Behav. lb. a Therapy, 1973. Vol. 11, PP. 505 to 521. Pr~samon press.

printed in England

DEVELOPMENT OF ASSERTIVE RESPONSES: CLINICAL,

MEASUREMENT AND RESEARCH CONSIDERATIONS

MICHELHERSEN,RICFIARDM. EISLERand PETERM. MILLER

Veterans Administration Center and University of Mississippi Medical Center, Jackson, Mississippi, USA

(Received 12 March 1973)

Summary-The development of assertive responses in unassertive individuaIs is surveyed in terms of clinical

application, measurement techniques and experimental study. Case reports indicate that assertive training
is an effective technique for a large variety of disorders as it enables patients to overcome deficits in inter-
personal functioning. Some of the effective elements in assertive training have been identified by using
analogne research designs. In most of these investigations the major focus has been on expressing hostile
feelings and thoughts. However, more efforts at instigating positive responses (clinically and experimentally)
are warranted. In addition, there is a need to assess the effects on ‘clinically’ unassertive subjects of techni-
ques in which the transfer of training is programmed rather than expected.

ASSERTIVE training (Wolpe, 1958, 1969; Wolpe and Lazarus, 1966) has been developed as a
treatment technique for those individuals who are generally unable to express their rights
and feelings (negative and positive) towards others. The rationale for training in assertion
is presented by Wolpe (1969) as folfows: ‘Assertive training . . .is required for patients who
in interpersonal contexts have unadaptive anxiety responses that prevent them from saying
or doing what is reasonable and right . . .suppression of feeling may Iead to a continuing inner
turmoil which may produce somatic symptoms and even pathological changes in predis-
posed organs. . .’ (p. 61). A variety of component techniques including advice, exhortation,
specific therapeutic instructions, therapist modeling of appropriate responses, role playing,
and behavior rehearsal (Hersen et al., 1973) are used during the full course of assertive training,
Although Wolpe emphasized the principle of ‘reciprocal inhibition’ in his earlier formu-
lations (Wolpe, 1958, Wolpe and Lazarus, 1966), in his more recent writings (Wolpe, 1969,
1970) the important influences of operant conditioning (shaping and reinforcement) during
assertive training have been acknowledged.
A careful examination of Wolpe’s (1958, 1969) theory suggests that anxiety inhibits
interpersonal responsiveness. There is the implicit assumption that the unassertive individual
is essentially cognizant of what he should say and do but that he is ‘blocked’ from his full
expression. However, in more recent clinical and experimental reports (Eisler and Hersen,
1973; Eisler et al., 1973; Hersen et al., 1973; Laws and Serber, 1971; Lazarus,
1971), data indicate that for many of the patients who fail to evidence appropriate
interaction in interpersonal settings the relevant verbal and nonverbal responses have never
been learned. Laws and Serber (1971) argue that ‘Assertive training with these subjects
becomes a process of habilitation rather than rehabilitation of old behaviors or facilitation
of suppressed behaviors.’ Lazarus (1971) notes that ‘Specific techniques are often necessary
to teach people to express feelings appropriately’ (p. 116). Hersen et al. (1973) found that
‘mere practice in the absence of additional techniques will not lead to behavioral change on

505
 506 MICHEL HER~EN,RICHA~ hf.EISLER and PETER hf.MILLER

either the verbal or nonverbal components of assertiveness’. It was therefore concluded

‘that an individual evidencing a behavioral deficit must be taught a new way of responding
as appropriate responses are simply unavailable in his current repertoire’.
Systematic research on the effects of assertive training has been difficult to conduct for
several reasons. First, a wide diversity of treatment techniques have been used. Second, it is
difficult to determine the specific behavior involved in ‘being assertive’ within various
interpersonal settings. Third, it is difficult to find laboratory or analogue measures of asser-
tive behavior that approximate real life situations. However, use of audio and audiovisual
media has markedly facilitated the precise study of interpersonal behavior in general (Eisler
and Hersen, 1972; Eisler and Hersen, 1973; Eisler et al., 1973a, 1973b; Hersen et al.,
1973) and assertive training in particular (Eisler et al., 1973c; Eisler et al., 1973d; Friedman,
1969; Hersen et al., 1973; McFall and Lillesand, 1971; McFall and Marston, 1970;
Rathus, 1973b; Serber, 1972). In the present review, development of assertive responding
will be examined in light of clinical, measurement, and research considerations. Specific
issues such as generalization of training into other interpersonal contexts and use of the
group psychotherapy approach will also be considered. In addition, suggestions as to future
research and clinical applications in this area will be presented.

CLINICAL STUDIES

Although in most clinical studies the focus has been on the expression of patients’
more negative feelings (Edwards, 1972; Geisenger, 1969; Goldstein et al., 1970;
Patterson, 1972; Roback et al., 1972; Stevenson and Wolpe, 1960; Wolpe, 1970),
the truly assertive individual should be equally facile in his expression of positive
thoughts. Wolpe (1969) makes a clear distinction between ‘Hostile’ Assertive
Statements (e.g. ‘Please don’t stand in front of me’) and ‘Commendatory’ Assertive State-
ments (e.g. ‘That’s a beautiful dress/brooch, etc’) (p. 66). Similarly, Lazarus (1971) contends
that ‘The behavior therapy literature devotes disproportionate space to assertive training, to
the expression of anger, and to the need to be able to contradict and verbally attack other
people’ (p. 138). He further points out that ‘Many of our patients are able to contradict and
attack, or to criticize and defend, but are completely incapable of voluntary praise and
approval, or of expressing love and affection’ (p. 138). Indeed, almost none of the research
literature on assertive training is devoted to an examination of the most effective methods
for helping the patient express his positive feelings. Moreover, this issue assumes consider-
able significance for the unassertive patient who is undergoing treatment, particularly as he
is likely to overreact and assert himself inappropriately to alleged slights (Wolpe, 1970).
Macpherson (1972) presents the case of a 45-year-old housewife who had a lengthy history
of responding submissively to her mother and overcritically towards her husband. In addi-
tion, she had a 16-year history of anxiety and globus hystericus, resulting in loss of weight.
Initially desensitization therapy was begun, but treatment was then changed to an inter-
esting application of operant conditioning in which unassertive statements to mother were
punished (faradic shock) while assertive statements towards her were reinforced (therapist
verbal reinforcement of ‘good’). Reinforcement contingencies were reversed with respect to
the husband. Ten role playing situations were developed (5 husband, 5 mother), with two
available responses (assertive or unassertive) to each. These were presented by the therapist
in random order in each of 36 outpatient treatment sessions. The patient was expected to
 DEVELOPMENT OF ASSERTIVE RESPONSES 507

respond as naturally and as rapidly as possible when presented with the stimulus materials.
‘Failure to respond within five set was followed by shock. Verbal reinforcement. . .for the
right response or shock for the wrong response was given on a 75 per cent schedule’ (Mac-
pherson, 1972, p. 100). Data for test sessions, in which novel role-playing situations were
interposed, showed that the treatment was effective. Moreover, clinical improvement was
evidenced in that the patient regained her weight, now reacted positively toward her hus-
band, and was appropriately assertive toward her mother when warranted. At the 2-year
follow-up therapeutic gains had been maintained.
Behavior rehearsal (Lazarus, 1966) is one of the major techniques used during the typical
course of assertive training. Under guidance of the therapist, the patient is asked to role-play
interpersonal situations that have caused him anxiety in the past or those that are likely to
elicit anxiety in the future. Often when the patient becomes excessively anxious or when he
simply does not possess requisite interactional skills, it becomes necessary for the therapist
to model appropriate behavior (Eisler and Hersen, 1973). Considerable practice takes place
during these sessions, and it behooves the therapist to ensure that the patient will have a high
probability of success when attempting to practice assertion in his natural environment
(Neuman, 1969; Wolpe, 1969, 1970). Wolpe (1969) cautions the therapist that he should
‘Never instigate an assertive act that is likely to have seriously punishing consequences for
the patient’ (p. 67). From the operant framework it is clear that punishment of assertive
attempts may decrease their frequency of occurrence in the future.
However, there are some cases where the above techniques are inapplicable as anxiety
generated by role playing of such interpersonal situations will have serious inhibitory or
disruptive effects. An obvious alternative, then, would be the application of the imaginal
variety of systematic desensitization. But here too, these patients find themselves unable to
relax or maintain the visual imagery required by the treatment. For these difficult cases,
Piaget and Lazarus (1969) developed a technique labeled Rehearsal Desensitization, in
which both aspects of behavioral rehearsal and systematic desensitization are incorporated.
Specifically, a hierarchy of anxiety-arousing interpersonal situations is constructed by the
patient and therapist. Piaget and Lazarus (1969) suggest that ‘The anxiety increment be-
tween the items should be relatively small to ensure successful graduation from item to item.
It is important to ascertain that the hierarchy items will consist of situations which can be
performed, rather than simply visualized’ (pp. 264-265). During treatment the therapist is
often required to model appropriate behaviors until the patient is performing adequately.
A considerable amount of practice is required, and it appears that the therapist reinforces
the patient’s successful efforts. As in systematic desensitization, when the patient proceeds
through the hierarchy and becomes anxious over a particular situation, a return to an easier
item lower on the hierarchy may be necessary before upward continuation. Piaget and Laza-
rus describe the successful treatment of a 37-year-old housewife who suffered from a variety
of social phobias. Several hierarchies were used during 28 sessions, and the 6-month follow-
up indicated improvement in assertive responding. Rehearsal Desensitization has been used
by the authors with success in six of seven cases following failure of other behavioral
therapies. However, to date, there are no research data supporting the efficacy of this mode
of treatment.
In a number of cases (Edwards, 1972; Lazarus, 1971; Stevenson and Wolpe, 1960)
development of appropriate interpersonal functioning through assertive training has proven
to be a successful treatment for sexual disorders which result from interpersonal rather than
sexual anxiety. Stevenson and Wolpe (1960) treated one pedophiliac and two homosexuals
508 bwxax ~RSEN,~C~RD M.EISLER and PETER M-MILLER

(normal heterosexual behavior previously was present in varying degrees). Each of the three
patients evidenced considerable anxiety when dealing with authority figures (parents)
and peers (adult women in particular). Subsequent to assertive training a pattern of normal
heterosexuality was re-established. Stevenson and Wolpe (1960) account for their successful
treatment as follows: “When the patients developed assertive responses toward other people,
their susceptibility to the arousal of anxiety became lowered so that the sexual stimulation
of women was no longer outweighed by their stimulation of anxiety. Thus, the basic prefer-
ence for women established early in life by social roles, . .could now assert itself’ (p. 740).
Follow-ups of these patients ranging from 3 to 6 years revealed continuation of normal
sexual relationships.
Edwards f1972) reports the case of a physician whose homosexual pedophitia with his
three sons began shortly after he learned of his wife’s infidelity. At the time of initial
therapeutic contact the patient’s pedophilia had lasted 10 years. His marriage was close to
dissolution, and he was experiencing difficulty maintaining an erection during his infrequent
attempts at intercourse with his wife. An examination of the marital relationship revealed
that the patient’s wife was rather domineering. In response to her unreasonable demands he
became sullen but did not vent hostile feelings directly. Following a course of 13 sessions of
assertive training (patient also taught thought-stopping to control pedophilic impulses),
the patient was expressing himself when irritated. Pedophilic activity had ceased, the sexual
relationship was satisfactory and the marital relationship was markedly improved. As in
Stevenson snd Wolpe’s (1960) three cases, Edwards (1972) attributes success to the fact that
the patient’s anxieties were interpersonal rather than sexual.
Using a similar rationale, Lazarus (1971) treated secondary impotence evidenced by a
24-year-old lawyer who had been married only 64 months. Historical data indicated that the
patient was raised by a domineering mother who taught him to ‘fear and revere women’. In
his relationship with his wife the patient was unable to express negative feelings. Three
sessions of assertive training, focusing on rehearsal of appropriate responses in preparation
of confrontation with his wife, led to resolution of the sexual difficulties. ‘He also had a
successful confrontation with his mother and reported therapeutic gains which extended
beyond his originai marital and sexual impasse’ (p. 157). Lazarus, notes however, that most
cases are not as easily resolved.
Similar to the indirect treatment of sexual deviation through assertive training, Goldstein,
Serber and Piaget (1969) report using induction of anger as a reciprocal inhibitor of fear in
three cases. None of the three patients exhibited clear cut psychopathology, but in each there
appeared to be some interpersonal or social phobia. The therapeutic technique involved
teaching patients how to pair both verbal and motor components of anger to imagined and
in vi50 fear situations. In one case ‘The expression took the form of righteous indignation
and violent disagreement at the top of her lungs. . . . In addition she was instructed to accen-
tuate her verbal behavior by punching a pillow placed on a chair in front of her’ (p. 68).
The patient was subsequently asked to imagine anger arousal when confronted with the fear
producing situation. Treatment in this case required a maximum of 19 sessions. In the other
cases additional techniques including systematic desensitization and thought-stopping were
combined. Six-month follow-ups availabIe for two of the three cases described indicated
absence of symptomatology. The authors further note that their treatment was successful
in six out of ten cases; but no hard data are provided.
In a number of clinical case studies assertive training and other behavioral techniques have
been combined to treat a variety of disorders (Nydegger, 1972; Patterson, 1972; Roback
 DEVELOPMENT OF ASSERTIVE RESPONSES 509

et ai., 1972). Patterson (1972) combined assertive training (presented as a game)

and time-out in his successful treatment of a St-yr-old dependent boy. Nydegger (1972)
used verbal conditioning, assertive training, and systematic desensitization in the
treatment of a 20-yr-old, paronoid schizophrenic evidencing both auditory and visual
hallucinations. Following successful inpatient treatment, the author insured continued
success by having the patients’ parents maintain a similar program at home. It is reported
that 2: yr subsequent to the patient’s inpatient stay he was still free of psychotic symp-
tomatology. Roback et al. (1972) used assertive training as part of a comprehensive behav-
ioral and chemotherapeutic program designed to extinguish self-mutilating behavior in a
19-yr-old female patient. Modeling, role playing, and therapeutic instructions were used
to enable the patient to express anger in a more socially acceptable manner. The treatment
prograin required 44 days, during which time self-burning episodes were eliminated. A
number of treatment recommendations including continuation of group psychotherapy and
chemotherapy were made at discharge. A 4-month follow-up revealed maintenance of gains.
Although the aforementioned studies are certainly of interest from a clinical point of view,
the combination of treatment techniques precludes an analysis of the effective ingredients
in the overall program. Only by examining effects of individual and combined techniques on
specified target responses in a sequential order that includes planned reversals (experimental
analysis of behavior design), can such an analysis be made (Barlow and Hersen, 1973).
There are a number of clinical studies in which assertive training techniques have been
used in the tn atment of marital discord. Fensterheim (1972a) presents a case in which
application of assertive training was used to remediate marital difficulties for a young
couple. The marriage had lasted 6 yr, but when treatment was initiated a major problem
centered over the deteriorating sexual relatiol~ship. Inasmuch as this couple experienced
considerable difficulty in expressing feehngs in regard to various aspects of the sexual rela-
tionship (e.g. wife unable to inform husband about his absence of tenderness when making
sexual advances; husband unable to express anger at wife’s remoteness during sexual
activity), role playing and role reversal sessions were instituted. Exercises in the use of
positive and negative communications, similar to Salter’s (1949) ‘feeling talk’ were suggested.
In addition, systematic desensitization for both spouses with respect to ‘a fear of offending
the other was employed. Considerable improvement was noted in 16 sessions over a period
of 4 months. A 1-yr follow-up revealed maintenance of gains in all aspects of the marital
relationship. The couple’s ability to communicate freely was now apparent.
Eisler and Hersen (1972) examined the effects of assertive training for one spouse on
various behavioral measures of marital interaction. Initial videotaped observations of this
couple revealed an overly critical wife and a submissive husband. A number of specific
verbal and nonverbal target behaviors (looking, speech, questions, smiles, positive state-
ments, negative statements) were obtained during the 24-min segment of ad libitum marital
interaction. The husband was then given a four-session course of training during which he
was instructed to role-play typical marital conflict-situations with a surrogate wife. The
patient’s actual wife did not receive treatment. During role-playing situations the patient
was encouraged to respond more assertively, with emphasis directed towards improvement
in target behaviors. The surrogate wife verbally reinforced emission of this behavior. A
second 24-min ad libitum post-session with the actual wife showed increases in the husband’s
duration of speech, duration of eye contact, and number of questions posed. Despite the
fact that the wife remained untreated, both spouses evidenced an increase in positive state-
ments and a decrease in negative statements. There also appeared to be an increase in
510 MI~HEL HERSEN,RICHARD M. EISLER and PETER M.M~LLER

smiling for both spouses. Eisler and Hersen (1972) conclude that ‘While these data by no
means represent the results of a controlled study, the methods employed show promise for
clinical research and practice’.
Fensterheim (1972b) describes the use of assertive training into the context of group
psychotherapy. He specifically notes how ‘The social nature of assertive training suggests
that it would be particularly effective in the treatment of groups’ (p. 162). Alberti and Emmons
(1970) also underscored the advantages of the group setting in that feedback, reinforcement,
modeling and support from other patients sharing similar difficulties may be provided.
Fensterheim (197213)outlines the typical sequence followed during group assertive training.
The session begins with each patient reporting on completion of the previous week’s assign-
ment (e.g. telephoning a girl for a date ).‘Successful task completion evokes compliments
and expression of approval from the therapist and from other group members. Failures
or questionable results are discussed by the group’ (p. 143). Patients assigned difficult tasks
are given the opportunity to practice assertive responding in group. In addition, modeling
by the therapist or by other patients may facilitate acquisition of appropriate expression.
Sharing of assertive experiences, practicing of specific exercises (e.g. talking in a loud voice,
expressing tender and positive feelings), and group desensitization may also be included in
those sessions. A session generally concludes after a new assignment has been formulated
for each group member. Fensterheim (1972b) recommends that group size be limited to nine
or ten members, and that there be similarity in socioeconomic, age, achievement and marital
characteristics.

MEASUREMENT OF ASSERTIVENESS
Although innovative treatment methods are presented in the clinical studies reviewed, the
precise evaluation of particular techniques on specified target behaviors is generally
unavailable. In most of the case studies only global clinical judgments of improvement are
offered. However, more specific assessment techniques have been developed. As in the study
of fear (Hersen, 1973), attitudinal (self-report), motor (overt responses to behavioral
tasks), and physiological measures have been used for evaluating efficacy of assertive train-
ing techniques in research paradigms.
Wolpe and Lazarus (1966) and Lazarus (1971) included sample questionnaires in their
chapters on assertive training to enable therapists to assess patients’ interpersonal deficien-
cies. The Wolpe and Lazarus Assertiveness Questionnaire (Wolpe and Lazarus, 1966) has
also been used as one method of evaluating pre-post differences in research paradigms
(Hersen et al., 1973; McFall and Marston, 1970). Questions in this scale are presented in
a dichotomous yes-no format (e.g. ‘If a friend makes what you consider to be an unreason-
able request are you able to refuse?). However, with the exception of two studies (Eisler
et al., 1973; McFall and Marston, 1970), little in the way of formal validation
of this measure has appeared in the literature. Eisler et al. (1973) found that subjects
judged to be high and low in overall assertiveness on the basis of their reactions to
a standard series of 14 interpersonal situations requiring assertive responses were differen-
tiated (p < 0.05) on the Wolpe-Lazarus Assertiveness Questionnare McFall and Marston
(1970) report that 36 unassertive college volunteers were differentiated (p < 0.02) from a
sample of 10 normals on the basis of the Wolpe-Lazarus Scale.
Rathus (1973a) developed a 30-item scale (Rathus Assertiveness Scale) that is based,
in part, on assertive questions previously used by Wolpe and Lazarus (1966) and Wolpe
 DEVELOPMENT OF ASSERTIVE RESPONSES 511

(1969). This scale is suitable for use with male and female college students and has accept-
able split-half reliabilities. Norms are available, with males scoring higher than females.
Validity studies yielded Y’Svarying from 0.60 to 0.70 and were, obtained by correlating scores
on the scale with judgments of overall assertiveness made by close acquaintences of the
respondents. Gambrill and Rickey” recently compiled statements for an Assertive Inventory
and currently are in the process of collecting data on both clinical and nonclinical popula-
tions.
McFall and Lillesand (1971) compiled a list of items relating to unreasonable requests that
college students are unable to refuse. Eighty-two such items were selected from an extensive
pool submitted by their subjects. These were subsequently administered to an additional
sample of 60 subjects. Each item was presented in a five-point scale format. In addition, the
following item (‘How much of a problem do you feel you have when it comes to saying
“no” to people regarding things you don’t want to do?) was presented to subjects in a LOO-
point scale format. Subjects responding above 65 to this item were operationahy defined as
unassertive; subjects scoring below 3.5 were considered to be assertive. High and low scorers
were then compared on the original 82 items, and items discriminating the two groups were
retained. The final form of the Conflict Resolution Inventory (CRI) contains 35 items relat-
ing to specific refusal situations.
Friedman (1971) describes one additional self-report measures of assertiveness (Action
Situation Inventory) consisting of ten behavioral situations, with five or six alternatives to
each. Some preliminary data regarding differences in responding for high and low assertive
college subjects are presented.
Other types of self-report measures employed include satisfaction with progress in treat-
ment and anxiety level in role-playing situations (McFall and Marston, 1970), client satis-
faction, level of specific interpersonal fears, and dating frequency (Martinson and Zerface,
1970), and diary entries of the instigation of specified assertive responses (Hedquist and
Weinhold, 1970). Hedquist and Weinhold (1970) obtained validity checks on the latter
measure and found no instances of false reporting. However, in other contexts, self-reports
have proven notoriousIy unreliable and frequently do not coincide with motoric behavior
(Begelman and Hersen, 1973; Hersen, 1973). The intercorrelation of verbal, motor and
physiological measures of assertiveness will be discussed at the end of this section.
A number of contrived behavioral tasks have been employed in assessing efficacy of
assertive training (Eisler et al., 1973c; Friedman, 1971; McFall and Marston,
1970). Friedman’s task consisted of an S-min interpersonal situation directed towards
irritating and frustrating the subject. His subjects were required to put together a 1Zpiece
puzzle. While this puzzle was being assembled, the experimenter’s accomplice entered the
room and engaged in progressively more irritating and disruptive behavior (e.g. insulting
the subject, talking loudly and playing the radio, etc). Subject’s verbal responses to the
accomplice were audiotaped and rated by independent judges on the basis of 24 behavioral
units. A Sum Assertion Score (O-24) was obtained, with responses falling in the following
categories receiving a positive score : ‘threat, demand, insult, strong disagreement, request
to stop.’ However, interrater reliabilities for this measure were not particularly high (r’s
range from 0.56 to 0.86).
McFall and Marston (1970) used a behavioral role playing test in which subjects were
asked to respond to a series of audiotaped interpersonal situations. Each situation required
an assertive response on the part of the subject. Responses were tape recorded, and overall
* Gambrill, Personal communication, 1972.
512 MICHEL HERSEN,RICHARD M. EISLER and PETER M. MILLER

judgments of assertiveness were then made by independent judges. In addition, response

latency was used as a measure of assertiveness.
Eisler ef al. (1973~) extended the use of McFall and Marston’s role
playing technique by developing a series of 14 standard interpersonal situations requiring
assertive responses (Behavioral Assertiveness Test). The Behavioral Assertiveness Test was
then administered to 30 psychiatric inpatients. A female role model prompted subjects’
responses, and these were videotaped. Several verbal and nonverbal components of asser-
tiveness were identified and then rated by judges (duration of reply, frequency of smiles,
duration of looking, latency of response, loudness of speech, fluency of speech, compliance
content, requests for new behavior). Interjudge agreement for specific components of asser-
tive behavior ranged from 96 to 100 per cent. Overall judgments of assertiveness were
obtained, and subjects were divided at the median into high and low assertive groups.
T tests were then performed and yielded the following results: Subjects judged to be high in
overall assertiveness evidence more pronounced affect, less compliance, more requests for
changes in the behavior of the interpersonal partner, lengthier responses, louder speech,
and shorter latencies than those judged low in overall assertiveness. Specific measures
discriminating high and low assertive subjects have subsequently been used to assess the
effects of techniques (e.g. instructions, practice, modeling) designed to modify unassertive
behavior (Eisler et al., 1973d; Hersen et al., 1973b).
Rathus (1972, 1973b) also used scenes requiring assertive responses as a measurement
technique. Audio (Rathus, 1973b) and videotape recordings (Rathus, 1972) of responses
were rated by independent judges on the basis of overall assertiveness (r’s range from 0.86
to 0.94). In these studies specific components comprising assertiveness were not evaluated.
Serber (1972) recommends teaching both verbal and nonverbal aspects of assertion during
the course of treatment. Among the variables considered are loudness of voice, facial
expression, body expression, eye contact and fluency. A number of these variables
have already been defined and examined empirically (Eisler and Hersen, 1972; Eisler
et al., 1973~; Eisler et al., 1973d; Hersen et al., 1973). In a separate study, Laws
and Serber (1971) videotaped responses of a male pedophiliac while attempting
to make appropriate heterosexual advances (e.g. asking a girl to leave a party with him)
under role-playing conditions. Interactions with a female role-model instructed to respond
in either a cooperative, civil, or hostile fashion were then rated with respect to disfluency
and body expression. Although precise descriptions of disfluency and body expression are
provided, information as to rater reliability is not available.
Weinman et al. (1972) used four successive behavioral tasks (Behavior
in Critical Situations Scale) to study the effects of assertive training in hospitalized
chronic schizophrenic subjects. In the first task (Affiliation), subjects’ interactions with
the experimenter’s confederates in a doctor’s waiting room were observed and rated from
behind a one-way mirror. In the second task (Failure), subject’s responses to the experi-
menter’s critical comments following an induced failure experience were rated. In the third
task (Disagreement), subjects’ responses to an experimenter disagreeing with him were
evaluated. In the fourth task (Default), subjects’ reactions to being short-changed following
an experimenter’s promise of pay were rated. When the scores for these situations were
combined, interrater agreement reached a 98 per cent level. Test-retest reliability of the
Behavior in Critical Situations Scale is 0.72. A moderately elevated correlation (r = 0.60)
was obtained between this scale and length of hospitalization.
McFall and Marston (1970) devised a most unusual covert method of assessing the effects
 DEVELOPMENT OF ASSERTIVE RESPONSES 513

of assertive training. Subjects treated expe~men~aIIy in a number of conditions were fefe-

phoned by an ~experimenter-saIesma~’ who used a variety of prepared ‘high-pressure’ sales
tactics to induce subjects to obtain a subscription to two magazines while receiving three
on a free basis. Telephone calis were monitored and taped, and subjects’ responses were
rated with respect to sales resistance. Interrater reliabilities for judgments of sales resistance
ranged from 0.82 to 0.91. In addition, length of telephone conversation was used as a
further measure of sales resistance.
In only one study have physiological indices been used to measure the effects of assertive
training. Following the work of Paul (1966), McFail and Mnrston (1970) used subjects’
pulse rate as an index of autonomic arousal. Measurements were obtained prior and subse-
quent to adn~in~stration of the behavioral role-playing test during both pre- and post-test
assessment sessions.
As in the study of fear (Hersen, 1973), there are contradictory findings with respect to
the relationship between self-reports of assertiveness and overt indices of assertiveness.
For example, McFali and Lillesand (1971) found that subjects’ self-ratings of assertiveness
‘on the CRI and ratings of their refusal behavior in the behavioral assessment task’ cor-
related 0.69 in the pre-test and 0.63 in the post-test. Similarly, McFall and Marston (1970)
found that overall ratings of improvement ‘correlated highly (r = 0.76)’ with subjects’
ability to refuse a telephone salesman who was using ‘high pressure” sales tactics. Rathus
(1973a) also obtained concordance between self-reports of assertiveness and observer
ratings of overall assertiveness in a post-test assessment. However, Friedman (1971) reports
relatively low correlations (0.00,0.49 for males; 0.49,0.34 for females) between his Action
Situations Inventory and behavioral ratings on the Sum Assertion measure. Hersen et af.
(I973), in an analogue study, found no differences tpre-post) on the Wolpe-Lazarus
Assertiveness Questionnaire, but found significant changes on seven behavioral components
of assertiveness. Similar findings have been reported by McFalt and Marston (1970).
However, when they combined and then compared their two experimental and two control
groups, significant pre-post differences were found on the Wolpe-Lazarus Scale. It would
appear that ‘given the brevity of treatment in the typical analogue experiment, it is not
surprising that self-report measures do not coincide with rapid overt behavioral improve-
ment’ (Hersen et al., 1973). This type of discrepancy in behavioral paradigms has pre-
viously been given the label of “attitudinal lag’ (Hersen, 1973). Such ‘attitudinal lag’ was
not noted by Rathus (1973b) inasmuch as his experimental treatment was conducted over
a more extended period of time (7 weeks). Correlation of physiological measures with self-
report and behavioral indices of assertiveness would allow for a more comprehensive
analysis of this relationships

REINFORCEMENT OF ANGER
From the review of the clinical literature, it is apparent that therapist reinforcement of
patients’ assertive verbalizations takes place during the typical course of training in assertion
(Fensterheim, 1972b; Lazarus, 1971; Wolpe, 1969, 1970). Wolpe (1969) notes how ‘the
motor act itself is reinforced by its consequences, such as the attainment of control of a
social situation, reduction of anxiety, and later, the approbation of the therapist’ (p. 62).
Fensterheim (1972b) describes how in the group setting reports of successful assertion and
in vim trials are heavily reinforced by both group members and the therapist.
The specific effects of reinforcing angry ~erbaIizations have been examined in several
514 MKHEL HERSEN, RICHARD M. EISLER and PETER M. h4ILLER

studies (Doering et al., 1962; Wagner, 1968a, 1968b). Using a verbal reinforcement para-
digm, Doering et al. (1962) developed a training procedure in which the subject was pre-
sented with a card containing a description of a frustrating situation. Two replies to the
situation were typed on the back of this card, one of the two considered ‘angrier’ in accord-
ance with prerated items presented in a scale. In one study, in which college students were
used as subjects, verbal reinforcement of the angrier response during a training series
resulted in the selection of angrier replies in a test series when compared to a no reinforce-
ment group. Facilitation of discrimination of reply choices also led to increased use of
angrier replies during the post-test session. Reinforcement of angrier responses during
training as compared to no reinforcement resulted in greater intensity of verbalization
during the test series. Finally, use of a ‘shouting versus a quiet voice’ during training failed
to yield differential effects with respect to intensity of reply during the post-test. The success-
ful verbal conditioning of hostile verbalizations had previously been reported by Buss and
Durkee (1958).
In an extension of the aforementioned work, Wagner (1968a) examined the effects of
positive and negative reinforcement presented contingently on ‘the expression of anger by
patients in role playing situations.’ Subjects described as ‘mildly inhibited’ were assigned
to three groups and were pre-tested on 12 of the 24 anger-arousing situations comprising
the Anger Expressive Test. All subjects were then required to role-play additional situations
requiring the expression of anger. In the Positive Reinforcement Group the role model
encouraged (reinforced) the patient’s expression of anger. By contrast, in the Negative
Reinforcement Group patients’ angry verbalizations were countered by yet angrier verbaii-
zations on the part of the role model. In the Control Group role playing situations did not
involve expressions of anger. Post-test data were obtained for the three groups by adminis-
tering the remaining 12 situations of the Anger Expressiveness Test. The results indicated
that positive reinforcement of anger led to an increase in post-test expression of anger when
compared to the Negative Reinforcement and Control Groups. No significant differences,
however, were found between the latter two groups. Wagner (1968a) suggests that for the
Negative Reinforcement Group ‘retaliation was not sufficiently intense. . .affective practice
served to extinguish the previously inhibitive response continguous with anger expressive-
ness’ (p. 94). In a subsequent study, Wagner (1968b) found that a group of psychiatric
subjects reinforced with a light stimulus for increased anger expression during training
showed significantly more anger expressiveness in the test series than a yoked control
receiving practice and a test-retest control.
In summary, the above studies point towards the importance of reinforcing approxi-
mations of appropriate assertive behavior during the treatment of the unassertive patient.
Moreover, the importance of a patient undergoing a successful ‘assertive experience’ when
applying what he has learned in the consulting room to his natural environment is under-
scored (Neuman, 1969; Wolpe, 1969, 1970).

EXPERIMENTAL MODIFICATION OF UNASSERTIVE BEHAVIOR

The effects of assertive training and its component techniques have been examined in a
number of group analogue and clinical outcome studies. Lazarus (1966) conducted the
initial study in which efhcacy of four 30-min sessions of behavior rehearsal, direct advice,
and nondirective therapy were compared with respect to improvement in the management
of interpersonal difficulties. Results indicated that the behavior rehearsal condition led
 DEVELOPMENT OF ASSERTIVE! RESPONSES 515

to the greatest change, then followed by the direct advice and nondirective groups. Although
specific criteria for improvement were designated, the author administered treatment for
the three groups in addition to making the evaluations of success. Lazarus (1966) acknow-
ledges ‘the possibility of experimenter bias’, but argues that the superiority of behavior
rehearsal is predicted on a theoretical basis.
Friedman (1971) conducted an analogue study in which the following treatments were
compared : modeling, modeling plus role-playing, directed role-playing, improvized role-
playing, assertive script, and nonassertive script. Subjects in the modeling plus role-playing
condition showed significantly more changes on the behavioral task (Sum Assertion Meas-
ure) than all other groups. However, the modeling plus role-playing and the improvized
role-playing groups were not significantly differentiated on this measure. Differences among
the six groups on the self-report measure of assertiveness (ASI) were not significant. Simi-
larly, differences among groups on self-reported measures of anxiety were generally not
significant.
McFall and Marston (1970) compared the effects of behavior rehearsal (performance
and no performance feedback) with placebo therapy and a no treatment control. The results
revealed that the two behavioral techniques were significantly better than the two control
procedures on behavioral (semiautomated role-playing task), self-report (Wolpe-Lazarus
Assertiveness Questionnaire), psychophysiological (pulse rate), and in viva (resistance to
high pressure telephone salesman) measures of assertion. The addition of performance
feedback appeared to enhance improvement but not at a significant level. It should be
noted that significant differences were found on these measures only when data from the
two experimental and two control conditions were combined and then compared. In further
analogue study with college subjects, McFall and Lillesand (1971) examined the short-term
effects of overt rehearsal with modeling and coaching, covert rehearsal with modeling and
coaching, and an assessment placebo condition. As in the McFall and Marston (1970)
study, both experimental groups evidenced greater pre-post changes on self-report and
behavioral measures than the control group. In addition, subjects in the covert rehearsal
group generally showed the most pronounced change in both self-report and behavioral
laboratory measures.
Eisler et al. (1973) compared modeling, practice-control, and test-retest
groups on several verbal and nonverbal dimensions of assertiveness (see Eisler
et al., 1973). Pre-post differences were obtained in this analogue study by videotaping
subjects’ responses to five standard interpersonal situations requiring assertive
responses. Psychiatric subjects in the modeling condition were exposed to a videotaped
model who was trained with respect to appropriate verbal and nonverbal responses in the
five interpersonal situations. Subjects in the practice-control condition received an equal
number of intervening trials but without the benefits of videotaped exposure. The results
showed that significant pre-post differences on five of the eight components of assertiveness
were obtained for the modeling condition when compared with the two control procedures.
With respect to the absence of change in the practice control group, it was concluded that
‘in cases where response deficits exist (lack of assertiveness), repeated exposure to the diffi-
cult situation does not change the behavior’ (Eisler et al., 1973). In continuation
of this research program, Hersen et al. (1973) examined pre-post differences in
the five interpersonal situations for the following five groups: test-retest, practice-control,
instructions, modeling, modeling plus instructions. The results indicated that the modeling
plus instructions group was either superior or equal to the modeling or instructions alone
516 MICHEL HERSEN, RICHARD M. EISLER and PETER M. MILLER

groups on five of seven verbal and nonverbal components of assertiveness. However,

there were no differences between the practice-control and test-retest groups, thus confirm-
ing results obtained in the Eisler et al. (1973) study.
Rathus (1972) compared efficacy of assertive training and a discussion procedure with
unassertive college females using a group treatment approach. Subjects received seven
sessions of treatment in each of the two groups. In the assertive training group subjects
practiced tasks derived from Salter’s (1949) ‘excitatory exercises’. In the group discussion
condition subjects met with the experimenter and reviewed the nature, acquisition and elim-
ination of fear. Pre-post differences on the Rathus Assertiveness Scale indicated that
assertive training subjects reported significantly greater gains than discussion or no treat-
ment control subjects. However, methodologically there are two major problems with this
study. First, subjects were drawn from the experimenter’s own classes. Second, the experi-
menter served as therapist for both experimental groups. Thus, when the issues of experi-
mental demand and experimenter bias are considered (see Lazarus, 1966), the conclusions
that can be drawn from this experiment are limited. In addition, judgments of overall
assertiveness made by independent judges (subjects’ videotaped responses to situations
requiring assertiveness) failed to differentiate the groups at a statistically significant level.
In a subsequent study, Rathus (1973b) compared the effects of assertive training,
placebo therapy, and no treatment. Subjects in the assertive training group evidenced
signi~cantly greater pre-post changes on the Rathus Assertiveness Scale than those in the
placebo and no treatment conditions. In addition, independent judgments of subjects’
overall assertiveness, based on audiotaped question-and-answer sessions, confirmed the
superiority of the assertive training group. However, as in the previous study (Rathus,
1972), subjects were drawn from the experimenter’s classes and treatment for both experi-
mental conditions was provided by the same experimenter.
Hedquist and Weinhold (I 970) examined the efficacy of two methods of behavioral group
counseling for socially anxious and unassertive college students. Subjects in the behavior
rehearsal group engaged in role-playing, bolstered by modeling and coaching on the part
of the therapist. In the social learning group the leader’s task involved modeling a method
for problem solving. Subjects in this group were required to carry out prescribed tasks in
their natural environment. The control condition consisted of group discussions centered
on teaching and interpersonal process. The dependent measure selected for study was the
subject’s self-report of instigating verbal assertive responses. Results indicated the superior-
ity of the two behavioral groups, but these differences were no longer significant at the
2-week follow-up.
Martinson and Zerface (1970) evaluated the differential effectiveness of individual psy-
chological counseling, a social program of arranged interactions with college females, and a
delayed treatment control for male students evidencing a fear of dating. Individual coun-
seling involved one to five sessions (mean = 3.2) and was described as being ‘eclectic’. In
the arranged interactions group male subjects met once a week for 5 weeks with female
subject volunteers ‘interested in improving their social skills’. No concurrent treatment was
provided for the delayed treatment control group. Results of this study show that the arra-
nged interactions group significantly decreased fear of dating (verbal report) and increased
actual dating frequency when compared to the other two groups. Martinson and Zerface
(1970) underscore the fact that ‘a sea-structured social program. . .which included no
contact with a professional counselor proved more effective than professional counseling
for young men characterized by a fear of dating’ (p. 39).
 DEVELOPMENT OF ASSERTIVE RESPONSES 517

Weinman et al. (1972) conducted an extended clinical outcome study in which three types
of therapeutic approaches were administered to hospitalized chronic schizophrenics. The
major treatment goal involved increasing interpersonal assertiveness and interaction in
these patients. Dependent measures selected for study were the Behavior in Critical Situ-
ations Scale (objective behavioral assessment of assertiveness), an Anxiety Questionnaire,
and the Fear Survey Schedule II. Subjects were carefully matched on several criteria and
were assigned to the following three groups: Socioenvironmental Therapy, Systematic
Desensitization, Relaxation Therapy. Subjects in the Systematic Desensitization group
received 36 one-half hour sessions over a period of 3 months. Hierarchies related to the
assertiveness dimension were constructed. Subjects in the Relaxation Therapy group also
received 36 one-half hour sessions over the 3-month period, but without systematic desen-
sitization. Socioenvironmental Therapy (conducted over a 3-month period) consisted of
5 weekly group activities directed towards promoting social interaction. Subjects were
divided into older (48-67) and younger (20-42) groups for purposes of data evaluation. The
results indicated that older patients in the Socioenvironmental Therapy condition demon-
strated the greatest pre-post changes in assertiveness (Behavior in Critical Situations Scale).
No differences were obtained for the younger group of patients. Decreases in self-reported
anxiety occurred for all three groups irrespective of patients’ age. Weinman et al. (1972)
conclude that ‘The treatment of choice for the older chronic schizophrenic remains socio-
environmental therapy’ (p. 252). However, Krasner (1970) has argued that any ‘total push’
therapy is likely to produce results with chronic psychiatric patients. Moreover, relaxation
and systematic desensitization are not the most ideal controls, particularly as these techni-
ques are generally not considered applicable to psychotic patients. In light of the aforemen-
tioned, conclusions that can be drawn from this study must be somewhat more restricted
than indicated by Weinman et al. (1972).

GENERALIZATION OF RESULTS
With the exception of the studies reported by McFall and his associates (McFall and
Marston, 1970; McFall and Lillesand, 1971), the issues of generalization of treatment effects
and transfer of training into different contexts have received little attention in the research
literature. As previously noted, McFall and Marston (1970) developed a surreptitious method
for assessing the effects of assertive training in which subjects’ reactions to a ‘high pressure’
salesman were obtained. Five measures of resistance to the salesman were audiotaped and
then rated by independent judges: overall resistance, subjects’ activity level during the
telephone call, subjects’ social poise during the call, latency between initiation of the tele-
phone conversation and subjects’ first sign of resistance, and total time of the telephone
conversation. Results on these measures followed the patterns seen on laboratory measures,
but with the exception of one measure (‘derivative index of resistance latency. . .obtained by
calculating the arc sine of the ratio of elapsed time to first resistance divided by the total
time for the call’) (p. 301) differences between experimental and control groups were not
significant. Moreover, the significant difference on this derivative measure of latency was
obtained only when data from the two experimental and two control groups were combined
and compared. In a subsequent study McFall and Lillesand (1971) failed to obtain transfer
when using the telephone follow-up measure, but the results were in the expected direction.
For example, control subjects required a mean of 50.67 set before refusing the telephone
salesman’s request, whereas experimental subjects needed only 29.00 and 28.70 sec.
518 MI~HEL HERSE~,RI~~~ M. EISLER and PETER 74. MILLER

In summary, the above data suggest that some transfer of training does take place.
However, in light of the brevity of treatment in the typical analogue experiment, it is not
surprising that the results are relatively weak. Furthermore, no attempts were made to
program generalization in these experiments. In this connection Baer et al. (1968)
argue that ‘generalization should be programmed, rather than expected or lamented’
(p. 67). Moreover, they point out that assessment of transfer should be restricted to those
behaviors actually manipulated during treatment. This argument apparently holds true
for the McFall and Lillesand (1971) study. Although transfer of training was not obtained
in the telephone sales presentation, ‘experimental Ss showed a generalization of training to
refusal situations on which they received no training’ (p. 321). Subjects initially had received
training on similar refusal situations. Comparable transfer of training was reported by
Macpherson (1972) in his clinical case study.

CONCLUSIONS
The preceding review suggests that assertive training can be an effective treatment
approach for a wide range of disorders including sexual deviation, self-mutilation, impo-
tence, crying spells, and a variety of interpersonal problems. On first examination it is
difficuh to find a common element underlying these disorders. However, following careful
analysis of the clinical reports it becomes apparent that these patients are characterized by
moderate to severe interpersonal deficits. That is to say, these patients simply do not evi-
dence the requisite social and interpersonal skills to ensure successful functioning Assertive
training, then, is specifically directed towards teaching patients (regardless of presenting
symptomatology or diagnosis) a new mode of responding. When patients become more
skilled in routine interpersonal interactions, the probability of obtaining reinforcement
from their social milieu is increased. At that point symptomatic behaviors become non-
functional and are eliminated from their repertoires. Although there is ample clinical
evidence to support this formulation, empirical verification is warranted.
The specific techniques contributing to the overall success of assertive training have been
examined in analogue designs (Eisler et al., 1973; Friedman, 1971; Hersen et al.,
1973; McFall and Marston, 1970; McFall and Lillesand, 1971). Although a full
understanding of all elements producing change has not been achieved, some definite
patterns are beginning to emerge. Most striking is the extent to which an active process
takes place between the therapist and his patient. Indeed, the relationship approximates
that of teacher and student. The therapist instructs, models, coaches and reinforces appro-
priate verbal and nonverbal responses. Concurrently, the patient first practices his newly-
developed repertoire in the consulting room and then in actual situations requiring assertive
responses.
Most research in assertive training to date has been carried out as analogues to treatment,
and with the exception of three studies (Eisler et al,, 1973; Hersen et al.,
1973; Weinman et al., 1972), college students were used as subjects. Despite the fact that
continued analogue work is necessary to identify those elements contributing to behavioral
improvement, the need for therapeutic outcome studies with a variety of patient populations,
is obvious.
With respect to assessment of assertive training procedures, a number of specific analogue,
in viva, and surreptitious measures have been developed. The use of audiotape and videotape
recordings has facilitated more precise descriptions of the verbal and nonverbal components
 DEVELOPMENT OF ASSERTIVE RESPONSES 519

that constitute assertive behavior (see Eisler et al., 1973). Videotape feed-
back has also been suggested as an ancillary method in teaching the patient how to improve
the ‘style’ of his delivery (Serber, 1972). Unfortunately, researchers concerned with the
measurement and modification of unassertive behavior have primarily focused on what
Wolpe (1969) labels as ‘Hostile’ assertion. By contrast, the empirical study of how to pro-
mote patients’ expressions of affection, agreement and approval of others (‘Commendatory’
assertion) has not yet been conducted. In this connection, Lazarus (1971) underscores the
need for helping individuals to better express their positive thoughts and feelings.
The present authors are currently examining the verbal and nonverbal behaviors that
comprise responses to be judged high and low in overall ‘Commendatory’ assertiveness
(Wolpe, 1969). Once these data are obtained, it would be of interest to assess whether the
component techniques used for instigating ‘Hostile’ assertion are equally effective with
‘Commendatory’ assertion.
Finally, the important issue concerning transfer of training of assertive responding across
different interpersonal situations has received very little attention in the research literature.
In the two studies (McFall and Marston, 1970; McFall and Lillesand, 1971) where transfer
of training was evaluated, the results were generally disappointing. However, in these studies
the experimental treatment was introduced for only a brief period of time. It is quite possible
that in a test of extended treatment, where considerable attention is given to specific
verbal and nonverbal elements of assertiveness, evidence of transfer effects will be seen. On
the other hand, it may be useful to program the patient to be assertive in multiple real life
situations that pertain to his specific behavioral deficits. Moreover, it may be necessary to
teach the patient’s relevant interpersonal partners to reinforce his efforts at being assertive.
A comparative analysis of naturally occurring versus programmed transfer of training
would shed light on this issue.

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