Whatever Happened to Assertiveness Training?

My fellow blogger over at BehaveNet had an interesting entry on 4/23 that described an experience with a consultant who came to talk to a psychiatric hospital staff on the topic of "physician burnout." The consultant suggested that the psychiatric staff consider using mindfulness techniques to basically chill out about all the stresses under which they have been working.

In the mindfulness post that I wrote, which is linked above, I opined that so-called mindfulness techniques can be quite helpful under certain types of circumstances. Most important, they can help one stay relaxed and clear-headed when being subjected to environmental stressors that fall mainly into two categories: 1. Common, everyday types of stresses due to the vicissitudes of life that change from day to day and that almost all of us experience, or, 2. Those stressful environmental contingencies over which one has zero hope of changing or correcting. (Mindfulness techniques can also help one stay more relaxed when tackling situations that need to be changed or corrected).

The stresses that lead to physician burnout may not fall into one of these two categories. In fact, one of the most common causes is managed care insurance companies and business types with no medical or psychiatric expertise who are constantly telling doctors what they can or cannot do, and making their professional lives miserable. 

What this consultant seemed to be recommending was using mindfulness techniques as a means of employing something that is definitely not called for in this type of situation: passivity. 

Insurance companies and business people need us doctors more than we need them. We should be doing whatever we can to get them out of the way of effective patient treatment as well as to stop them from preventing us from having a normal and balanced work/life schedule.

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

This recommendation should also be applied to what psychotherapists do with their patients.

There is unfortunately a current psychotherapy craze of teaching mindfulness techniques to help patients with major family issues to learn to tolerate their stressful family and relationship lives with more equanimity. This is crazy. Not to mention invalidating to patients, as it seems to imply that the problem resides entirely with them. Instead, therapists should be inspiring them, and teaching them how, to fix the situations that are creating their stress in the first place.

I am not saying that the patients' own behavior does not contribute to the dysfunctional family patterns of which they are a part. Clearly it does. But that just means they have to change their own behavior in reaction to the abuse, distancing, and double messages which they receive on a daily basis from their family system members. Doing so is in fact a good strategy for stopping these patterns, not merely tolerating them better.

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

Basically, in response to mistreatment, assertiveness training theory described one helpful general pattern of responding and three dysfunctional ones. The dysfunctional ones were labeled passive (just sit there, take it, and do nothing about it), aggressive (attack the other person verbally or even physically to impose your will on them), and passive-aggressive (mad at your husband? Burn his toast).

The healthy response was called assertiveness - that meant speaking up for yourself and demanding respect without trying to bring the other person down, disrespecting their needs and viewpoints, casting aspersions on them, or in any way attacking them.

After a period of teaching assertiveness skills to their patients, CBT therapists began to back down from it little by little. They were later forced to admit that the "healthy" responses they taught might get someone beat up or killed in some situations, so it might be best to let some things go.  If you speak up when someone butts in front of you in line these days, the other person may go ballistic and hit you or even pull out a gun. Thankfully this does not happen very often if one is not aggressive, but it is a risk.

Additionally and gradually, the CBT therapists began to fall into the trap of thinking that everyone's problems are all just in their heads. Just like the psychoanalysts they replaced. Last, when it came to intractable family dysfunction, assertiveness skills just did not seem to work all that well anyway.

I have found that with ongoing repetitive family problems, the sort of generic assertiveness skills taught by CBT therapists in fact do not work. That is because family members have developed a whole repertoire of counter-moves that scream to the member attempting to be assertive, "You are wrong, change back." Some of these counter-moves are quite frightening - I described many in a previous post. All involve the person who is trying to be assertive being invalidated in some way and made to feel small for daring to speak up.

This hardly means, however, that the proper strategy for handling these problems is passivity. What I discovered is that the assertiveness training techniques that used to be taught had to be modified to fit the sensitivities and histories of each of the other family members being addressed. These modifications were different for every family, and they had to be tailored specifically to each one. No "one size fits all" here. 

Furthermore, there is no way to know in advance which strategy might work best in a given context, but there was almost always one that could be devised that could help diffuse the family drama significantly for any patient.

I discussed many different strategies in my series of posts in this blog on How to Disarm a Borderline and in another series entitled Ve have Vays of Making You Talk.

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

Mindful passivity? Plenty of time for that at a certain point in the future. As the lyrics from an old song by "Weird Al" Yankovic that used to be played by satirical disc jockey Dr. Demento proclaimed, "I'll be mellow when I'm dead."

Mindfulness or Mindlessness?

“God grant me the serenity
to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference” ~ The Serenity Prayer

The latest fad in both psychotherapy and self help is “mindfulness.” Mindfulness, which is derived from Zen Buddhism and first made popular in psychotherapy by Marsha Linehan (founder of Dialectical Behavior Therapy [DBT] for borderline personality disorder [BPD]) and others, is basically a set of skills that one can use to better tolerate and cope with emotional distress.

Fads in psychotherapy are nothing new. For a while there seemed to be a new one every few weeks, from "neurolinguistic programing" to "solution-focused therapy." 

Even therapists who swear by the gods of empirical correctness that the techniques of Cognitive Behavior Therapy (CBT) - of which DBT is a variant - are so much more powerful than any other known therapy interventions are subject to fads just like anyone else. Besides mindfulness, there is  another current one, "Acceptance and Commitment Therapy (ACT)," which seems to all boil down to telling people that they "don't have to believe everything they think" in a variety of different ways. 

If CBT techniques are so darned powerful, why would practitioners need to keep discarding the old ones and coming up with replacements? Very amusing.

Anyways, getting back to mindfulness, Gregory J. Johanson, Ph.D. discusses it thusly: 

“For clinical purposes, mindfulness can be considered a distinct state of consciousness distinguished from the ordinary consciousness of everyday living (Johanson & Kurtz, 1991).  In general, a mindful state of consciousness is characterized by awareness turned inward toward present felt experience.  It is passive, though alert, open, curious, and exploratory.  It seeks to simply be aware of what is, as opposed to attempting to do or confirm anything. 

Thus, it is an expression of non-doing, or non-efforting where one self-consciously suspends agendas, judgments, and normal-common understandings.  In so doing, one can easily lose track of space and time, like a child at play who becomes totally engaged in the activity before her.  In addition to the passive capacity to simply witness experience as it unfolds, a mindful state of consciousness may also manifest essential qualities such as compassion and acceptance, highlighted by Almaas, R. Schwartz and others; qualities that can be positively brought to bear on what comes into awareness.

These characteristics contrast with ordinary consciousness, appropriate for much life in the everyday world, where attention is actively directed outward, in regular space and time, normally in the service of some agenda or task, most often ruled by habitual response patterns, and where one by and large has an investment in one’s theories and actions.

Mindfulness was even featured as a cover story on a recent issue of Time Magazine, pictured above. It often incorporates another concept pioneered by Marsha Linehan, radical acceptance. Radical acceptance means completely and totally accepting the reality of your own life. You stop fighting this reality and learn to tolerate it and go with the flow, so to speak. 

Practicing mindfulness techniques can indeed help you to stay calm when things are going badly without resorting to a tranquilizer or booze, although in a sense it accomplishes much the same thing. So therapists like to teach these skills to get their highly reactive, chronically upset, or emotionally unstable patients to calm down and not resort to acting out, such as cutting oneself or other self-destructive or self-defeating acts.

So, is there anything wrong with that?  Well, no, not intrinsically.  Certainly remaining calm and not going off the deep end in the face of adversity is a very useful skill.  Some people prefer learning skills to accomplish this over taking medication or having a stiff drink, although there’s nothing wrong with temporarily taking medications to keep calm either. 

But I started this post with the serenity prayer for a reason. Mindfulness is relevant to the first part of of the prayer – accepting things that one cannot change. What about changing things that need changing? Where does the wisdom to know which things can be changed and which cannot come from, and how does one go about changing them?

People feel emotional pain for the same reason they feel physical pain – it is a signal to the person that something in the environment is wrong and needs attention.  A metaphor I’ve used before:  What if another person is walking behind you continually stabbing you in the shoulder with a pen knife.  If I am a doctor, I can give you an opiate so you don’t feel the pain, and you can go on with your life.  But would it not be much better to get the guy with the knife to stop stabbing you?

Most of the non-psychotic people in therapy who are highly reactive, upset and emotional, and who are not in the midst of an episode of a major affective disorder, are reacting predominantly to the environment. Specifically, the social environment. Even more specifically, as anyone who reads this blog should know by now, the family social environment. Biological psychiatrists and some cognitive behavioral therapists seem to think that it’s all going on inside a patient’s head and has nothing to do with other people.  Bull.

Marsha Linehan herself acknowledges this.  In her Skills Manual for Treating Borderline Personality Disorder, she lists the following goals of the "skills training" portion of DBT treatment.

Goals of Skills Training: To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Specific Goals of Skills Training:

Behaviors to decrease:

1.      Interpersonal chaos

2.      Labile emotions, moods

3.      Impulsiveness

4.      Confusion about self, cognitive dysregulation

Behaviors to Increase:

1.      Interpersonal effectiveness skills

2.      Emotion regulation skills

3.      Distress tolerance skills

4.      Core Mindfulness skills

Notice that she talks about becoming more effective in dealing with the interpersonal environment before she even gets to her distress tolerance skills - numbers 2, 3, and 4.

Unfortunately, in practice, dealing with specific dysfunctional family interactions is one of the last things many DBT therapists get to, if they get to them at all. Marsha Linehan believes – with precious little of her beloved “empirical” evidence by the way - that the reactivity of patients with borderline personality disorder is both biologically innate AND caused by an “invalidating environment.”  As I pointed out in an earlier post, the invalidating environment is not described well or very specifically - although it seems to be the patient's family of origin - nor is there anything written about what makes family members act that way.

The Skills Training Manual is 180 pages long, including a section containing handouts that starts on page 105 and goes to the end.  Of the first 104 pages, only 14 are devoted to interpersonal effectiveness skills, and most of that strongly implies that the interpersonal problems experienced by someone with BPD are due to their own skill deficits rather than the fact that they are dealing with people who are difficult (if not nearly impossible) or frankly abusive or distancing.  Blaming the victim.

In the handout section, interpersonal effectiveness skills are only addressed from pages 115-133. The rest is all about emotional regulation. Almost all of the skills described in the interpersonal skills section are basic assertiveness skills or are descriptions of “myths” about interpersonal effectiveness such as “I can’t stand it when someone gets upset with me.”  Is that really the worst thing that can happen in a family?

Listing "myths" in a way that classifies them as some of cognitive therapy's irrational beliefs means that the problem is being thought of as a flaw that exists squarely in the mind of thinker. Paradoxically, telling a person with BPD that their thinking is skewed is incredibly invalidating!

Besides, when the patient with BPD says "The other person would get upset with me," what they REALLY mean most usually is "All hell would break lose!"

In all of the DBT handouts, I find only one mention of the fact that it may be the environment that is the problem, not the person in the environment.  In the Interpersonal Effectiveness Handout #3 on page 117, it concedes that "Characteristics of the environment make it impossible for even a very skilled person to be effective."

So what happens if someone with BPD gets assertive with their families? In order to find out the true answer to this question for patients in therapy, the therapist usually needs to ask a version of the Adlerian Question such as: "What would happen if I could wave a magic wand and you could fearlessly stand up for yourself with your parents, and tell them to quit mistreating or invalidating you?

So what are the answers I get when I ask for details - without letting the patient go off on a tangent - about exactly what would happen next if the parents were "upset" with the patient?

Oh, nothing much, he said sarcastically. Just responses that include such minor inconveniences as violence, suicides, suicide threats, increased interpersonal chaos, increased drinking and drug use, parental infidelity or a break up with the patient being blamed for it, further invalidating the patient, taking anger out on other family members, literally exiling the patient or giving him or her the silent treatment for weeks on end. Just to name a few. Nothing too bad, really.

So back to the serenity prayer. Are these things one can change?  You betcha!!  It’s not easy, or the person could easily figure out how to do it and would have already proceeded. It’s emotionally trying.  It requires patience, persistence in the face of adversity, and ingenuity. It usually requires the services of a therapist who knows a little about the family dynamics of BPD.

So if your therapist is telling you to just tolerate the person stabbing you in shoulder with the pen knife, fire your therapist and find one who can actually help you.