal component in the cognitive therapy; while cognitive
therapy might have been effective, it is often unclear whether the results
were due to the behavior rehearsal component or to the interaction
between behavior rehearsal and the cognitive therapy. Even when systematic desensitization has been used alone, there is the likelihood, as
Kazdin (1974) suggests, that desensitization may be construed as selfmodeling or covert rehearsal and that the effect may be similar to behavioral rehearsal. A similar problem exists in determining the effective
component in the skill training programs. Although the only observable
cognitive components in most programs are skill oriented instructions
and feedback, it is likely that the client is also learning a new set of
cognitive-evaluative appraisals. However, since even the act of accepting
a person into an assertion training program is communicating, and thereby
perhaps also teaching, an appraisal of the value of assertive behavior, this
aspect of the skill training program is potentially inherent in any treatment
approach.
The primary aim of this study was to compare a therapy designed to
modify cognitive appraisals directly (Goldfried, Decenteco, & Weruberg,
1974), controlling for covert behavior rehearsal, with a program designed
to teach overt assertion skills. Both treatments were also compared to a
treatment combining skill training with cognitive restructuring. While all
three behavior therapies utilized rehearsal, modeling, coaching, self-

374

LINEHAN, GOLDFRIED, AND GOLDFRIED

statements, and in vivo practice, the target differed----overt behavior,

cognitive appraisals, or a combination of the two.
A second aim of this research was to study whether therapist gender is
an important variable in assertion therapy. To date, little evidence exists
demonstrating a differential effectiveness of male or female therapists on
treatment outcome (Parloff, Waskow, Wolfe, 1978). Sex of therapist is a
particularly relevant issue in the case of the treatment of women clients;
questions about the role of therapy in the possible perpetuation of sex-role
stereotypes which may be harmful to women are being increasingly
raised.
METHOD
Participants
Seventy-nine women, mean age 43.2 years and mean education level
14.5 years, were selected according to the following criteria: (1) a score
below zero on the Rathus Assertiveness Inventory (Rathus, 1973), and (2)
a score of 3 or above on the Assertion Difficulty Inventory described
below.
The study was carried out at both The Catholic University of America
and the State University of New York at Stony Brook, and a final aim of
this research was to demonstrate the feasibility of conducting collaborative outcome research at more than one setting. Although the need for this
type of research has generally been agreed upon, the difficulties in
standardization have made such ventures relatively rare (Bergin & Strupp,
1970).

Assessment
Participant questionnaires. The Rathus Assertiveness Inventory
(Rathus, 1973), the Assertion Difficulty Inventory, the S-R Inventory of
Anxiousness (Endler, Hunt, & Rosenstein, 1962), and the S-R Inventory
of Hostility (Endler & Hunt, 1968) were administered at pretest, posttest,
and follow-up measures to all participants. The situations used in the two
S-R Inventories as well as the Assertion Difficulty Inventory are described
below. Both before and immediately after the first session, participants
rated their expectations for therapy success on a 5-point scale ranging
from "zero chance of success" (1) to "100% chance of success" (5).
Peer questionnaire. Each participant gave the name of a person who
she believed knew her well and saw her often enough (generally, at least
once a week) to complete a questionnaire at posttest evaluating her
assertive behavior. Open-ended questions requested such information as
whether changes were observed and the effect of such changes on their
relationship.
Behavioral role-play test. An extended interaction behavioral roleplaying test was administered at pre- and posttest. A trained male-female
assessment team delivered role-play lines verbatim to participants from
predetermined scripts. Following a response of the participant, the as-

A S S E R T I O N : S K I L L OR C O G N I T I V E R E S T R U C T U R I N G

375

sessors delivered an additional predetermined prompt, and up to five

prompts, depending on the point at which the participant gave in or
stopped responding. The role-play interactions were tape recorded, and
the sex of the assessor was varied across the six situations.
The major dependent variables were: assertion content, speech dysfluencies, loudness/affect, eye gazing, number of responses per interaction, and subjective reports of anxiety, guilt, and anger obtained
after each of the role-play situations. Assertion content was rated on a
5-point scale from transcriptions of the audio tapes. Speech dysfluencies
were scored by counting the number of stammers, blockages, etc.
(adapted from Mahl, 1959). The loudness/affect quality of the response
was rated from audio tapes (1 = barely audible response to 5 = volume
strong, affect does not detract from assertiveness). For these three measures, two separate scores were computed for each situation: a first
response only score, and an average situation score. Duration of eye
gazing was timed by the unoccupied assessor and a percentage score was
obtained by dividing by the total time of the interaction. Number of
responses was obtained by counting the number of prompts delivered by
the experimenter. Following each role-play situation, participants estimated on a scale of 0 (low) to 100 (high) how much anxiety, guilt, and
anger they had experienced during the role-play. A measure of base
anxiety was also obtained prior to any of the role play situations, by
asking participants to estimate their typical or average level of anxiety in
their everyday life.
Contrived situational test. While participants were trying to complete a
questionnaire at posttest, a female confederate, following a predetermined script, set up six interactions that interfered with the participant's
efforts, such that the participant was required either to initiate assertive
behavior or exhibit refusal behavior. The confederate delivered up to a
total of five prompts (refusals or repeated requests) until the participant
stopped responding or gave in. The entire situation was tape recorded,
and the dependent variables consisted of assertion content for the first
response per interaction, average assertion content per interaction, and
number of responses per interaction. Assertion content and number of
prompts were scored as in the behavioral role-play test.

Development o f Assessment and Training Situations

One hundred eighty situations, collected from previous assertion
studies and inventories, were compiled into booklets and distributed to
147 women (mean age, 33 years). Subjects rated on a 6-point scale how
difficult it would be to handle each situation in an assertive way and
indicated how many times they had encountered each situation in their
lifetimes. Twenty-six of the most frequent situations were selected,
evenly divided between interactions with both sexes and interactions
requiring refusal of an unreasonable request and those requiring initiation
of assertive behavior. Since the few items rated as extremely difficult

376

LINEHAN, GOLDFRIED, AND GOLDFRIED

were also very low in frequency, most items included were rated as mildly
to moderately difficult.
Assertion difficulty inventory. An inventory was constructed by rewriting the 26 situations into one-sentence summaries, with instructions to
rate each situation on the amount of difficulty one would have in responding assertively in that situation. Ratings varied from easy (1) to extremely
difficult (5).
Training, role-play, and S - R inventories situations. Situations for training, role-play assessment, and for the S-R Inventories of Anxiousness
and Hostility were drawn from the Assertion Difficulty Inventory. Situations required refusal and initiation with both males and females. The six
pre and posttest role-play situations were similar in content but not identical, and were matched on rated difficulty and frequency.

Therapists
Therapists were four female and four male advanced graduate students
and postdoctoral fellows. All therapists had prior training in both behavior
and cognitive therapy and received approximately 20 hr of training for this
study. Therapists received weekly group supervision from the first two
authors during which audio tapes were reviewed to insure that the
therapies were being conducted appropriately and progress of each participant was discussed.
Treatment Conditions
There were a total of five conditions: behavior rehearsal (n = 16),
systematic rational restructuring (n = 16), behavior rehearsal/rational
restructuring (n = 16), relationship control (n = 16), and a waiting-list
control, (n = 15). Treatment was conducted individually in eight sessions
over an 8-week period. A within-sample matching technique, based on
pretest questionnaire inventory scores, was used to assign participants to
the five conditions such that groups were equated on mean scores for each
inventory.
The overall format for the three behavioral treatment groups was similar: treatment components included coaching, modeling, self-coaching,
rehearsal, self-evaluation, feedback, therapist praise, and in vivo practice.
Therapy consisted of practicing assertive behaviors, rational restructuring, or a combination of both in 12 training situations, with 4 rehearsal
trials per situation. Modeling was faded out over the course of the
therapy. The in vivo practice was discussed at the beginning of each
session and coaching, feedback, and praise were given as appropriate.
Behavioral rehearsal. Training focused on verbal content, nonverbal
behaviors, and strategies of assertive behavior. A list summarizing principles of assertive behavior was given to each client. Using a tape recorder,
the therapist modeled an assertive response and then the client roleplayed each situation four times with the therapist. The number of predetermined prompts per trial delivered by the therapist increased from one

ASSERTION" SKILL OR C O G N I T I V E R E S T R U C T U R I N G

377

to four over the four trials. Before each trial, the client verbalized one or
more self-coaching statements (e.g., "Remember, keep good eye contact"). Following each trial the client evaluated her own behavior, using
the principles of assertive behavior as criteria, on a 5-point scale, and
feedback and coaching were given. Therapists maintained a skill oriented
focus to insure that participants did not engage in verbal cognitive restructuring. Clients were instructed to practice and record a description of their
assertive behavior at least five times during the week.
Systematic rational restructuring. Treatment was a modification of the
systematic-rational restructuring procedure proposed by Goldfried et al.
(1974). The therapist modeled the cognitive restructuring process and
each participant was given a list of assertive beliefs. After the participant
verbalized several self-coaching statements (e.g., "Remember, saying no
to a friend probably won't make her dislike me forever."), she practiced in
her imagination cognitively restructuring the situation read by the
therapists over four separate trials. To ensure that participants did not
covertly practice assertive responding, they were instructed to verbalize
or "think out loud" their self-defeating thoughts and reevaluations immediately following each of the four situation presentations. Therapist
prompts ensured that participants focused on their self-statements instead
of on what they would do in the situation. Inasmuch as this condition
involved no overt behavioral response, prompts were written for trials 2-4
to indicate that the other person in the situation had continued to refuse or
persist one or more times. The prompts were taken directly from the
script used for the comparable trial in the behavior rehearsal condition.
Following each trial, the participant rated her anxiety and anger levels and
was given feedback and coaching on her ability to reevaluate the situation. Participants were instructed to practice cognitive restructuring at
least five times each week in situations that might call for assertive
behavior and to record a discription of the situations and the restructuring
process.
Behavior rehearsal~rational restructuring. A combined procedure was
used and the participant both practiced rational restructuring and behaviorally rehearsed each situation. Homework assignments were a combination of those given to participants in the restructuring and behavioral
rehearsal therapies.
Relationship Control. This treatment was designed to control for the
effects of being in individual treatment for assertion problems and therapist
approval and "permission" to behave assertively. Participants were told
that assertion problems are due to a lack of self-confidence, which can be
overcome by expressing opinions, beliefs and feelings in an accepting and
supportive atmosphere. During session 1, the treatment rationale and the
participant's assertion problems were discussed. During sessions 2-8, any
topic of concern which the participant brought up was discussed. The
therapist responded to comments with one or more of the following; attending behavior, reflection of feelings, open-ended questions, and summariza-

378

LINEHAN, GOLDFRIED, AND GOLDFR1ED

tion of content. Assertion was discussed at least once during each session
and therapists generally expressed approval for attempts at behaving assertively. Therapists refrained from giving advice, directions, cognitive
restructuring-type comments, and skill training comments.
Waiting list. Participants assigned to the waiting-list control were told
that because of the large numbers of applicants, there would be a time
delay before they would receive treatment. At the end of 8 weeks they
were contacted and told they would have to retake the assessment battery
before beginning treatment. Participants were then offered treatment and
were not included in the follow-up assessment.

RESULTS

Expectancies and Demand Characteristics

Separate one-way analyses of variance indicated no significant differences among treatments on estimates of success either prior to or after the
first session. The absence of difference after clients had been provided
with the therapy rationale and a description of the treatment procedures
suggests that the effects of expectancy and demand characteristics, at
least at the beginning of treatment, were comparable across treatment
conditions.
At the follow-up assessment, 8 to 10 weeks after termination, each client
confidentially rated her therapist on 7-point scales for a number of different
variables (e.g., warmth, comfortableness). Analyses of variance for the
average score across all variables indicated no significant differences
among treatment conditions.

Location of Therapy
Due to the nonrandom assignment to location, any differences at posttest between the participants in Washington, D.C. and Stony Brook (a
distant suburb of New York City) would be difficult to interpret. Nonetheless, location was included as one of the factors in the three-way analysis
of covariance. The results reflected a main effect for location on only one
dependent variable: Washington, D.C. women across all treatment conditions had fewer speech dysfluencies per situation than Stony Brook
women (.70 vs .90 respectively, F (1,57) = 3.86, p < .01).

Sex of Therapist
There were no main or interaction effects for sex of therapist on any
dependent variable used in this study. To assess whether sex of therapist
might interact with sex of the other person depicted in the assertion
situations used for assessment, the situations in the behavioral roleplaying test and the S - R Inventories of Anxiousness and Hostility were
divided into two groups according to sex of the other person in the
interaction. Sex of therapist had no effect in any of these analyses.
Further, assessment scores on interactions with females were found to be
almost identical to scores with males, irrespective of therapist sex.

ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G

379

Treatment Effects: Posttesting

Inasmuch as no main or interaction effects were found for sex of
therapist, and location was significant on only one variable, treatment
effects were analysed by one-way analyses of covariance for unequal n
values (Winer, 1975). With the one exception, noted below, all regression
assumptions were met. Post-hoc comparisons of means were done by
Newman-Keuls adjusted for covariance (Dayton, 1970).
Questionnaire battery. Tests for differences between adjusted means
indicated that participants in the behavior rehearsal/rational restructuring
condition showed significantly greater improvement on all questionnaire
measures when compared with the waiting-list control (see Table 1). In
comparison to those in the waiting-list control, participants in rational
restructuring showed greater improvement on the Assertion Difficulty
Inventory and the S-R Inventories of Anxiety and Hostility. Participants
assigned to behavior rehearsal improved more than waiting-list control on
only the Assertion Difficulty Inventory. With the exception of differences
on the Assertion Difficulty Inventory, where the combined treatment was
superior to the relationship control, there were no significant differences
among the four contact groups on questionnaire measures (see Table 1).
To focus specifically on the direction of change, analyses of pre-post
within-group differences by t tests were computed (see Table 2). Results
indicate a significant improvement across all questionnaire measures,
except the S-R Inventory of Hostility, for the four treatment contact
conditions.
Behavioral role-playing test. The performance ratings based on either
the transcripts or tape recordings of the participant's response to the
role-playing test, were conducted by two or more pairs of judges. On each
of the variables, the resulting Pearson product-moment correlation
coefficients across all of the data revealed high reliability. For assertion
content, reliability was .90 between two raters; for loudness/affect, the
average reliability for three pairs of raters was .91 with a range of .86 to
.97; for speech dysfluencies, the average reliability for six pairs of raters
was .94, with a range of .88 to .96. Since only one assessor recorded eye
gazing, it was not possible to calculate reliability. However, during
training, reliabilities of .90 and above were obtained with two observers.
The unadjusted pre- and posttest means for the variables associated
with the role playing assessment are depicted in Fig. 1. The behavior
rehearsal/rational restructuring condition and behavior rehearsal alone
did not differ from each other on any of the measures, and each was
superior to both the relationship and the waiting-list control on measures
of assertion content, speech dysfluencies, and total number of responses
(see Table 1). In addition, behavior rehearsal/rational restructuring and
behavior rehearsal alone were superior to rational restructuring on assertion content and speech dysfluencies. Behavior rehearsal demonstrated
significantly greater improvement than waiting-list control on percentage
of eye gazing, which was the only significant finding with this measure. All
three behavior therapy conditions were comparable on total number of

taJ

37.39
3.01
1.69
7.55
19.02

1
l
3.69
2.23

Behavioral role-play test:

performance ratings
Assertion Content
Speech dysfluencies
Loudness/affect
Eye gazing (percentage)
No. of responses

Behavioral role play test:

subjective emotional responses
Anxiety
Guilt
Anger
Base anxiety

(4,73)
(4,72)
(4,69)

(4,72)
(4,72)
(4,72)
(4,69)

(4,73)
(4,73)
(4,69)
(4,72)
(4,73)

(4,73)
(4,73)
(4,73)
(4,73)

df

.001
ns
ns

ns
ns
.01
ns

.001
.05
ns
.001
.001

.001
.001
.001
.001

4.33a
0.72a
3.35a

26.02a
20.48a
25.56a
22.15a

4.21a
.38a
3.35a
8lab
4.76a

1.99a
3.54a
206.99a
109.92a

BR/RR

3.72a
1.32a
3.03a

32.02a
20.05a
21.65a
28.52a

3.49b
1.04b
3.03a
74ab
4.57a

2.37ab
-5.15ab
199.97a
120.50a

RR

4.29a
0.61a
3.50a

28.43a
19.07a
18.63 a
33.02a

4.27a
.53a
3.50a
86a
4.87a

2.48ab
- 15.17ab
225.25ab
130.53ab

BR

RC

3.16b
1.26a
3.23a

31.14a
21.69a
35.92a
41.30a

2.80c
.82b
3.23a
72ab
3.76b

2.83b
-22.98ab
243.43ab
157.16ab

Adjusted treatment means

2.93b
0.88a
2.92a

39.86a
21.80a
38.69a
34.40a

2.50c
1.03b
2.92a
66b
3.46b

3.43c
-36.98b
263.79b
172.36b

WL

Note. Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship
control; WL = waiting list. Means in the same row with different subscripts differ from each other at least at the .05 level. The lower the score the more
positive the self-esteem.

24.02
3.36
1.69

13.25
6.57
6.46
8.32

Questionnaire battery
Assertion Difficulty Inventory
Rathus Assertiveness Inventory
S - R Inventory of Anxiousness
S - R Inventory of Hostility

Behavioral role play test:

first response
Assertion content
Speech dysfluencies
Loudness/affect

Analyses of covariance

1 ANALYSES OF COVAR1ANCE FOR TREATMENT EFFECTS AND ADJUSTED MEANS AT POSTTESTING

Measures

TABLE

381

ASSERTION: SKILL OR C O G N I T I V E R E S T R U C T U R I N G
=-- --e
"
~=c
?
t-

8R/RR
RR
8R
RC
WAIT

BEHAVIOR REHEARSAL/RATIONAL RESTRUCTURING

RATIONAL RESTRUCTURING
BEHAVIOR REHEARSAL
RELATIONSHIP CONTROL
WAITING LIST

Assertion
Content

50

Number of
Responses

30

Percent
Eye Gazing

90

o:
o 20
(ji

70
15
15

I0
T

I
PRE

I
POST

6O
I

PRE
POST
Number of Speech
Dysfluencies
1.45;

1.15

0.85

0.55

L~udness/Affect

Roting

"T

PRE

t_

POST

Bose Anxiety
50

3O

X.

20
\
W

0.25
1"

PRE

POST

60

60

,.w 5C

I
POST

Subjective
Guilt

Subjective
Anxiety

I
PRE

IO
T

60

50

50

30

30

PRE

POST

Subjective
Anger

n- 40
3O

2O

2C
T

PRE

POST

PRE
POST
ASSESSMENT PERIOD

20
PRE

POST

FIG. 1. Unadjusted mean scores for behavioral role-play test performance and subjective emotional response measures at pretest and posttest assessment. With the exception of
base anxiety, all scores reflect averages across six role-played situations.

responses and superior to both control groups. The only other m e a s u r e on

which rational restructuring showed significantly greater i m p r o v e m e n t
than control groups was on assertion content. The two control conditions
did not differ from each other on any of the p e r f o r m a n c e measures. N o

bo

battery

Inventory

Inventory

S-R

S-R

of Hostifity

of Anxiousness

Inventory

Difficulty Inventory

Rathus Assertiveness

Assertion

Questionnaire

Measures

TABLE

-57.50***
-40.87***
16.63

Pre-follow-up

Post-follow-up

5.07

-40.18"*

-45.25***

0.12

- 76.44* * *

- 61.00" **
2.44

-76.56***

9.94*

46.76***

36.82* * *

- 0.28"

- 1.57***

- 1.29"**

RR

-63.44"**

Pre-post

Post-follow -up

Pre-follow-up

Pre-post

7.69

52.32***

Post-follow-up

44.63 * **

- 0.11

Post-follow-up

Pre-follow-up

- 1.66"**

Pre-follow-up

Pre-post

- 1.55***

Pre-post

BR/RR

Mean

-0.94

-29.44*

-28.50

- 8.00

- 57.00" **

-49.00**

9.62

36.56***

26.94* **

- 0.37" *

- 1.42***

- 1.05"**

BR

differences

WITHIN-GRouP MEAN DIFFERENCES FROM PRE- TO POSTTESTING~ PRETESTING TO FOLLOW-UP,

AND POSTTESTING TO FOLLOW-UP

- 17.37

-33.69**

- 16.32

- 13.31

- 42.69* **

-29.38**

6.70

25.62**

18.62*

- 0.18*

-0.89***

-0.71"**

RC

--

--

2.93

--

--

- 14.67

--

--

4.47

--

--

-0.10

WL

Pre-post
Pre-post
Pre-post

Assertion content
Speech dysfluencies
Loudness/affect

1.49"**
-0.59*
0.51"

-25.25**
- 12.92"
- 14.28"*
- 16.60"*

1.88"**
-0.70**
0.51 *
7*
1.49***

0.79***
-0.21
0.21

18.03"*
13.28"
18.68"*
12.92'

1.16"**
-0.34
0.21
5
1.47***

1.42"**
-0.72**
0.83"*

-20.13"
- 16.40"*
-23.13"*
-3.93

1.99"**
-0.61"*
0.83 * *
15"**
1.76***

0.25
-0.20
0.43

-21.35"*
- 19.71"**
-5.74
0.72

0.49**
-0.39
0.43
1
0.63**

0.09
-0.52
0.11

-7.56
- 14.99
-2.13
-7.33

0.22
-0.19
0.11
-6
0.29

Significance of change based on within-group t tests. Follow-up data were based only on questionnaire measures, and were not obtained for the
waiting-list control. For the Self-Esteem Scale, the lower the score, the more positive the self-esteem.
* p < .05.
** p < .01.
*** p < .001.

Note. BR/RR = behavior rehearsal/rational restructuring; RR = rational restructuring; BR = behavior rehearsal; RC = relationship control; WL =
waiting list.

Pre-post
Pre-post
Pre-post
Pre-post

Pre-post
Pre-post
Pre - p o s t
Pre-post
Pre-post

Anxiety
Guilt
Anger
Base anxiety
Behavioral role play test:
first response

Behavioral role play test:

subjective emotional response

Behavioral role play test:

performance ratings
Assertion content
Speech dysfluencies
Loudne s s/affect
Eyegazing (percentage)
No. of responses

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significant differences emerged among any of the treatment procedures on

loudnes s/affect.
The data for the total number of responses should be interpreted in light
of the violation of homogeneity of regression assumption on this variable
(F (4, 69) = 3.05, p < .02). An examination of the correlations between
pretesting and posttesting indicated a positive relationship in the rational
restructuring and two control groups, but not in either of the two procedures involving behavior rehearsal, where the correlations approached
zero.
Within-group mean differences between pre- and posttesting for each of
the performance ratings reflect significant improvement on all measures
for both the behavior rehearsal/rational restructuring and behavioral rehearsal alone conditions (see Table 2). The results for rational restructuring and the relationship control are comparable in that significant improvement was found for content of assertive responses and and total
number of responses. No significant changes were obtained for the
waiting-list control.
Participants' ratings of their subjective emotional responses showed a
main effect of Treatment for anger. Tests for differences between individual adjusted means, however, did not reveal a significant difference
between any pair of means. There were no main effects for treatment of
subjective measures of anxiety and guilt.
Examination of pre- and posttest means and associated t tests (see
Table 2) indicated that all three behavioral treatment groups reported less
anxiety, guilt, and anger following treatment; the relationship control
reported less anxiety and guilt, but no significant change on subjective
anger. Once again, there were no pre-post differences on any variable for
the waiting-list control. The analyses of covariance did not indicate any
significant treatment effect for base anxiety, that is, participants' estimate
of their typical level of anxiety (see Table 1). However, within-group t
tests between pre- and posttesting indicated significant decrements in
base anxiety for those procedures incorporating rational restructuring,
either alone or in combination with behavior rehearsal (see Table 2).
Behavioral role-play test: First response. Separate analyses were carried out for the first response only on the extended interaction test.
Participants in each of three behavioral groups were rated as significantly more assertive on their first responses than those in either of the
control conditions (see Table 1). There were no significant treatment
effects for speech dysfluencies or loudness/affect. Analysis of the withingroup t test (see Table 2) revealed a pattern similar to that found for the
extended interaction analysis.
Contrived situational test. The assertive content of each response in the
contrived situational test was determined on the basis tf two raters, with an
interrater reliability of .88. Inasmuch as the test was administered at
posttesting only, a one-way analysis of variance was computed for each
variable. A main effect for Treatment condition was found on each measure (see Table 3). Tests between adjusted means indicated that while

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385

TABLE 3
ANALYSES OF VARIANCE FOR TREATMENT EFFECTS."
CONTRIVED SITUATIONAL TEST
Analyses of
variance a
Measure
Assertion content:
across responses
Assertion content:
first response
No. of responses

Treatment means

df

B1URR

RR

BR

RC

10.28

(4,55)

.001

3.87ab

3.46ac

4.05b

3.20c

3.07c

3.12
3.92

(4,57)
(4,49)

.022
.002

4.17ab
4.89a

3.92ab
4.58ab

4.30b
4.92a

3.63a
4.32b

3.79ab
4.44b

WL

Note: Abbreviations: BR/RR = behavior rehearsal/rational restructuring; RR = rational

restructuring; BR = behavior rehearsal; RC = relationship control; WL = waiting list.
Means in the same row with different subscripts differ from each other at least at the .05
level.
a Only the main effects for treatment are presented. The complete three-way table
(treatment location sex of therapist) may be obtained from the first author.

behavior rehearsal/rational restructuring and behavioral rehearsal alone

did not differ from each other, each of these two conditions was superior
to both controls on the basis of assertion content across responses and
total number of responses. Further superiority for the behavior rehearsal
condition was reflected by significantly higher scores than rational restructuring on assertion content score for first response when compared
with the relationship control. No other significant differences were found.
Peer questionnaire. X2 analyses indicated that when compared with
participants in the relationship and waiting-list control groups, clients in
the three behavioral treatment groups (behavior rehearsal/rational restructuring, behavior rehearsal, and rational restructuring) were more
likely to be seen as easier to get along with (X2 --- 5.8, df = 1,p < .05; 44%
for the behavioral conditions vs 17% for the control conditions). There
were no differences between individual treatments in either group. Only
11% of the peers in the behavioral treatment conditions and 14% in the
two control groups reported more difficulty in relationships.

Treatment Effects: Follow-Up

Analyses of covariance were carried out to test whether treatment
differences were maintained on the self-report measures at follow-up 8 to
10 weeks after termination. As noted previously, waiting-list participants
were not included because of ethical considerations, and instead were
offered treatment following the posttesting. Main effects for treatment
were found for the Assertion Difficulty Inventory (F (3, 59) = 3.5, p < .02)
and the Rathus Assertiveness Inventory ( F (3, 59) = 3.5, p < .02).

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LINEHAN, GOLDFRIED, AND GOLDFRIED

Although the direction of differences was similar to the direction at

posttesting, comparisons between adjusted means indicated no significant
pair-wise differences.
Within-group t tests between pretest and follow-up questionnaire measures revealed a significant improvement for all conditions on all measures (see Table 2). To determine whether the questionnaire changes
obtained at posttesting were maintained at follow-up assessment, withingroup t tests were also computed between posttest and follow-up assessment on both the Assertion Difficulty and Rathus Assertiveness Inventories. Participants in both behavior rehearsal and the relationship control
also showed continued improvement on the Assertion Difficulty Inventory.

DISCUSSION
The findings indicate that a combined intervention procedure, employing both behavioral rehearsal and systematic rational restructuring, was
the most effective in increasing assertive behavior and reducing the emotional discomfort associated with such interactions. This superiority,
however, was a function of the greater improvement in the combined
group relative to the control groups. Participants receiving behavior rehearsal, for the most part, demonstrated gains on self-report measures as
well as superiority over participants not receiving the behavioral rehearsal
component on qualitative measures of overt assertion. Of particular interest is the finding that behavior rehearsal therapy, in which clients were
told to ignore their emotional responses, was effective in reducing a range
of maladaptive emotional responses related to assertion in addition to
increasing the number and quality of assertive responses. Cognitive
therapy alone also showed improvement at posttesting. Although the
content of the responses given by participants in rational restructuring
was not as assertive as those emitted by individuals in the other two
behavioral interventions, it was superior to those given by participants in
both control conditions. Our findings lend tentative support to the clinical
observations of Lange and Jakubowski (1976), who have suggested that a
combination of cognitive restructuring and skill acquisition interventions
are the optimal treatment for facilitating assertive behavior. Despite the
fact that the relationship control was both not significantly better than the
waiting-list control group on any measure used in the study, and significantly less assertive on many performance measures than the behavioral
interventions, the participants self-reported the same degree of success in
learning to behave assertively and in reducing their problematic emotional
responses in assertive situations. These results are comparable to the
results of Wolfe and Fodor (1977) who found a similar relationship between
their consciousness-raising group and the two behavioral interventions.
The subjective experience of benefit reported by the relationship control
participants suggests that the very experience of being in therapy may help

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387

women at least feel better in assertive situations. It is not clear whether this
is due to the stated purposes of the treatment (i.e., expressing oneself in a
supportive environment), the giving of the permission to behave assertively inherent in any assertion therapy, or any number of other variables
that might have been operating.
Another major finding of this research was that sex of therapist was not
a significant factor in assertion training with our female participants.
While our findings are clear, care must be taken as to how they are
interpreted. Within the context of the present research, potential bias may
have been undercut by virtue of a built-in agreement between client and
therapist that the goal was to facilitate assertive behavior. There may be
differences in actual clinical settings, particularly in selecting goals and
specifying actual behavioral changes needed.
In light of the much publicized popular view that assertion training with
women may result in increased aggression, hostility, and anger and, thus
jeopardize interpersonal relationships, our results are of particular interest and give evidence to the contrary. Across all three behavioral interventions, there was a self-reported decrease, not increase in hostility and
anger as a result of treatment. Although retrospective reports on the
quality of a relationship must be viewed with caution, the results suggest
that relationships were improved as a result of participation in the program.
Content of the initial response only for participants in the rational
restructuring condition was just as assertive as for those in either behavior
rehearsal/rational restructuring or behavior rehearsal alone. When all
response associated with the extended interaction are considered, however, rational restructuring participants were not as assertive as either of
the other two behavioral conditions. An extended interaction role-playing
test may be preferable to use in future outcome research on the grounds
that it more closely parallels the nature of an assertion interaction in real
life. Although the role-play test may be quite adequate as a measure of the
person's assertion capability, this may not reflect the extent of the person's actual assertive responding in the natural envionment.
Our finding that a treatment procedure combining both behavior rehearsal and rational restructuring is most effective could be the result of
its greater applicability to the range of controlling variables associated
with unassertive behavior, rather than evidence of its superiority for use
with all unassertive persons. It could be that some of the particip~ :s in
the cognitive restructuring therapy might have benefited more t am a
behavior rehearsal therapy, and vice versa. A more appropriate
methodology in future research would be to carefully assess each participant across each of the assertion response systems, including verbal and
nonverbal assertive motor skills, social-evaluative anxiety, and beliefs
about both the appropriateness and consequences of assertion; treatment
packages, ideographically designed, could then be implemented and compared.

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LINEHAN, GOLDFRIED, AND GOLDFRIED

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RECEIVED: May 25, 1978; REVISED: December 1, 1978
FINAL ACCEPTANCE: January 18, 1979