Relationships of Assertiveness, Depression, and Social Support ...

BEHAVIOR 10.1177/0145445503259391 Segal / ASSERTION, MODIFICATION DEPRESSION, / July 2005 AND SOCIAL SUPPORT

Relationships of Assertiveness, Depression, and Social Support Among Older Nursing Home Residents DANIEL L. SEGAL University of Colorado at Colorado Springs

This study assessed the relationships of assertiveness, depression, and social support among nursing home residents. The sample included 50 older nursing home residents (mean age = 75 years; 75% female; 92% Caucasian). There was a significant correlation between assertiveness and depression (r = –.33), but the correlations between social support and depression (r = –.15) and between social support and assertiveness (r = –.03) were small and nonsignificant. The correlation between overall physical health (a subjective self-rating) and depression was strong and negative (r = –.50), with lower levels of health associated with higher depression. An implication of this study is that an intervention for depression among nursing home residents that is targeted at increasing assertiveness and bolstering health status may be more effective than the one that solely targets social support. Keywords: assertiveness; depression; social support; long-term care; intervention

Most older adults prefer and are successful at “aging in place”—that is, maintaining their independence in their own home. For the frailest and most debilitated older adults, however, nursing home placement is oftentimes necessary. About 5% of older adults live in a nursing home at any point in time, a figure that has remained stable since the early 1970s (National Center for Health Statistics, 2002). Depression is one of the most prevalent and serious psychological problems among nursing home residents: About 15% to 50% of residents suffer from diagnosable depression (see review by Streim & Katz, 1996).

AUTHOR’S NOTE: The author thanks Jessica Corcoran, M.A., for assistance with data collection and data entry. BEHAVIOR MODIFICATION, Vol. 29 No. 4, July 2005 689-695 DOI: 10.1177/0145445503259391 © 2005 Sage Publications

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Social support is also an important factor in mental health among nursing home residents, and psychosocial interventions often seek to bolster the resident’s level of supportive relationships. Assertiveness training plays an important role in traditional behavioral therapy with adults, and it has been recommended as a treatment component among older adults with diverse psychological problems as well (Gambrill, 1986). Assertiveness may be defined as the ability to express one’s thoughts, feelings, beliefs, and rights in an open, honest, and appropriate way. A key component of assertiveness is that the communication does not violate the rights of others, as is the case in aggressive communications. It is logical that nursing home residents with good assertiveness skills would more often get what they want and need. Having basic needs met is a natural goal of all people, and failure to do so could lead to depression or other psychological problems. Personal control has long been noted to improve mental health among nursing home residents (see Langer & Rodin, 1976), and assertiveness training would likely help residents express more clearly their desires and needs. Two studies have examined links between assertiveness, depression, and social support among older adult groups. Among 69 community-dwelling older adults, Kogan, Van Hasselt, Hersen, and Kabacoff (1995) found that those who are less assertive and have less social support are at increased risk for depression. Among 100 visually impaired older adults, Hersen et al. (1995) reported that higher levels of social support and assertiveness were associated with lower levels of depression. Assertiveness may rightly be an important skill among nursing home residents because workers at the institutional setting may not be as attuned to the emotional needs of a passive resident and the workers may respond poorly to the aggressive and actingout resident. However, little is known about the nature and impact of assertiveness in long-term care settings. The purpose of this study, therefore, was to assess relationships of assertiveness, social support, and depression among nursing home residents, thus extending the literature to a unique population.

Segal / ASSERTION, DEPRESSION, AND SOCIAL SUPPORT

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METHOD

Participants were recruited at several local nursing homes. Staff identified potential volunteers who were ostensibly free of cognitive impairment. Participants completed anonymously the following selfreport measures: Wolpe-Lazarus Assertiveness Scale (WLAS) (Wolpe & Lazarus, 1966), Geriatric Depression Scale (GDS) (Yesavage et al., 1983), and the Social Support List of Interactions (SSL12-I) (Kempen & van Eijk, 1995). The WLAS consists of 30 Yes/ No items and measures levels of assertive behavior. Scores can range from 0 to 30, with higher scores reflecting higher levels of assertiveness. The GDS includes 30 yes/no items and evaluates depressive symptoms specifically among older adults. Scores can range from 0 to 30, with higher scores indicating higher levels of depression. The SSL12-I is a 12-item measure of received social support that has good psychometric properties among community-dwelling older adults. Respondents indicate on a 4-point scale the extent to which they received a specific type of support from a member of their primary social network (1 = seldom or never, 2 = now and then, 3 = regularly, 4 = very often). Scores can range from 12 to 48 with higher scores corresponding to higher levels of support. The sample included 50 older adult residents (mean age = 74.9 years, SD = 11.9, age range = 50-96 years; 75% female; 92% Caucasian). RESULTS AND DISCUSSION

The mean WLAS was 18.1 (SD = 4.1), the mean GDS was 9.0 (SD = 5.5), and the mean SSL12-I was 29.2 (SD = 7.3). The correlation between the WLAS and GDS was moderate and negative (r = –.33, p < .05), with lower levels of assertiveness associated with higher depression. The correlation between the SSL12-I and GDS was small and nonsignificant (r = –.15, ns), indicating a slight negative relationship between overall support and depression. Similarly, the correlation between the SSL12-I and WLAS was small and nonsignificant

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(r = –.03, ns), indicating almost no relationship between overall support and assertiveness. Next, correlations between a subjective selfrating of overall physical health status (0-100 scale, higher scores indicating better health) and the WLAS, GDS, and SSL12-I were calculated. As expected, the correlation between physical health and GDS was strong and negative (r = –.50, p < .01), with poorer health associated with higher depression. The correlation between health and WLAS was positive in direction but small and nonsignificant (r = .17, ns), indicating little relationship between health and assertiveness. Similarly, the correlation between health and SSL12-I was also small and nonsignificant (r = –.02, ns), indicating no relationship between health and overall support. The slight relationship between health and assertiveness is an encouraging sign because it suggests that assertiveness (which is primarily achieved through effective verbalizations) is not limited to only the least physically impaired nursing home residents. Finally, gender differences on all dependent measures were examined (independent t tests) and no significant differences were found (all ps < .05). Notably, the mean assertion and depression scores among nursing home residents are consistent with means on identical measures in community-dwelling older adults (assertion M = 19.1; depression M = 7.9; Kogan et al., 1995) and visually impaired older adults (assertion M = 18.3; depression M = 10.4; Hersen et al., 1995), suggesting that the higher functioning group of nursing home residents are no more depressed and no less assertive than other samples of older persons. Regarding social support, our nursing home sample appeared to show somewhat higher levels of overall support than community older adults in the normative sample (N = 5,279, M = 25.5) in the SSL12-I validation study (Kempen & van Eijk, 1995). This may possibly be due to the nature of institutional living and the large numbers of support staff and health care personnel. The correlational results regarding the moderate negative association between assertion and depression are consistent with data from community-dwelling older adults (r = –.36; Kogan et al., 1995) and visually impaired older adults (r = –.29; Hersen et al., 1995), suggesting a pervasive relationship among the variables in diverse older adult samples and extending the findings to nursing home residents. Con-


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trary to the literature, the relationship between social support and depression among nursing home residents was weaker than the one reported in community-dwelling older adults (r = –.50; Kogan et al., 1995) and visually impaired older adults (r = –.48; Hersen et al., 1995). The relationship between assertiveness and overall support in this study was almost nonexistent, also contrary to earlier reports in which the relationship was moderate and positive in direction. Our results are consistent with prior research showing no gender differences among older adults in assertiveness, depression, and social support using similar assessment tools (Hersen et al., 1995; Kogan et al., 1995). This study also suggests a strong negative relationship between health status and depression among nursing home residents. An implication of this study is that an intervention for depression among nursing home residents that is targeted at increasing assertiveness and bolstering health status may be more effective than the one that solely targets social support. Several limitations are offered concerning this study. First, the sample size was modest and the sample was almost exclusively Caucasian. Future studies with more diverse nursing home residents would add to the knowledge base in this area. All measures were selfreport, and future studies with structured interviews and behavioral assessments would be stronger. We are also concerned somewhat about the extent to which the WLAS is content valid for older adults. Notably, a measure of assertive behavior competence has been developed specifically for use with community-dwelling older adults (Northrop & Edelstein, 1998), and this measure appears to be a good choice for future research in the area. A final limitation was that participants were likely the highest functioning of residents because they were required to be able to complete the measures independently and were selected out if there was any overt cognitive impairment (although no formal screening for cognitive impairment was done), thus limiting generalizability to more frail nursing home residents. Cognitive screening should be done in future studies. Nonetheless, results of this study suggest a potentially important relationship between assertiveness and depression among nursing home residents. Finally, it is imperative to highlight that there are many types of interventions to combat depression among nursing home residents:

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behavioral interventions to increase exercise, participation in social activities, and other pleasurable activities; cognitive interventions to reduce depressogenic thoughts; and pharmacotherapy to name a few. (The interested reader is referred to Molinari, 2000, for a comprehensive description of psychological issues and interventions unique to long-term care settings.) The present data suggest that training in assertiveness may be yet one additional option for psychosocial intervention in nursing homes. A controlled outcome study is warranted in which intensive assertiveness training is compared to a control group of nursing home residents who do not receive such training. Only with such a study can cause-and-effect statements be made about the role that assertiveness skills training may play in the reduction of depressive symptoms among nursing home residents. REFERENCES Gambrill, E. B. (1986). Social skills training with the elderly. In C. R. Hollin & P. Trower (Eds.), Handbook of social skills training: Applications across the lifespan (pp. 211-238). New York: Pergamon. Hersen, M., Kabacoff, R. I., Van Hasselt, V. B., Null, J. A., Ryan, C. F., Melton, M. A., et al. (1995). Assertiveness, depression, and social support in older visually impaired adults. Journal of Visual Impairment and Blindness, 7, 524-530. Kempen, G. I. J. M., & van Eijk, L. M. (1995). The psychometric properties of the SSL12-I, a short scale for measuring social support in the elderly. Social Indicators Research, 35, 303-312. Kogan, S. E., Van Hasselt, B. V., Hersen, M., & Kabacoff, I. R. (1995). Relationship of depression, assertiveness, and social support in community-dwelling older adults. Journal of Clinical Geropsychology, 1, 157-163. Langer, E. J., & Rodin, J. (1976). The effects of choice and enhanced personal responsibility for the aged: A field experiment in an institutional setting. Journal of Personality and Social Psychology, 34, 191-198. Molinari, V. (Ed.). (2000). Professional psychology in long term care: A comprehensive guide. New York: Hatherleigh. National Center for Health Statistics. (2002). Health, United States, 2002. Hyattsville, MD: Author. Northrop, L. M. E., & Edelstein, B. A. (1998). An assertive-behavior competence inventory for older adults. Journal of Clinical Geropsychology, 4, 315-331. Streim, J. E., & Katz, I. R. (1996). Clinical psychiatry in the nursing home. In E. W. Busse & D. G. Blazer (Eds.), Textbook of geriatric psychiatry (2nd ed., pp. 413-432). Washington, DC: American Psychiatric Press. Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy techniques. New York: Pergamon.


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Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., et al. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 314-317.

Daniel L. Segal received his Ph.D. in clinical psychology from the University of Miami in 1992. He is an Associate Professor in the Department of Psychology at the University of Colorado at Colorado Springs. His research interests include diagnostic and assessment issues in geropsychology, suicide prevention and aging, bereavement, and personality disorders across the lifespan.