Assertive Behaviors

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Your Perfect Right

Always wondered if you could use assertiveness and equality in your relationships and in your life? Here are some great information on how to be more assertive! Do you want to improve your career and the amount of money that you bring home? Do you want to break all the sales records in your office? Do you want to bring home more money? Do you feel as though you are just short of reaching all of your goals?

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Assertive community outreach

The assertive community treatment model developed in Madison, Wisconsin (originally called 'training in community living' (35 ), has attracted a huge amount of interest worldwide. The intervention is particularly targeted at seriously mentally ill people who are high service users it has also been seen as relevant for people who are hard to engage in services. Assertive community treatment provides a comprehensive range of treatment, rehabilitation, and support services through a multidisciplinary team based in the community. Basic characteristics of assertive community treatment programmes include assertive engagement, in vivo delivery of services, a multidisciplinary team approach, continuous responsibility and staff continuity over time, caseloads with high staff to client ratios, and brief but frequent contacts (high service intensity). (25) The assertive community treatment approach has been quite widely copied across the world, although outside the United States usually only in...

Key workers and care programmes

The terms 'case manager' and 'care programme' have been used above to refer to individual mental health professionals in direct contact with the patient, but these simple meanings must not be confused with care management, a more recently introduced concept that refers to a model of 'extended brokerage case management' recommended by, for instance, the United Kingdom Department of Health(38,39 in which care managers are not directly involved in direct service delivery. These terms are unfortunately sometimes used synonymously, and further confusion is sometimes caused by the terms and models of the Care Programme Approach, also of the United Kingdom Department of Health,(49 and the more positively evaluated Programme for Assertive Community Treatment 4 Reviews by Burns(42 and others'41.) are very helpful guides through the complexities of this topic.

Effects of psychosocial factors on the course of disease

Long-term survivors with clinical AIDS and those who remain asymptomatic for prolonged periods of time in the face of very low CD4 counts seem to be those who have good coping skills, lead meaningful lives, find new meanings as a result of illness, are relatively not distressed, and are emotionally expressive and assertive. HIV-associated dementia, which is reversible in its early stages, appears to be closely related to the action of proinflammatory cytokines, particularly tumour necrosis factor, on neurones. Psychiatric symptoms, as well as cognitive defects, probably also cytokine induced, also occur in conjunction with HIV infection (primarily of microglia) of the brain they include apathy, withdrawal, psychosis, and regressive behaviours.

Some Major Factor Models

Four other factors round out the five-factor model. Definitions of each factor and their facet traits are described in Costa and McCrae (1992) and paraphrased here. The second factor, extroversion, includes the facets of warmth, a tendency to be affectionate and friendly gregariousness, a tendency to seek social stimulation assertiveness, a tendency to be dominant and forceful activity, a tendency toward movement and energy excitement seeking, a tendency to crave stimulation and positive emotions, a tendency toward joy, happiness, love, and optimism. The third factor, openness to experience,

Helping motivation the social matrix

When incentives are powerful, many newly abstinent patients are able to abstain for short periods. Others lack the skills to cope with the triggers to drinking even when their motivation to abstain has been strong. Cognitive-behavioural therapies seem to improve the coping skills of these patients. If the triggers are in social situations, assertiveness or conversation skills training can help. If the trigger is related to life problems, cognitive therapy may be effective. Other patients are helped by learning to handle frustration and criticism without anger, and to express anger instead of harbouring it. Treatment can be in groups, where the opportunity to discuss these topics with others who have similar problems is appreciated. Groups also enable learning through role playing and by modelling on others.

Services for individuals with comorbidity

There is an increasing recognition of the problems associated with alcohol and other drug misuse and mental illness (see Chapter. Often alcohol misuse is complicated by multiple substance misuse. For example, in the Epidemiologic Catchment Area Study half of all patients with schizophrenia also had a substance misuse disorder,(76 and a recent British survey of psychotic patients found that 36 per cent misused drugs or alcohol. (77) However, there is currently no consensus on the most appropriate treatment services for patients with comorbidity.(78) Substance misuse can be particularly problematic in the context of mental illness, and is associated with higher rates of violence and poor treatment outcome (see Chipie.L11 4.4). Such patients are often non-compliant and disruptive in mental health services, and typically do not engage in alcohol or drug services. Assertive community outreach and integrated service models, covering both mental illness and substance misuse, have...

Do school prevention programmes work

Outcome research of prevention programmes in the United States has been the subject of a comprehensive review.(21) Programmes should be guided by awareness that the average age of trying alcohol, cigarettes, solvents, or cannabis for the first time is between 11 and 13 years, and that exposure to drugs is now the norm for older teenagers.(22) The two distinct aims are to delay experimentation in younger children and to minimize harm in those over 13, many of whom can be assumed to be dabbling already or to have friends who are doing so. Only those programmes that actively involve students in discussion and debate, and provide relevant skills training such as assertiveness, ways of resisting social pressure, problem solving, stress management, and confidence boosting, have any measurable benefit. Improvement in knowledge without this practical dimension has no effect on behaviour, and scaremongering or moralizing can be actively counterproductive.

Involuntary subordination

Evidence that some kind of internal regulator or mental mechanism(s) for subordination is operative in depression is offered by findings that depression is associated with seeing oneself as inferior, subordinate, or subordinated with increased inclination to behave submissively, and to withdraw from conflicts with more powerful others (Allan & Gilbert, 1997) and with failed efforts to be assertive (Arrindell et al., 1990). Vulnerability to depression has long been linked with low self-esteem (e.g., Brown & Harris, 1978), but self-esteem is itself rooted in social rank (social comparison) judgements (Price, 2000). Whether self-esteem is trait-like or state-like, low self-esteem seems to operate like a subordinate defensive strategy in that it is associated with damage-limitation strategies (trying to stop bad things from happening) rather than a PA-enhancement strategy (Baumeister et al., 1989). In line with the idea that damage-limitation (subordinate) strategies are important in some...

Variations of the Antisocial Personality

Antisocial Personality Disorder

Indifference, taken lightly, or pushed around. Whenever their status or ability is slighted, they may erupt with ferocious intensity, posturing, and threatening until their rivals back down. Some reputation-defending antisocials are loners, some are involved in adolescent gang activities, and still others simply seek to impress peers with aggressive acts of leadership or violence that secure their status as the alpha male, the dominant member of the pack. Being tough and assertive is essentially a defensive act intended to prove their strength and guarantee a reputation of indomitable courage.

Overcoming barriers to communication

Patient Physician Empathy

Practising primary care is stressful because of the rapid pace and an obligation to accommodate patients' demands at inopportune moments, health professionals must meet these challenges by being empathic, assertive, and respectful. This is more easily said than done. Being empathic is a first step in developing a patient-physician relationship. Empathy is defined as the ability to reflect accurately the inner experience of another person. It allows the clinician to open the door to patients' emotions. Despite their belief that empathy is important, physicians often are not empathic. ( 9 In order to express empathy, the physician must be courageous enough to tolerate and accept patients' feelings, secrets, and fears, and be willing to reveal feelings and emotions to the patient when it is appropriate and useful. Empathy requires patience. Physicians' emotions anger, irritation, sympathy, attraction interfere with their ability to be patient, and to listen to what their patients are...

Social and occupational functioning

The interpersonal domain has been considered a secondary outcome in most treatment studies of Axis I disorders, its measurement restricted to a few items embedded in instruments that have broader coverage, such as the LIFE and the SAS. However, psychotherapy studies which specifically target interpersonal problems have advanced scale development in this area, and there is a fair amount of data on two self-report instruments appropriate for adult outpatients The Inventory of Interpersonal Problems(66) and the Dyadic Adjustment Scale.*6 ) The Inventory of Interpersonal Problems is a 127-item self-report measure with high internal consistency and test-retest reliability of each of the six subscales assertive, social, intimate, submissive, responsible, and controlling. The Dyadic Adjustment Scale is a 32-item scale designed to assess the severity of relationship discord in married and unmarried cohabiting couples, with higher scores indicating better adjustment. Responses on the Dyadic...

Dealing with Devolution

It is difficult, however, to find a single case in the region where this bundle of necessary entitlements has been conferred on local regimes in communal conditions (in contrast to alienated land). There are instances of effective, in-place devolution, where through local assertiveness or administrative dispensation, communities hold these rights as exceptional cases.

Government and society

At the highest level of aggregation, economic evaluations can and should influence government policy and resource allocation decisions. For example, such evaluations have influenced policy with respect to the reprovision of care for the long-term mentally ill from hospital to community settings, (44 the development of 'assertive community treatment' models for acutely ill people (see above), the organization of services (through care management perhaps), and the overall level of funding.

Specific psychotherapies

Assertive and direct methods of communicating, and help in conceptualizing alternative solutions to problems. Meetings with parents were sometimes held to augment the treatment, and psychopharmacology was used adjunctively if depressed adolescents had not improved after 4 to 6 weeks of pharmacotherapy.

Rehabilitation in hospital prison and the community

Impressed with a forensic mental health service which produces optimal mental health outcomes if there is a high rate of further serious offending. As noted earlier there is fortunately considerable overlap between those factors essential for good psychiatric management and those likely to reduce the risks of recidivism. (41,4 4 and 44) A number of service models have been described for the community care of mentally abnormal offenders. Intensive case management, programmes of conditional release, assertive follow-up, and outreach services provided by those skilled in the forensic area, all offer appropriate service delivery models. (2 ,45,46 and 47) Implicit in these approaches is the development and maintenance of a forensic community service operating in parallel with general services. This service delivery model meets considerable scepticism from administrators concerned with minimizing funding. It is also unwelcome to those interested in maintaining the hegemony of general...

The correctional context

Developing separate mental health facilities within prison is problematic. The dominant correctional culture tends to overwhelm the minority, and inherently less assertive, mental health cultures. Such units may produce more humane prison units, but they have to struggle constantly to sustain a therapeutic environment appropriate to providing quality mental health services. However, given, the limited secure facilities available in most jurisdictions to which prisoners can be transferred prison-based psychiatric units remain a necessity.

From Normality to Abnormality

Characteristics of an antisocial personality style rather than disorder can also be developed by normalizing the diagnostic criteria of DSM-IV (see Sperry, 1995). Whereas the disorder consistently violates social norms through illegal activities (see criterion 1), the style puts its own value system above that of the group and is occasionally caught up in conflict thereby. Whereas the disorder uses various forms of deceit to achieve its own ends (see criterion 2), the style is slippery, tending to finesse critical points and spin objective events to its advantage without engaging in outright deception. Whereas the disorder is too impulsive to consider the consequences of its actions (see criterion 3), the style is naturally spontaneous and self-indulgent, but knows when failure to delay gratification would violate social norms or lead to substantial harm to self or others. Whereas the disorder is irritable and aggressive to the point of repeated fights or assaults (see criterion 4),...

The Psychodynamic Perspective

But do they follow through and sustain that initial impression Are they good lovers Apparently, the answer is no. Apt and Hurlbert (1994) studied a sample of women who had been diagnosed as histrionic using the MCMI-II and compared them to a matched sample of other nonhistrionic women in a series of measures of sexual behaviors and attitudes. Histrionic women were found to have significantly lower sexual assertiveness, greater ero-tophobic attitudes toward sex, lower self-esteem, and greater marital dissatisfaction they were found to be more preoccupied with sexual thoughts and they reported having lower sexual desire and more sexual boredom. They also reported a greater incidence of orgasmic dysfunction and indicated a greater likelihood of entering into an extramarital affair. Despite such negative findings, histrionics reported greater sexual self-esteem.

The Biological Perspective

Portraits similar to the avoidant personality have been put forward by psychobiologi-cal researchers. In 1970, before the avoidant appeared in the DSM-III, Klein distinguished two schizoid subtypes. The first was noted by an asocial disposition, which he believed was accurately labeled in the DSM. A second type was described as a shy, socially backward, inept, obedient person who is fearful and therefore isolated but appreciates sociability and would like to be part of the crowd (p. 189). These characteristics, Klein noted, occurred in conjunction with anticipatory anxiety and low esteem. Other researchers (Siever & Davis, 1991, p. 1655) regard anxiety inhibition as providing one of the core psychobiological dispositions in the development of personality. Exploring beyond the safety of a nearby caretaker is an important development task for all children those with a low threshold for anxiety would be seen as shy, inhibited, and fearful. They would not form new relationships easily,...

Self Defeating Personality Disorder Dsmiiir Appendix A

After the apparent establishment of solid and trusting rapport with their therapist, self-defeating personality disordered patients may start to make special demands and then react with noticeable anger and disappointment when their unrealistic requests are not met. In therapy, these patients may also engage in a yes, but game, as they come up with reasons for maintaining unhealthy behaviors. The therapist's attempt to subtly suggest more assertive and successful modes of behaving are often met with sometimes subtle and sometimes blatant refusal. These interactions often mirror their social and family interactions as well, where offers of assistance are also met with rejection, despite clear needs for the help and assistance. Not surprisingly, people with Self-Defeating Personality Disorder very often do not comply or agree with treatment plans but are adept at sabotaging them to confirm that nothing helps. Table 5.2 lists the DSM-IV-TR diagnostic criteria for Self-Defeating...

Selfdefeating masochistic personality disorder JLC

People with self-defeating personality disorder do not defend themselves against expressions of disgust and resentment directed towards them and rarely accuse or reproach others. They do not feel confident and are not assertive. They fear that optimism may lead to greater problems. They are not worried by these attitudes. Rather, masochists believe that by exaggerating their weaknesses and inefficiency they will protect themselves from aggression by others. They feel protected when someone needs something from them, and many non-assertive masochists engage in self-sacrifice for their own protective feelings rather than for the welfare of others. What seems to be a comprehensive and self-sacrificing attitude reflects a lack of confidence and empathy. Antidepressants and anxiolytics may be useful to alleviate a dysphoric state. Psychological treatment should take into account that masochistic patients sometimes induce an aggressive countertransference as a response to their own wish to...

The Evolutionary Neurodevelopmental Perspective

In early development, children begin the struggle to acquire autonomous skills and to achieve a sense of self-competence. During this period, most children become assertive and resistant to parental direction and admonition. Overcontrolling parents respond to these efforts with firm and harsh discipline they physically curtail the child, berate the child, withdraw love, and so on in short, they are relentless in their desire to squelch troublesome transgressions. Children who are unable to find solace from this parental assault submit entirely, withdraw into a shell, or become adamant and rebel. However, if children uncover a sphere of operation that leaves them free of parental condemnation, they are likely to reach a compromise they will restrict their activities just to those areas that meet parental approval. This, then, becomes the action available to the compulsive child the youngster sticks within circumscribed boundaries and does not venture beyond them.

Therapeutic Patient Education of Obese Patients

Cognitive Analytic Therapy Formulation

By analyzing the flow from trigger to consequence, patients will gain a better understanding of the underlying mechanisms involved. They will move progressively from a vicious circle into a virtuous circle (fig. 5). For example, frustration at work will be reduced by patients learning to be more assertive, to say no politely, to step back, to express their emotions, etc. Expressed emotions will grow less painful and thoughts will become less negative. Meanwhile, replacement strategies for binges will be found which will become both rewarding and pleasurable. As a result, food binges will decrease in number. Finally, the consequences for quality of life and biological results will become more tangible and increasingly felt by the patient.

NEO Personality Inventory Revised

The NEO PI-R is comprised of 243 self-report items rated on a 5-point scale. It measures the five global factors as well as six facets for each domain. Specifically, the facets for Neuroticism are anxiety, hostility, depression, self-consciousness, impulsiveness, and vulnerability. Facets for Extraversion are warmth, gre-gariousness, assertiveness, activity, excitement-seeking, and positive emotions. Facets for Openness to Experience are fantasy, aesthetics, feelings, actions, ideas, and values. Facets for Agreeableness are trust, modesty, compliance, altruism, straightforwardness, and tender-mindedness. Facets for Conscientiousness are competence, self-discipline, achievement-striving, dutifulness, order, and deliberation. As can be seen, the five domains provide a general description of personality, whereas facet scales allow more detailed analysis.

Alpf Medical Research Personality Disorders

As noted by Turkat (1990) and as with most pathological personality patterns, paranoids do not present stating, I need help, I am paranoid, but instead present seeking symptom relief from the fallout of their own hostile vicious circles. One subject may complain of an inability to relax, another may want to become more assertive because others are so antagonizing, and another may complain of being passed over for a promotion. Because symptom-focused treatment misses the real problem, therapists should be sensitive to the possibility that these symptoms are driven by an underlying personality disorder and ask, Why is this person having these problems (p. 47). Questions must be offered in a supportive context, however, for paranoids are naturally secretive and do not readily lay themselves open to scrutiny by others.

Quantity of social interactions in MDD

Continued to report restricted social networks even when they were no longer symptomatic (Billings & Moos 1985a, 1985b Gotlib & Lee, 1989). Moreover, there is strong evidence that depression is associated with such stable characteristics as low assertiveness, social withdrawal, avoidance, and shyness all traits that have been found to be associated with reduced social activity (Alfano et al., 1994 Anderson & Harvey, 1988). In fact, both the lack of assertiveness (Ball et al., 1994) and the presence of social withdrawal (Boivin et al., 1995) have been found to predict future depression, a pattern of results that suggests that reduced social activity may serve as a risk factor for depression. Although promising, it is clear that more research using prospective designs needs to be conducted before we are able to understand fully the causal nature of the relation between reduced social activity and episodes of depression.

Anxiety management stress inoculation

The goal of this treatment is to teach the patient a set of skills that will help them cope with stress. Examples include relaxation training, training in slow abdominal breathing, thought stopping of unwanted thoughts, assertiveness training, and training in positive thinking. (59) Anxiety management is more effective than supportive psychotherapy. In the long term it appears to be somewhat less effective than exposure treatment.(101) Relaxation treatment alone is less effective than exposure and cognitive therapy in the short and long term.(102)

Biochemistry Hormones

Testosterone from blood is correlated with sensation seeking, particularly that of the experience seeking and disinhibitory types (Aluja & Torrubia, in press Daitzman & Zuckerman, 1980), although Bogaert and Fisher (1995) and Dabbs (2000) found only nonsignificant tendencies toward association using salivary testosterone. Hypogonadal men with very low testosterone referred for complaints of erectile dysfunction were lower on sensation seeking than men with normal levels of testosterone (O'Carroll, 1984). Testosterone in young males correlates with their sexual experience, as defined by the number of sexual partners they have had (Bogaert & Fisher, 1995 Dabbs, 2000 Daitzman & Zuckerman, 1980). Other corelates of testosterone in males include assertiveness, impulsivity, and low self-control. A history of antisocial behavior, beginning in childhood, is found in men with high testosterone levels (Dabbs, 2000).


Although low-ranking animals are commonly stressed, they are not necessarily depressed. Moreover, socially anxious people and low self-esteem people can feel inferior and behave submissively but may not be depressed (Gilbert, 2001b). Indeed, Brown and Harris (1978) suggest that low self-esteem is a vulnerability factor that can fuel depression in the face of provoking agents. There are, in fact, two other ingredients that may need to be present for depression defeat and entrapment. Price (1972, Price & Sloman, 1987) first argued that depression might be an evolved response to social defeats where either there is a loss in social standing (rank) and or an animal is being harassed from above and cannot escape to somewhere else or try something else. He argued that under such conditions the best response may be a form of demobilisation which stops the animal from engaging in behaviour that elicits further attacks, and signals to potential attackers that 'one is defeated and out of...

Coping with stress

Unrelieved stress in a high proportion of workers results in a department with low morale and high staff turnover. To prevent this, each stressor should be looked at and methods of coping and alleviating the stress should be used. Interpersonal communications can be improved by encouraging staff to attend courses that include interpersonal skills and assertiveness training. Talking about stress-related problems with colleagues, family, partners, or friends may also be an effective coping mechanism. Problems about communicating with awake patients who cannot speak may be reduced by open discussions with other members of the team looking after the patient.


As part of the training process, weekly meetings are held between the preceptor and trainee, in conjunction with the training supervisor, to discuss every detail of each case in which they are involved. The check-list and case evaluation are reviewed and goals are set for the trainee. A monthly report is developed by the preceptor and training supervisor and forwarded to the manager of recovery services. RSC training at STA lasts an average of six months depending on the available experiences during each individual's training period. Trainees need experiences in a variety of hospitals with different patient acuity levels. Although each trainee may experience many things under the direction of his her preceptor, prior to practicing independently, the preceptor must be certain that the trainee will be confident and assertive when faced with the challenges of the recovery process. RSCs at OPOs that cover a logistically diverse territory may work in entirely different hospital settings...

Table 1413

Testosterone, with a basic structure as a steroid ring, is the natural endogenous androgen.97-99 Testosterone is synthesized primarily in the Leydig cells of the testes in males and by the ovaries and adrenal glands in females. Healthy adult men produce 3 to 10 mg d, yielding plasma concentrations ranging from 300 to 1000 J.g dl.93-95 Testosterone acts on the cell androgenic receptors found mainly in skin, muscle, and male sex glands. It has both androgenic or masculinizing properties and anabolic properties. Androgenic effects are present to some degree in all anabolic steroids. Androgenic affects include development of male sex glands, male hair growth pattern, increased libido, and assertiveness (Table 14.14). Most testosterone analogs or anabolic steroids have androgenic properties much lower than testosterone


People high in positive affectivity or extraversion frequently feel joyful, optimistic, and assertive, while those low in positive affectivity are disinterested and pessimistic. Positive affectivity is a stable temperamental dimension with a substantial genetic component. There is also evidence that it is specifically linked to depression. However, the details of this link are far from clear. Some studies indicate that low positive affectivity reflects a predisposition to developing depressive symptoms, while other studies suggest that it modulates the course of depressive symptoms.(34) Another unresolved issue concerns the precise cognitive variables that mediate the connection between positive affectivity and depression. It is well established that individuals who rely on a pessimistic explanatory style (i.e. who habitually ascribe bad life events to their own faults) run a greater risk of becoming depressed than those who rely on an optimistic explanatory style. It is also clear...


Frotteurism involves uninvited touching or rubbing against another person for sexual gratification (DSM-IV code 302.89 ICD-10 indicates that frotteurism should be coded under Other Disorders of Sexual Preference F65.8).(34) Frotteurs carry out paraphilic behaviour in crowded environments such as bus terminals, subways, sporting events, crowded bars, etc. Fantasy is an extensive part of frotteurism, since frotteurs are able to convince themselves that touching behaviour will not offend victims and, furthermore, victims will find touching pleasurable. Initially, the nature of crowded environments is used as an excuse for being in close proximity to potential victims. For example, subway passengers typically stand close to the tracks when waiting for a train. Frotteurs stand 2 to 3 metres back from the crowd, searching to identify potential victims. Once a female is identified, the frotteur moves behind her and extends his arms toward her waist to prevent others from getting in front of...

The Thorn programme

One of the most exciting developments in psychiatric nursing has been the development of the Thorn programme. This initiative takes its name from the Sir Jules Thorn Trust, a charitable foundation which provided the funds to inaugurate the first 3 years of the training programme for nurses, started in 1992. The initiative was originally led by Jim Birley, who, with a group of colleagues from other professions, became impressed by the work of nurses working in cancer care. Birley's initial aim was to train a substantial number of nurses specifically dedicated to the care of people with schizophrenia and their relatives. Indeed, Birley, who was one of the pioneers of social psychiatry in the United Kingdom, noted that the families of people with schizophrenia were often in great need of intervention. Previous work had confirmed that nurses could be trained in family intervention skills. (.1.9 This training in family work formed the basis of what has now become a much more general...

Time management

Time management is crucial for the successful manager. By prioritizing, delegating, and planning a good manager can be assertive and achieve more in a limited time. Time management is about making choices and keeping to them. Zarod(U has illustrated some successful and pragmatic techniques for time management. The individual must identify particular time-management problems. Following processes of prioritization, a key step is to be able to delegate to others with complementary their skills. Individuals can manage time more effectively by being proactive rather than reactive.

Question Of Choice

There now seems to be a political will and consensus on the need for more consumer information. In the UK, the Labour Party policy document A Fresh Start for Health supports the development of patient autonomy. This means a patient population that is more self-confident, more assertive and more knowledgeable. Furthermore, this document promotes the rights of patients to gain more information about choices of treatment and proposes that patients who are better informed about alternative forms of treatment and who participate in the management of their case are more likely to cooperate in beneficial changes and may contribute to a better prospect for a successful outcome. Access to the right information at the right time is a crucial ingredient of modern healthcare. Across the world there is growing interest in information about health and health services, and to keep the momentum, it is important to develop a culture among healthcare workers that promotes a positive attitude to...

Ending treatment

The patient's own goals tend to be outcome rather than process goals and are more easily defined the decline of symptoms, improved relationships, greater well being, increased capacity for work, higher self-esteem, a capacity for assertiveness. As such changes are clearly achievable without psychodynamic treatment, many psychodynamic clinicians erroneously regard such criteria for ending as superficial. Independent evidence will be required to show that the achievement of process aims results in a more permanent or general achievement of outcome aims, in order to validate process aims as an appropriate criterion for ending.


The initial goal of cognitive-behavioral therapy is to restore control over dietary intake. Caloric restriction and dieting efforts should be discontinued. Patients should record their food intake and feelings and receive extensive feedback concerning their meal plan, symptom triggers, caloric intake and nutritional balance. Patients are instructed in methods for challenging rigid thought patterns, improving self-esteem, assertiveness training, and appropriate expression of feelings.

Type A personality

The acute cardiac event and the coronary care unit heighten the anxiety of a type A personality patient. Admission to such a unit also threatens the patient's need for control and sense of infallibility. The cardiologist or cardiac nurse, who expects and desires a co-operative appreciative patient, instead encounters a hostile abrasive patient who tries to control anxiety and the fears of death via aggressiveness. (29 A request for psychiatric consultation will insult such a patient. The best approach is to be respectful and reassuring 29 ) Encourage the patient to ask questions about his or her illness and treatment, and involve him or her actively in plans for recuperation. In this way, the patient's characteristics of assertiveness and the need for control are channelled in a positive direction.