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Substance Abuse Treatment Modalities: Literature Review

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Assertion Training

Assertion training is normally included as a standard component of substance abuse treatment programs with the objective of training participants how to respond to difficult interpersonal situations with assertive rather than drinking/drug-using behaviour. It has been found that some alcoholics are deficient in assertive skills (Twentyman et al., 1982) and it has been argued that training would address deficiencies in assertive behaviour in negative situations and discomfort in negative situations that call for assertive behaviour (Pfost et al., 1992). These situations have been found to be a determinant of drinking in alcoholics (Brown et al., 1986; Marlatt & Gordon, 1985), but similar investigations are lacking for drug abusers.

The majority of evaluations have focused on the impact of assertiveness training as a standard component of multimodal treatment programs. The evaluations have utilized samples of problem drinkers only, and similar examinations for other drugs have not been performed. The following summary of outcome evaluations is therefore limited to alcohol abusers who participated in programming that utilized assertion training as part of the overall treatment curriculum.

Ferrell and Galassi (1981) examined the effects of adding an interpersonally-oriented treatment component, either assertion training or human relations training, to an existing milieu program in order to reduce drinking behaviour and increase interpersonal skills among a sample of skill-deficient, chronic alcoholics. Results showed that although both treatments led to comparable sobriety rates at a 6-week follow-up, the treatment group which contained the assertion training demonstrated significant gains in interpersonal skills as compared to the treatment group which contained the human relations training. A 2-year follow-up indicated that the assertion training group maintained sobriety significantly longer than the human relations training group.

Rist and Watzl (1983) instructed a sample of female alcoholics, prior to and following skills training, to rate for social drinking situations (a) how difficult it would be for them to refuse a drink (relapse risk) and (b) the degree of discomfort they expected to feel in these situations (specific assertiveness). Patients who relapsed 3 months after treatment evaluated the situations as more difficult to deal with and creating more discomfort than abstaining patients. Additional analyses revealed that relapse risk and not specific assertiveness discriminated between the two outcome groups, thereby reflecting a general efficacy expectation evident in a strong relation to patients' conviction of being able to stay abstinent, stated already at admission.

A more recent study by Pfost et al. (1992) examined three outcomes of assertion training considered relevant for alcoholics: (a) assertive behaviour in negative situations; (b) discomfort in negative situations that call for assertive behaviour; and (c) expectations of assertive behaviour in sober vs. intoxicated states. Results demonstrated that alcoholics acquired some assertive skills in negative situations and experienced less discomfort in such situations, but continued to believe that intoxication leads to more assertiveness. Less encouraging was the fact that assertion training did not differentially reduce discomfort in negative situations or the discrepancy between perceptions of assertiveness in sober vs. intoxicated states at post-test or at 6-week follow-up.

In summary, assertion training has demonstrated behavioural gains that increases the tendency of alcoholics to respond to interpersonal situations with assertive rather than drinking behaviour. Although reports as to the positive impact of increased assertiveness are equivocal, it has been argued that assertive behaviour in meaningful contexts is critical, particularly with a chronic population whose profile can impede recovery (Chaney, 1989). Similar information is lacking for drug abusers, although it could potentially be argued that the same situational determinants surrounding drug use could be addressed through assertion training in the same manner as alcohol use.

References for Assertion Training:

Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986), “Understanding and preventing relapse”, American Psychologist, 41, 765-782.

Chaney, E. F. (1989), “ Social skills training”, In R.K. Hester & W.R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, (pp. 206-221). New York: Pergamon Press.

Ferrell, W. L., & Galassi, J. P. (1981), “Assertion training and human relations training in the treatment of chronic alcoholics”, International Journal of the Addictions, 16, 959-968.

Marlatt, G. A., & Gordon, J.R. (Eds.) (1985), Relapse prevention. Maintenance strategies in addictive behaviour change, New York: Guilford Press.

Pfost, K. S., Stevens, M. J., Parker, J. C., & Gowan, J. F. (1992), “The influence of assertion training on three aspects of assertiveness in alcoholics”, Journal of Clinical Psychology, 48(2), 262-268.

Rist, F., & Watzl, H. (1983), “Self-assessment of relapse risk and assertiveness in relation to treatment outcome of female alcoholics”, Addictive Behaviours, 8, 121-127.

Twentyman, C. T., Greenwald, D. P., Greenwald, M. A., Kloss, J. D., Kovalski, M. E., & Zibung-Hoffman, P. (1982), “An assessment of social skills deficits in alcoholics”, Behavioural Assessment, 4, 317-326.