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."

Where the Analysts Went Wrong: Part II

In the introduction to this post, I mentioned that a major problem with psychoanalytic formulations concerning the origins of personality dysfunction is that they presume that problematic interactions with parents and other family-of-origin members are only powerful in shaping personality functioning with young children.

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

Until I started asking about these interactions, as I described in my post Don’t Ask Don’t Tell, the patients had not described them in much detail. When they broke out in tears while telling me about them, however, it became hard for them to deny that the interactions were at least part of what was making them feel bad.

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in this particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out -although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs.  Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, either for good or for ill. And it was not just her. I found out – again and again - that parents were way more potent influences on the patient than I as a therapist could ever be.

Behavior therapists do not seem to have figured out that the interactions of a patient and his or her family of origin are important triggers to many of the complaints that patients come to therapy with. Nonetheless, their behavioral interventions do often change certain aspects of a patient’s behavior, and therefore they feel that their patients are responding to treatment. In fact, if a patient’s family of origin is not too dysfunctional, they are correct. The patients change their behavior and the family basically accepts the change, so everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempt at self actualization, or doing what they want and not what the parents seem to want. 

The psychoanalyst Karen Horney once opined that “basic anxiety” requires a sense of isolation from others, helplessness, and of being surrounded by hostility. Such perceptions and cognitions are closely related to attachment to others in one’s family system. The human brain encodes social events from the family exceptionally well, and is exquisitely sensitive to them.

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. 

The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. Lesions of amygdala in primates cause an inability to appraise social signals from other members of same species. An afflicted individual cannot distinguish whether another member of their species is coming towards them to fight with them or to mate with them. And again this is in adults, not juveniles.

In general, the attachment system seems to be one of the most important regulators of overall arousal. The amygdala is the first responder within fractions of a second; one’s initial fear orientation is not affected by conscious cognition. However, the signals then go to the other areas of the brain for further evaluation. Information regarding social context directly affects this appraisal process.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place – a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has in the past continued to have survival value throughout the life cycle.  

Parental behavior has such a powerful effect in triggering old schemata that it does not have to occur with any great degree of frequency in order for its effects to continue. In adults, the reinforcement of schemata occurs in a manner analogous to the learning theory paradigm of a variable intermittent reinforcement schedule. That is, the powerful parental behavior may be witnessed infrequently but unpredictably, leading the patient to continue to react rigidly in ways consistent with old role-relationship expectations.