Efficacy of Assertiveness Training for Social Anxiety:
A Meta-Analysis of Randomized Controlled Trials
Evie Levens, John Malouff, & Jai Mynadier
University of New England, Australia
Abstract
Social anxiety involves high fear in social situations due to the expectation of scrutiny or negative assessment by others. Persistent social anxiety can negatively affect an individual’s behavior, quality of life, and success in life. The present meta-analysis synthesized research assessing the efficacy of assertiveness training for reducing social anxiety. A comprehensive search led to six randomized control trials with a total of 207 participants. A meta-analysis using a random-effects model showed that assertiveness training was significantly more effective for reducing social anxiety than a wait-list control. The weighted meta-analytic effect size, g = 1.21, 95% CI [0.49, 1.92], indicated a very large positive effect. These results suggest that further research is warranted on assertiveness training as a method of reducing social anxiety.
Key words: assertion, assertiveness training, efficacy, meta-analysis, social anxiety
Introduction
Social anxiety involves an acute fear of scrutiny or negative judgment by others (Creed & Funder, 1998). Thus, social situations are met with intense anxiety or avoided entirely. The distress caused by social anxiety can have an adverse effect on everyday activities, such as shopping, eating in public, or talking with unfamiliar people (National Institute of Mental Health, 2022). To meet the criteria for social anxiety disorder, an individual must experience persistent marked anxiety in social situations and significant impairment in social, occupational, or other crucial aspects of functioning (American Psychiatric Association, 2013). However, social anxiety likely exists on a spectrum, with many individuals experiencing moderate levels of social anxiety and resultant problems (Dell’Osso et al., 2003), without meeting the criteria for the disorder.
Prevalence of Social Anxiety Problems
Social anxiety develops early in life. Of people with social anxiety disorder, 50% are affected by age 11 (Stein & Stein, 2008). Jefferies and Ungar (2020) found that 23-58% of people aged between 16 and 29 globally met the criteria for social anxiety disorder.
Theories of Social Anxiety
Several theories have been advanced to explain the causes of social anxiety. Learning theorists propose that social anxiety arises from conditioned responses to social cues (Mattick et al., 1995). Bandura (1982) suggested that individuals learn social anxiety by observing the behavior of others. Attachment theory (Bowlby, 1973) posited that experiences early in life form working models (cognitive schemas) that influence later interactions with others. Secure attachment to caregivers in childhood enables the development of supportive relationships later in life. Conversely, an insecure attachment can result in emotional unavailability and impaired social skills in adulthood (Mallinckrodt & Wei, 2005). Impaired social skills can negatively affect self-esteem, social self-assurance, and assertiveness. These working models influence how social information is received, which then determines emotional and behavioral responses. These emotional and behavioral responses are likely to be reflexive, often without conscious influence or realization (Collins, 1996).
Cognitive schemas also inform assumptions relating to social situations. A socially anxious individual may pre-empt negative feedback from others, inhibiting social interaction. Any negative feedback confirms this prediction. Further, self-criticism can arise from this want of assertiveness (Beck et al., 2005). A study by Hope et al. (1998) demonstrated that individuals with social anxiety class themselves as subordinate in relation to others and lack self-assuredness. This belief was expressed through behaviors characteristic of a subordinate status, such as inhibition, passivity, and hesitancy. Such unassertive behavior can be used as a safety measure to minimize risk in anxiety-inducing circumstances (Swee et al., 2018).
Interventions for Social Anxiety
Effective interventions for social anxiety can reduce the burden on the individual and, by extension, society. Interventions for social anxiety include pharmacotherapy, cognitive therapies, and behavior training. Pharmacotherapies, involving benzodiazepines, SSRIs, and monoamine oxidase inhibitors, often produce improvement, but they also pose side-effect risks to the patient. (Hall & Buckley, 2003; Lane, 1998; Stahl, 2013; Volpi-Abadie et al., 2013).
Psychological interventions for treating social anxiety include cognitive behavior therapy, which involves prompting re-appraisal of negative cognitions, re-evaluation of physical responses to anxiety-inducing circumstances, and teaching coping methods (Spain et al., 2017). Encouraging awareness and analysis of symptoms helps individuals to understand and manage their anxiety. Rational-emotive therapy involves challenging one’s irrational beliefs through logical disputation, while also reinforcing positive social experiences and moods (Gardner, 1980). Acceptance and commitment therapy involves modifying one’s response to troubling thoughts and feelings. The model proposes that emotional disturbance arises from efforts to suppress or eradicate uncomfortable thoughts and emotions, and less so from the circumstances themselves. The aim, therefore, is not to address the mental phenomena but instead to alter the responses to them (Dalrymple, 2005). Assertiveness training is a behavioral intervention aimed at increasing assertive behavior. Through instruction and roleplay, participants learn the differences between submissiveness, assertion, and aggression; begin to recognize and exercise their rights while respecting those of others; learn to change habitual maladaptive thought processes and behaviors; and develop assertiveness skills (Lange & Jakubowski, 1976; Larsen & Jordan, 2017). This training can be viewed as part of the positive psychology movement (Seligman, 2007) in that it helps increase a person’s psychological skill.
Assertiveness Training as a Means of Reducing Social Anxiety
Wolpe (1958) hypothesized that assertiveness inhibits social anxiety, an idea supported in studies by Orenstein et al. (1975), Gardner (1980), McGowan (1980), Lee et al. (2013), and Speed et al. (2018). Bijstra et al. (1994) found that unassertive behavior adversely impacted social performance, resulting in greater social anxiety and reduced self-esteem.
Lazarus (1973) identified four key assertive abilities: the ability to refuse; the ability to request; the ability to express positive and negative emotions; and the ability to begin, hold, and end conversations. These behaviours are integral to many assertiveness training programmes (Gardner, 1980; Lee et al., 2013; Lin et al., 2004, 2008; Manesh et al., 2015; McGowan, 1980).
Studies assessing the efficacy of assertiveness training on social anxiety have focused on specific populations, including individuals with autism spectrum disorder (Spain et al. 2017), deaf and hearing-impaired adolescents (Ahmadi et al., 2017), and patients with schizophrenia (Lee et al., 2013). A meta-analysis of randomized controlled trials focusing on assertiveness training could provide evidence useful for purposes of choosing interventions for social anxiety.
Study Objectives and Hypotheses
To assess the efficacy of assertiveness training in reducing social anxiety, the current meta-analysis combined the results of randomized controlled trials to calculate a weighted meta-analytic effect size. We hypothesized that assertiveness training would reduce social anxiety.
Method
Eligibility Criteria
Studies examining the effects of assertiveness training on social anxiety were included if the following criteria were met: (1) the study compared an intervention condition with a control condition, using random assignment of a minimum of ten total participants to conditions; (2) the study assessed social anxiety in both conditions before and after the intervention or assessed social anxiety in both conditions after the intervention; (3) assertiveness training was a stand-alone therapy and not part of an intervention package; (4) other bona fide interventions intended to reduce social anxiety were separated from typical control conditions; and (5) sufficient information was provided for the calculation of an effect size.
There were no restrictions on language, though non-English articles had to be translatable into comprehensible English using Google Translate in order to be used in the study. There were no restrictions on study publication dates, participant demographics, or other criteria. Randomized controlled trials (RCTs) were included to the exclusion of other study designs due to the value of RCTs in reaching causal conclusions. No treatment, placebo, and wait-list control groups constituted the possible control conditions.
Search Strategy
We registered our plan for completing the meta-analysis, including the search strategy, with PROSPERO at [withheld to preserve author anonymity]. We identified suitable studies by searching electronic databases, manually searching reference lists of included articles, and writing to authors of included studies to request unpublished data. No responses were received from authors. The online databases searched were PubMed, ProQuest, EBSCO, EBSCO Open Dissertations, and Scopus. Search terms used were: (“assertiveness training” or “assertion training”) and (“social phobia” or “social anx*”). The use of a wildcard function, the asterisk, returned results with prefix anx-, for example, “social anxiety” and “social anxiousness.” We also used forward-citation searches with Google Scholar to locate articles that cited the studies included in the meta-analysis; we scrutinized these for relevant other studies.
A total of 73 articles were found, six of which met the selection criteria. A PRISMA flow diagram (Liberati et al., 2009) shows the procedure for selection of studies. Two researchers conducted a simultaneous search of the databases and then compared their search results and decided which studies to include by consensus.
Coding Procedures
One researcher selected and coded data for all studies, in conjunction with a second researcher. A third researcher then independently coded data relevant to the calculation of an effect size. The level of agreement for independent coding was 98%. We discussed differences and resolved them by consensus.
Descriptive Data
Items coded included: (1) author and publication year of study (2) sample description, (3) total number of sample participants, (4) sample mean age (age range used where mean could not be calculated), (5) percentage female, (6) country of origin, (7) type of control, (8) analysis type (all completed, intention-to-treat, completers), (9) social anxiety measures used, (10) whether measure used to assess social anxiety has evidence of validity and reliability, (11) treatment delivery format (online, individual in-person, group in-person), (12) duration (in months) from baseline to final assessment, (13) total number of training weeks, (14) total number of training sessions, (16) weeks after the end of training prior to final assessment used in the meta-analysis, (17) overall attrition rate prior to assessment used in the meta-analysis, and (18) whether participants had high anxiety (on some measure), or no identified level of social anxiety.
Effect Size Data
We used pre- and post-score means and standard deviations of the training and control groups for each measure, the effect direction for each measure, and group sample sizes to calculate effect sizes.
Quality Criteria
We also coded data for quality assessment variables. These evaluated the reliability, validity, and bias risk of studies. They assessed whether: (1) groups were similar at baseline, (2) all therapists were trained to provide treatment, (3) an assertiveness training manual was used, (4) training manual use was assessed; (5) all participants were accounted for in report; (6) attrition at included final assessment did not exceed 25% in any condition.
We coded items as “Yes” if the criterion was present, “No” if not present, “Unknown” or “ND” (no data) if there were insufficient data to determine whether the criterion was present, and “NA” if not applicable. Where quality information was unclear or incomplete, we attempted to contact the authors to request further information. However, we did not obtain any data that way.
Exclusions
Of the 10 full-text articles retained for assessment of eligibility, four were excluded. The study by Asadnia et al. (2013) was published in Persian; an English version could not be obtained and attempts to translate the study using Google Translate were unsuccessful. DiGiuseppe et al. (1991) did not include data for post-intervention SDs or means, preventing the computation of an effect size. The report of the study by Abdolghaderi et al. (2021) began with an experimental group and a control group; however, the results section introduced a second experimental group without explanation, making the study too unclear to include. Finally, Faghihi and Goodarzi’s (2017) study employed a “semi-experimental” method, and the study report did not state that participants were randomly assigned to a condition.
Measures
The four questionnaires used in at least one study were the Social Phobia Inventory (SPIN; Connor et al., 2000), Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998), the Fear of Negative Evaluation Scale (FNE; Watson & Friend, 1969), and the Social Avoidance and Distress Scale (SAD; Watson & Friend, 1969).
The Social Phobia Inventory (SPIN; Connor et al., 2000) is a 17-item self-report questionnaire. It is a measure for the evaluation of the fear, avoidance, and physiological discomfort symptomatic of social phobia. An example question is: “I am afraid of doing things when people might be watching.” The incidence of symptoms in the preceding week is rated by respondents on a Likert scale of 0 to 4: 0 (not at all), 1 (a little bit), 2 (somewhat), 3 (very much), and 4 (extremely). Summed raw scores range from 0 to 68, with higher scores indicating greater levels of social anxiety. Connors et al. (2000) described the SPIN as having sound psychometric properties, with high internal consistency and convergent and divergent validity.
The Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) is a 20-item self-report questionnaire used to assess social interaction anxiety. An example question is: “I get nervous if I have to speak to someone in authority, like a teacher, boss, etc.” Respondents indicate the degree to which they feel the statement is characteristic of themselves on a Likert scale of 0 to 4: 0 (not at all), 1 (a little bit), 2 (somewhat), 3 (very much), and 4 (extremely). Summed raw scores range from 0 to 80, with higher scores indicating greater levels of social anxiety. The SIAS has high internal consistency and discriminant validity (Mattick & Clarke, 1998).
The Fear of Negative Evaluation Scale (FNE; Watson and & Friend, 1969) is a 30-item self-report questionnaire. The FNE assesses anticipation and fear of negative evaluations, distress resulting from negative evaluations, and avoidance of circumstances where appraisal by others may occur. An example question is: “I worry about what people will think of me even when I know it doesn’t make any difference.” Responses options are true and false. Summed raw scores range from 0 to 30. High scores on the FNE indicate fear of appraisal by others in social settings. The FNE has sound psychometric properties, with good internal consistency and convergent and divergent validity (Oei et al., 1991; Watson & Friend, 1969).
The Social Avoidance and Distress Scale (SAD; Watson & Friend, 1969) is a 28-item self-report questionnaire used to evaluate social avoidance and related subjective distress. An example question is: “I often find social occasions upsetting.” Responses options are true and false. Summed raw scores range from 0 to 28, and higher scores indicate higher social anxiety and social avoidance. The SAD has sound psychometric properties, with high internal consistency and convergent and divergent validity (Oei et al., 1991; Watson & Friend, 1969).
Statistical Analysis
Data was analysed using Comprehensive Meta-Analysis, Version 3.3.070 (Borenstein et al, 2014). Hedges’ g was calculated as the effect size for each study using means and SDs, and the number of participants in each condition. Hedges’ g was used as it corrects bias caused by Cohen’s d in small samples. As there were fewer than ten samples in this meta-analysis, moderation analyses were inappropriate as per the Cochrane Handbook (Higgins & Green, 2021).
A random effects model was used since the true effect size likely varies across studies due to differences in sample characteristics and study methodology (Borenstein, 2009). This model assumes that the effect sizes of studies are normally distributed. Heterogeneity was measured using Q and I2 statistics. The Q statistic tests the null hypothesis that effect sizes are homogenous across studies. Heterogeneity is indicated by a significant Q statistic. The I2 statistic measures the proportion of variance in effect sizes across studies that is due to true heterogeneity, rather than sampling error (Huedo-Medina et al., 2006).
To assess for publication bias we used Egger’s intercept test (Egger et al., 1997), Kendall’s tau (Begg & Mazumdar, 1994), and Duval and Tweedie’s (2000) trim and fill test. A funnel plot, a visual representation of Egger’s test, provides the effect size of each study on the x-axis and its standard error on the y-axis. Skewness indicates bias whereby smaller intervention studies aggregate on the right-hand side of the plot (Borenstein et al., 2009). The rank correlation test (Begg & Mazumdar, 1994) is widely used in meta-analysis to test for publication bias in clinical studies. Using Kendall’s tau as the measure of association, the test standardizes the treatment effect and correlates it with the variance of the treatment effect (Gjerdevik & Heuch, 2014). A significant p value for Kendall’s tau or Egger’s intercept test indicates the presence of publication bias. Duval and Tweedie’s (2000) trim and fill method involves imputing missing studies into an asymmetric funnel plot to adjust the effect size for publication bias.
Results
Study Search and Selection
A search for relevant studies returned a total of 102 results. From these, 11 duplicates were removed, and the remaining 91 records were assessed using the inclusion criteria. Screening resulted in a final six included studies. The study selection procedure conducted in April 2022 is detailed in the PRISMA diagram (Figure 1).
Data for two dissertations (Gardner, 1980; McGowan, 1980) were combined for analysis as used the same wait-list control group and assertiveness training group. These dissertations included several bona fide treatment groups, in addition to an assertiveness training condition and a wait-list control. Because this combined study was the only one with bona fide comparison groups, we excluded those groups and included only the comparison of assertiveness training and control. However, we noted that the bona fide treatments had higher effect sizes than assertiveness training.
One article (Ahmadi et al. (2017) reported results separately for deaf and for hearing-impaired participants, including a separate control group for each. We combined data on the two samples to calculate for one effect size for the study.
Aggregated Results
Table 1 shows key study characteristics. The six studies included nine comparison conditions in total. These conditions were compared with assertiveness training: wait-list control, placebo, no treatment, treatment as usual, cognitive therapy, interpersonal cognitive problem solving, rational emotive training, and stress inoculation training. Cognitive therapy, interpersonal cognitive problem solving, rational emotive training, and stress inoculation training groups were used in the Gardner (1980) and McGowan (1980) studies. Because these were bona fide interventions, we excluded them from our analyses.
The total sample analysed comprised 207 participants. The included studies were published in Iran, Taiwan, and the United States between 1980 and 2021. The most common control condition was wait-list control (78%). Training periods ranged from 8 to 12 weeks. Baseline to final assessment ranged from 2 to 30 months.
Figure 1
PRISMA Flow Diagram of Study Selection Process [available from John Malouff at jmalouff@une.edu.au]
Table 1
Effect Size and Characteristics of Included Studies
|
Study |
Country |
%
Female |
Mean
Age |
No. of
treatment weeks |
No. of sessions | Baseline to
final assessment (months) |
Control conditions | Baseline anxiety level | High social anxiety at baseline | Long-term gains | Measures used | N | Effect size (g) | |||||||
| Ahmadi et al. (2017) deaf | Iran | ND | 14 | ND | 10 | ND | No treatment | ND | ND | ND | SPIN | 24 | 0.021 | |||||||
| Ahmadi et al. (2017) hearing impaired | Iran | ND | 14 | ND | 10 | ND | No treatment | ND | ND | ND | SPIN | 24 | 1.403 | |||||||
| Gardner & McGowan (1980)*
|
USA | 46 | 36.2 | 10 | 10 | 25 | Wait-list | High | Yes | ND | SAD
FNE |
25 | 0.821 | |||||||
| Janjani et al. 2021)* | Iran | ND | ND | 4 | 8 | 30 | Wait-list | ND | Yes | ND | SPIN | 30 | 2.360 | |||||||
| Lee et al. (2013)* | Taiwan | 39 | 42.8 | 4 | 12 | 7 | Treatment
as usual |
ND | Yes | Yes | SIAS | 74 | 0.596 | |||||||
| Manesh et al. (2015) | Iran | 100 | 35 | 8 | 8 | 2 | Placebo &
no treatment |
ND | ND | ND | SPIN | 90 | 2.138 | |||||||
.
Note. N = sample size; No. of weeks = total number of treatment weeks; No. of sessions = total number of treatment sessions; Effect size = Hedges’ g; ND = no data; FNE = Fear of Negative Evaluation scale; SAD = Social Avoidance & Distress scale; SIAS = Social Interaction Anxiety Scale; SPIN = Social Phobia Inventory. Manesh et al. – study had two control types. Baseline anxiety level reported only for McGowan & Gardner studies where SAD scale stated “scores above 12 indicate high anxiety”; mean SAD scores were above 12 in both studies. Long-term gains = continued reduction of social anxiety observed at 3 months follow-up. Not specified = Data not provided. Lee et al – treatment as usual refers to regular treatment for schizophrenia. Study information not obtained from authors: Ahmadi – no. of weeks, mean age, % female; Janjani – mean age; Lee – post-intervention SDs; Manesh – mean age.
Table 2
Quality Assessment of Included Studies
| Study | Were included participants screened using study measures? | Were groups similar at baseline? | Were participants blind to their assigned intervention? | Was a treatment manual used? | Were valid and reliable outcomes measures used? | Was the reason for dropout given? | Was study attrition rate below 25%? | Were ITT analyses performed? | |||||||
| Ahmadi et al.
(2017) deaf |
Yes | Yes | Unknown | Unknown | Yes | NA | Yes | Unknown | |||||||
| Ahmadi et al. (2017) hearing impaired | Yes | Yes | Unknown | Unknown | Yes | NA | Yes | Unknown | |||||||
| Gardner & McGowan (1980) | Yes | Yes | Unknown | Yes | Yes | Yes | Yes | Unknown | |||||||
| Janjani et al.
(2021) |
Yes | Yes | Unknown | Unknown | Yes | NA | Yes | Unknown | |||||||
| Lee et al.
(2013)
|
Yes | Yes | Unknown | Yes | Yes | Yes | Yes | Yes | |||||||
| Manesh et al.
(2015) |
No | Yes | Unknown | Unknown | Yes | NA | Yes | Unknown | |||||||
Note. NA = not applicable as there was no reported loss of participants; Unknown = data not provided. Validity of measures was not provided in text for the Gardner and McGowan studies; sourced instead from Oei et al. (1991). Reliability was shown using KR-20 index in the Gardner and McGowan studies. Janjani et al. and Manesh et al. studies did not report dropout data, therefore study attrition rate is assumed to be below 25%.
Study measures used: FNE, SAD: Gardner (1980), McGowan (1980); SPIN: Ahmadi (2017), Janjani (2021), Manesh (2015); SIAS – Lee (2013
Quality Assessment
Table 2 presents the results of the methodological quality assessment. All studies used reliable and valid outcome measures. One study used intention-to-treat (ITT) analysis.
Main Results
The weighted overall effect size indicated that assertiveness training improved social anxiety relative to inactive control conditions at post-intervention across six studies samples, g = 1.21, p = .001, 95% CI [0.49, 1.92]. Heterogeneity in effect sizes was significant, Q(5) = 30.67, p < .001. The amount of heterogeneity that reflected true variance in effect sizes was high (I2 = 83.70%). Figure 2 presents a forest plot of g and CI for the individual studies, as well as the weighted, overall g with CI.
Figure 2
Forest plot of effect size: Hedges’ g and 95% CI [available from John Malouff at jmalouff@une.edu.au]
Publication Bias
A non-significant Egger’s test of asymmetry (p = .50), together with visual inspection of the funnel plot (Figure 3), indicated no evidence of publication bias. This conclusion was further supported by a non-significant Kendall’s tau (p = .45). The trim and fill analysis did not suggest imputing any missing studies to adjust the overall estimated effect size.
Figure 3 Funnel Plot of Effect Sizes [available from John Malouff at jmalouff@une.edu.au]
Discussion
This is the first meta-analysis to assess the efficacy of assertiveness training for reducing social anxiety. Six RCTs, with a total of 298 participants, provided the data for analysis. The results of the analyses supported the hypothesis that assertiveness training would reduce social anxiety. The overall, weighted effect size of g = 1.21 indicates a large positive treatment effect, according to the standards of Cohen (1988).
Further, analyses found that the overall effect was robust to publication bias. Because most trials ended at the conclusion of treatment, it was difficult to evaluate whether immediate therapeutic effects persisted over time. Only the study of Lee et al. (2013) had a follow-up; that study showed significant effects at three months after the end of training. That study showed a long-term positive effect.
A barrier to treating social anxiety, as with other mental health conditions, is the stigma attached to receiving treatment, which reduces the likelihood of seeking treatment (Heinig et al., 2021). Assertiveness training, however, differs from pharmacological and psychological treatments in that it resembles more a training program than a treatment regime. The findings of this meta-analysis are important because assertiveness training has potential value over treatments in that it may be more appealing to some individuals.
Assertiveness training is used for various purposes, including increasing sexual assertiveness (Carlson & Johnson, 1975), reducing stress (Lee & Crockett, 1994), and improving self-esteem (Temple & Robson, 1991). Speed et al. (2017) noted a steady decline in research on assertiveness training for treating various clinical issues, including social anxiety. The present meta-analytic finding may help reinvigorate interest in the effects of assertiveness training.
The results of this meta-analysis demonstrate that assertiveness training is superior to wait-list and placebo conditions in reducing symptoms of social anxiety. The effect size is higher than those of meta-analyses that examined the effects of social skills training on social anxiety (Fedoroff & Taylor, 2001; Taylor, 1996); Fedoroff and Taylor (d = 0.86), and Taylor (d = 0.46). The present effect size was also higher than that found by Blanco et al. (2003) and Mayo-Wilson et al. (2014) for pharmacological interventions to treat social anxiety, with SSRIs having g = 0.65 (SSRIs) and phenelzine g = 1.02. Meta-analyses of psychological treatments for reducing social anxiety have produced small to large effect sizes, with cognitive behavioral group therapies, g = 0.80 (Barkowski et al., 2016); attention bias modification, g = 0.27 (Heeren et al., 2015); individual cognitive behavioral therapy, g = 1.9; group cognitive behavioral therapy, g = 0.92; exposure and social skills training, g = 0.86; self-help with support, g = 0.86; self-help without support, g = 0.75; and psychodynamic psychotherapy, g = 0.62 (Mayo-Wilson et al., 2014).
Caveats about the relatively high present effect size include that the present meta-analysis included only six studies and that almost all the studies in the present meta-analysis lacked long-term follow-ups. Further, the one combined study (Gardner, 2018 and McGowan, 2018) that compared assertiveness training with specific treatments found that each treatment had a higher effect size than assertiveness training, but the difference was not large.
Although we did not complete any moderator analyses, due to the small number of studies, we noted that half of the studies used samples identified as having high social anxiety and half did not. Effect sizes were similar for both types of samples.
Quality Assessment
The quality assessment of included studies yielded mixed results. All studies used valid and reliable measures for outcome variables, groups were similar at baseline, and the studies described a training regime with near identical methods. Three studies used treatment manuals, but there was no report of assessing adherence to the manuals. Only one study reported ITT results.
Strengths and Limitations
The present meta-analysis had strengths in its inclusion of randomized controlled trials. This experimental method is ideal for reaching causal conclusions. Further, the studies used reliable and valid measures of social anxiety.
This meta-analysis had two main limitations. One was the relatively small number of studies included. This situation restricted the ability to examine potential outcome moderators; it also put a limit on the generalizability of the findings. The other limitation was that most included studies did not determine whether gains were maintained long-term.
Future Directions
Future research could examine the effects of assertiveness training on social anxiety in different settings, with different types of participants, and with a long-term follow-up. The best evaluation methods would include the use of training manuals, reporting to what extent the manuals were followed, and reporting between-group results for completers and for intention-to-treat. Using a large number of participants would give the studies power to detect differences in effects. Comparisons with other types of interventions might help clarify the relative value of assertiveness training. It might be valuable to study whether socially anxious individuals are more willing to enter assertiveness training than to receive some type of pharmacological or psychological treatment..
Conclusion
The findings of this meta-analysis show that assertiveness training had a large, positive effect on social anxiety. More research on assertiveness training for social anxiety could help clarify the value of the training with different populations over the long-term.
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