It is rare to meet a patient who does not have assertiveness issues.  Passivity and aggressiveness are the two major obstacles to behaving in appropriately assertive ways.  Both passivity and aggressiveness serve to increase psychological distress.  People who are excessively passive do not express their preferences nor ask to have their needs met; and chronically failing to express oneself and get one's needs met fosters unhappiness.  At the other extreme, people who are excessively aggressive push others away and tend to wind up disconnected and alone, which likewise fosters unhappiness.  

Assertiveness training teaches patients more constructive ways to express their feelings and  present their needs, ways that appropriately balance the need for self-respect with the need to respect others. 

I.  Education About Assertiveness

The main idea is that there is continuum from passive to aggressive, with assertiveness lying in the middle.  Both ends of the continuum are problematic.

Continuum:  

Passive ... Assertive ... Aggressive

At the passive end, the person places too little value on the needs and rights of the self, and too much on the needs and rights of the other person.  When you are being passive, you do not express your needs.  You do not try to get your needs met.  Rather, your whole goal is meeting the needs of the other person.  You don't talk, you listen.  You submit to whatever you think the other person wants, even if it involves a loss of self-esteem.  In your effort to respect the other person, you forget to respect yourself.

At the aggressive end, the person places too little value of the needs and rights of the other person, and too much on the needs and rights of the self.  When you are being aggressive, you do not consider the needs of the other person.  Rather, your whole goal is meeting your own needs.  You do not consider the rights of the other person.  Your goal is making sure your own rights are taken into account, even if it is at the expense of the other person.  You don't listen, you talk.  You dominate and bully to get your way.  In your effort to make sure you are respected, you forget to respect the other person.

Midway between passivity and aggression lies assertiveness.  Here, the person places equal value on the needs and rights of the self and the needs and rights of the other person.  When you are being assertive, your goal is reciprocity and balance.  You try to treat both yourself and the other person with respect.  This is the central idea of assertiveness:  Always be respectful to yourself, and always be respectful to the other person. 

Assertiveness is not about content; it is about presentation.  Assertiveness is not about what you are saying; it is about how you are saying it.  No matter what you are trying to say, it is always possible to express yourself assertively.          

It is a common pattern for patients to swing from one pole to the other on the assertiveness continuum.  That is, the patient may be excessively passive in one devaluing situation after another, and then suddenly swing to the opposite pole and fly into a rage over some seemingly minor matter; then, in remorse, sink back into excessive passivity and start the cycle again.  

For example, you might have a friend who continually makes little "digs" at you.  You may take it and take it and take it, and then one time suddenly explode with anger at one of his "digs."  From the outside it might look as though you over-reacted, and it may even feel like an over-reaction to you.  But your reaction makes more sense when you consider that you are not just expressing anger for this one incident, but for all the other times it happened too.  

Alternatively, you may be aggressive for a period of time, and then swing to the opposite pole of passivity.  This is a common pattern in abusive relationships.  Following a period of abuse the abuser becomes contrite and excessively meek -- a situation bound to lead to anger in the abuser -- and then the abuse starts all over again.    

Another common pattern is to be "passive-aggressive."  This means to appear passive but actually to be aggressive.  For example, say your friend asks you for a favor that you consider excessive and unreasonable.  You feel angry at your friend and you want to say "no."  If you were to handle this situation passive-aggressively, you would say "yes" and then not follow through.  You would forget, or bungle the favor somehow, or do it too late.  On the surface you would seem affable and willing, but in fact you would be expressing anger at the friend by not following through with the request.

II.  Building Motivation:  Looking at the Consequences

In order to build the motivation to attempt change, examine the negative consequences of passivity and aggression. 

The main negative consequence of the passive style is unhappiness.  You don't ask for what you what or get what you need; your rights get trampled constantly; and you have to cope with a growing sense of resentment that simmers beneath the surface.  This resentment contributes to a multitude of symptoms, including anxiety, depression, insomnia, and psychosomatic symptoms such as headaches and irritable bowel.

The main negative consequence of the aggressive style is unhappiness as well.  This is because your aggressiveness costs you a great deal.  It costs you emotionally -- it pushes people away, even (or especially!) the ones you love most.  After a while the people closest to you leave you or retaliate.  And it costs you in other ways, as you lose jobs, get into arguments or fights, cause friends to dislike socializing with you, or otherwise pay for being a bully.    

Explore the negative consequences of your particular style.  Make a list, and then make a "flashcard" that summarizes the reasons to change.  Carry around the card and read it whenever you are trying to remember why it is important to work on your assertiveness skills.

II.  Building Assertiveness Skills

Here are the principles of assertiveness.  

The Principles of Assertiveness

1.  Respect yourself and the other person equally.  This is your overarching goal.  When you evaluate how you did afterwards, these are the questions to ask yourself:  Did I maintain my self-respect?  Did I respect the other person?

Here are some criteria you can use to evaluate your performance.

Respecting Yourself:  Becoming Less Passive

The "Do's " of Assertiveness

If you truly want to:

1.  Express your feelings.

2.  Ask for what you need.

3.  State your preferences.

4.  Assert your rights.

Respecting the Other Person:  Becoming Less Aggressive

The "Don'ts" of Assertiveness

1.  Do not yell.

2.  Do not hit nor otherwise physically dominate or intimidate the person.

3.  Do not call the person names or otherwise use words to attack them personally.

4.  Do not say things simply to hurt the person.

5.  Do not lose control of your anger.  

2.  Define your goal.  Before you carry out an assertiveness exercise, think it through.  What are you trying to accomplish?  Be clear about your goals.

    3.  Choose an appropriate setting.  If possible, choose a time and place that gives you privacy, quiet, peace -- whatever setting will most help you achieve your assertiveness goals.  

    4.  If possible, pick a time when the other person is calm.   Try your best to pick a time when the other person is maximally receptive to what you have to say.  

    5.  Stay calm.  Do not lose control of your anger.  If you feel you are going to lose control, leave the situation until you have regained control and can handle the situation calmly.    

    6.  Use assertive body language.  Stand or sit up straight, look the other person in the eye, and speak in a clear and audible voice.  

    7.  Be as brief and as clear as possible.  The more brief and clear you are, the more powerful your message will be.

    8.  Talk about your personal feelings, not about objective "rightness."  Don't preach to the other person about right and wrong.  Rather, speak in a personal way.  Use "I feel" statements.  Say things like:  "I feel angry that you ....  I feel uncomfortable when you .... I don't like it when you ...."  

    9.  Do not get defensive.  Do not over-justify your feelings.  Do not start listing all the reasons that explain why you are speaking.  Your feelings are enough justification.  You do not need to speak of any others.

    10.  Request specific behavior change.  Tell the person exactly what you want them to do to correct the situation.  Be specific and concrete.  Criticize the behavior, not the person.  Say:  "I don't like it when you throw your clothes on the floor;" not, "You are a slob."  Say, "Please start putting them in the hamper or putting them away;" not, "Stop being such a slob."    

    11.  When you want to say something negative, start and end with positives.  This is the "sandwich technique, " so called because you sandwich a negative between two positives.  Don't make up the positives:  use positives that are true.  

    12.  If the other person protests, simply keep restating your position.  This principle helps you stay on track and stay true to your goal.  Don't get lost in arguments the other person raises.  Don't go off on tangents.  Don't retreat because you have trouble tolerating the other person's anger.  No matter what the other person says, just calmly and succinctly keep repeating your point.  

Use these principles to evaluate your performance whenever you practice your assertiveness skills.

III.  Begin Self-Monitoring

Begin self-monitoring of your assertiveness skills.  The cue for you to begin self-monitoring  is noticing you are in a situation that you want to manage in an assertive way.  It can be a past situation you want to review and learn from; or it can be a current situation you want to handle well; or it can be a future situation for which you want to prepare.  Whenever any of these come up, self-monitoring will help you stay self-aware and in control.  Each time you are confronted with one of these situations, you have an opportunity to build your assertiveness skills.

Expressing a different opinion than another person, confronting someone when they do something you don't like; saying "no" when you want to say "no" -- these are the kinds of situations that might serve as cues for you to begin self-monitoring.

When you self-monitor, focus on the following:

1.  The situation.  Describe the situation in one or two sentences:  i.e., "I called my friend Elizabeth a week ago and left a message on her machine, and she still hasn't called me back."

2.  Your emotions.  Write down how you feel about the situation.  You may have more than one feeling:  anger, sadness, hurt, disappointment, jealousy, sympathy.  Look carefully at your feelings and write down all of them.  

As you write down each feeling, rate how intense each is on a 0 to 100 scale.

0 ............ 25 ............ 50 ............ 75 ............ 100

None        Mild     Moderate    Intense   Very Intense

3.  Your thoughts.  Write down your automatic thoughts about the situation:  i.e., "She does this to me all the time.  She never calls me back.  It makes me feel like she doesn't really care about me."

4.  A rational response to your thoughts.  Are there errors in your thinking?  Is your thinking in line with the evidence?  

Write a rational response to your thoughts if they are irrational:  "Elizabeth doesn't always do this, but she does it a lot.  Too much.  And I know she really cares.  But I still think her behavior is insensitive and I need to talk to her about it."  

5.  Your behavior until now and its consequences.  What have you done so far?  Write this down:  "So far I've done nothing, just waited for her to call me.  Sometimes I've called her back two or three times before she finally called.  I've never said anything.  I'm nice to her even though I'm mad."

What are the consequences of what you have done so far?  How do you feel inside about it?:  "I feel frustrated and angry with Elizabeth and with myself."  

6.  Define your goal.  What do you want to accomplish?  Write it down:  "I want to tell Elizabeth it makes me angry when she doesn't call me back.  I want to tell her to start calling me back when I call her."

Remember that your overarching goal is always to behave assertively -- to respect both yourself and the other person equally.  Do not make changing the other person one of your goals.    The other person may or may not change; that is not within your control.  

Judge the success of an assertiveness exercise by how well you have behaved.  Even if the other person does not change, you can walk away satisfied with yourself if you have behaved in accord with the principles of assertiveness.

7.  How you want to behave:  The assertive way to meet your goals.  Spell out how to handle the situation assertively:  i.e., "I could arrange a quiet time for us to talk, and clamly tell her that it makes me angry and hurts my feelings when she doesn't return my calls.  I could ask her to try to remember to call me back from now on.  I could sandwich this between two positive messages about how I care about her and value our friendship."

Rehearsing Assertiveness 

When possible, practice your assertiveness skills before carrying them out.  Ideally, you might practice until you have the whole thing down-pat -- until you know just how you want to handle yourself in every possible scenario that might come up.  Considering all possible scenarios is important because you want to be prepared.  You want to know exactly how you want to handle it if the other person responds well; and you want to know exactly how you want to handle it if the other person responds badly.

Remember that how the other person responds is not the important thing.  What is important is that you reach your goal and handle yourself well.  No matter what the other person does, you can always reach your assertiveness goals.