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'2; ' zaw‘g‘pd‘ ... . g ‘ “3'21”, ,;._'.f.[ ,‘iai -" fianhfifi. ‘ ‘1 h .‘r ,l I" hi If fl .'*~i;t~c'-3 LIBRARY Michigan State University This is to certify that the dissertation entitled Sexual Desire and Personality Correlates in Females presented by Martha Smith Whipple has been accepted towards fulfillment of the requirements for Counselin g Ph.D. degree in Psychology 4'» mt» Major professor Date July 20, 1987 MS U is an Affirmative Action/Equal Opportunity Institution 0- 12771 SEXUAL DESIRE AND PERSONALITY CORRELATES IN FEMALES BY Martha Smith Whipple A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY School of Health Education, Counseling Psychology and Human Performance 1987 ABSTRACT SEXUAL DESIRE AND PERSONALITY CORRELATES IN FEMALES BY Martha S. Whipple Sexual desire, the interest and readiness to engage in sexual activity, is affected by the personal dynamics of an individual. The purpose of this study was to investigate the relationship between sexual desire and personality patterns in married females. Hypotheses were developed from a theoretical investigation of the object relations and ego development of three personality disorders. It was hypothesized that the histrionic, passive-aggressive and borderline personality would report low sexual desire. In this descriptive study, the Millon Clinical Multiaxial Inventory (MCMI) eleven personality scales were correlated with Sexual Desire Assessment Form (SDAF) scores on thirty clinical (psychiatric inpatients) and forty-two non- clinical females, age eighteen to forty-five years and married for at least one year. In addition, exploratory hypotheses examined the SDAF as well Martha 8. Whipple as differences between the clinical and non- clinical samples. Hypotheses generated and tested were: 1. The presence of a significant negative relationship between the Histrionic (4), Passive- Aggressive (8) and Borderline (C) Scales of the MCMI and the SDAF. 2. The determination of a significant relationship between the other eight personality scales of the MCMI and the SDAF. 3. The reliability and interitem consistency of the SDAF. 4. Differences in the clinical and non-clinical samples on the SDAF and personality patterns. Pearson correlation, regression, partial correlation, t-test and z-tests were the statistical procedures employed in this study. The major results of the study were: 1. A significant positive relationship was found between the Histrionic (4) Scale of the MCMI and the SDAF, indicating a positive correlation with sexual desire. Martha S. Whipple 2. A significant negative relationship was found between the Passive-Aggressive (8) and Borderline (C) Scales of the MCMI and the SDAF, indicating a negative relationship with sexual desire. 3. A significant negative relationship was found between the Schizoid (1), Avoidant (2), Dependent (3) and Schizotypal (S) Scales of the MCMI and the SDAF. A significant positive relationship was found on the Narcissistic (5), Antisocial (6) and Conforming (7) Scales and the SDAF. The multiple regression revealed that, out of the remaining eight personality scales of the MCMI, only the Schizoid Scale was a significant predictor of the SDAF. 4. The SDAF was found to have interitem consistency (.847) and test-retest reliability (r= .966, p (.001). 5. Significant differences were found between the clinical and non-clinical samples on nine of the eleven items and on the total score of the SDAF. The clinical sample reported less frequent and less intense sexual desire than the non-clinical sample. Martha 8. Whipple 6. Significant differences were found in the two samples on the Histrionic (4), Passive— Aggressive (8) and Borderline (C) Scales of the MCMI. A difference in correlation was also found on the SDAF and the Passive-Aggressive (8) Scale of the MCMI between the two samples. Further study is necessary to validate the SDAF and expand the cognitive, behavioral and affective components of sexual desire. It is also essential to determine the personality patterns most likely to seek and profit from therapy for sexual desire disorders. DEDICATION TO SHANNON ii ACKNOWLEDGEMENTS I wish to express my appreciation to Dr. William Hinds, who served as chairperson of my dissertation committee. His encouragement and direction were essential to the completion of this study. Drs. Rebecca Henry, Richard Johnson and Harry Piersma, members of my committee also provided suggestions, critiques and frequent support during this endeavor. I would like to also acknowledge the help of Pine Rest Christian Hospital who allowed me to investigate a newly explored area of human behavior. To my family I owe a great deal. Their support, encouragement and belief in me eased the difficulties in my years of doctoral study. Thank you for being available to help me meet this goal. To my friends who have helped me in so many ways, I greatly appreciate that support. To Shannon, who has experienced most of her childhood watching her mother study for this doctorate, I have the utmost appreciation and respect. I am proud of your willingness to allow iii me to pursue non-traditional goals. I h0pe that I have provided a female role model for you in the pursuit of your own ambitions. Thank you, Shannon. iv TABLE OF CONTENTS LIST OF TABLES O O O O O O O 0 Chapter I. II. III. INTRODUCTION . . . . . . . Statement of the Problem Need for the Study . . Theory . . . . . Purposes of the Study Research Questions . Summary. . . . . REVIEW OF THE LITERATURE . . . Page General Research on Sexual Dysfunctions and Personality Patterns . . Psychiatric Problems and ISD--An Relations and Ego-Psychology Perspective . . . . . Histrionic Personality. . . Passive-Aggressive Personality Borderline Personality. . . Summary. . . . . . . . METHODOLOGY . . . . . . . Selection and Description of the Clinical Sample. . . . . Non-Clinical Sample . . . Measures . . . . . . . Object Sample Millon Clinical Multiaxial Inventory Reliability . . . . . . Validity . . . . . . . Sexual Desire Assessment Form. Reliability . . . . . . Validity . . . . . . Procedures for Collecting Data Hypotheses. . . . . . . Design . . . . . . . . viii Ohbbd Id 18 19 20 20 Chapter IV. Analysis . . . . . . Summary. . . . . . . ANALYSIS . . . . . . Results of Major Hypotheses . Results of Exploratory Hypotheses summary. O O O O O 0 SUMMARY AND CONCLUSIONS . Review of the Study. . . Conclusions . . . . . Major Hypotheses . . . Exploratory Hypotheses . Other Scales of the MCMI. Intercorrelation of the SDA Demographic Relationships F Differences in the Clinical and Non-Clinical Samples. Limitations . . . . . Sampling Limitations. . Page 106 112 113 113 126 142 143 143 149 149 159 159 161 163 164 167 168 Assumptions regarding of MCMI Scales 169 Measurement Limitations. Implications for Research and Therapy vi 169 175 APPENDICES A. B. C. LIST Sexual Desire Assessment Form Sexual Desire Assessment Form Information and Participation (Pilot Study) . . . . . Departmental Research Consent Sample) . . . . . . . Information and Participation Sample--Formal Study). . . Information and Participation (Non-Clinical Sample). . . Departmental Research Consent Clinical Sample) . . . . OF REFERENCES . . . . . vii Page (11 Items) 180 (8 Items). 184 Request Form . . . . 187 Form (Clinical 189 Form (Clinical . . . . 190 Request Form . . . . 192 Form (Non— . . . . 194 . . . . 195 Table 3.1 3.2 3.3 4.1 4.2 4.3 4.4 4.5 4.6 LIST OF TABLES Page Demographic Characteristics of Clinical, Non-Clinical and Total Subjects in Sample 80 Scales of the Millon Clinical Multiaxial Inventory . . . . . . . . . . . 82 Interitem Consistency of the Sexual Desire Assessment Form . . . . . . . . . 94 Correlation of Scores on the Millon Clinical Multiaxial Inventory Histrionic (4) Scale and Scores on the Sexual Desire Assessment Form 117 Correlation of Scores on the Millon Clinical Multiaxial Inventory Passive-Aggressive (8) Scale and Scores on the Sexual Desire Assessment Form . . . . . . . . . 118 Correlation of Scores on the Millon Clinical Multiaxial Inventory Borderline (C) Scale and Scores on the Sexual Desire Assessment Form 119 Multiple Regression Analysis of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72). . . . . . . 121 Simple Regression Analysis of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72) . . . . . . . . . . 123 Partial Correlation of Scores on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72). . . . . . . 125 viii Table 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 5.1 Page Correlation of the Schizoid (l), Avoidant (2), Dependent (3), Narcissistic (5), Anti- social (6), Conforming (7), Schizotypal (S), and Paranoid (P) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form. . . . . . . 128 Multiple Regression Analysis of Scales 1, 2, 3, 5, 6, 7, S and P of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72) . . 129 Correlation Matrix of each Item on the Sexual Desire Assessment Form (N=72) . . 131 Correlation of Age and Scores on the Sexual Desire Assessment Form. . . . . . . 133 Correlation of Years of Education and Scores on the Sexual Desire Assessment Form . . 134 t-test Mean Score Differences on all Items of the Sexual Desire Assessment Form in the Clinical (N=30) and Non-Clinical (N842) Samples. . . . . . . . . . . . 136 t-test Mean Score Differences on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory for the Clinical and Non-Clinical Sample. . . . . . . . 139 Differences in the Correlation Scores of the Histrionic (4), Passive-Aggressive (8) Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and Scores on the Sexual Desire Assessment Form. . . . . . . 141 t-test Mean Score Differences between the Clinical (N=30) and Non-Clinical (N842) Samples on the Scales 1-8, S, C and P of the Millon Clinical Multiaxial Inventory. 153 ix CHAPTER I INTRODUCTION Statement of the Problem In 1966, William Masters and Virginia Johnson published Human Sexual Response. It was followed in 1970 by Human Sexual Inadequacy from the same authors. These two books reflected two decades of research and study of the human sexual response in sexually functional and dysfunctional couples. Their research resulted in developing a four phase conceptual model of sexual response: excitement, plateau, orgasm and resolution. This model has had a major impact on the treatment of sexual problems in that it provided a short-term behavioral model for the treatment of sexual dysfunctions with greater success rates than previous long-term therapies. Since the early 1970's, numerous other strategies have emerged, but the Masters and Johnson short-term model continues to be the primary model for the short-term treatment of sexual dysfunctions. Masters and Johnson's initial work focused on problems in the excitement and orgasmic phase. The desire phase, which preceeds excitement, was not addressed with depth until several years later. In 1979, Kolodny, Masters and Johnson presented their observations on the diagnosis and treatment of inhibited sexual desire (ISD). Kaplan (1979) elaborated on these observations. Kaplan's expansion and work on ISD contributed to its addition to the DSM-III (Diagnostic and Statistical Manual for Mental Disorders, 1980). This diagnostic category, according to DSM-III, is described as the: Persistent and pervasive inhibition of sexual desire. The judgement of inhibition is made by the clinician, taking into account factors that affect sexual desire such as age, sex, health, intensity and frequency of sexual desire, and the context of the individual's life. ISD became an accepted diagnosis in the population of persons seeking therapy for sexual problems. The pepulation of persons with ISD has increased (Lief, 1977; LoPiccolo, 1980) to the point that it has been identified (Lief, 1977; Frank, Anderson and Rubenstein, 1978; and Kaplan, 1985), as the most prevalent of the sexual dysfunctions. LoPiccolo (1982) reports that 69% of the couples who seek treatment at the State University of New York at Stoney Brook include a diagnosis of low sexual desire in at least one spouse. Lief (1977) found ISD in 27.8% of the presenting clients at the Marriage Council of Philadelphia. The number is large and yet sex therapists have not achieved the success rate in their treatment of ISD clients as they have with other sexual dysfunctions. Kaplan (1979) writes that desire phase disorders are “a separate and more difficult syndrome to treat than other dysfunctions". Kaplan (1985) further goes on to state that ISD clients are likely to suffer from "more severe and complex psychological and relationship problems than those with psychogenic genital phase dysfunctions." Unfortunately, her statement on what the complex psychological and relationship problems are for the ISD population is global and vague. Instead of attempting to treat these clients with treatment plans that are not presently successful, a more effective approach needs to be planned. Therapists and researchers need to determine what some of these psychological and relationship problems are that Kaplan's statement refers to so that future treatment planning can take these variables into consideration. This is the direction of this study: To identify some of these psycholgocial variables which affect sexual desire. Need for the Study As cited earlier, the reported presence of ISD appears to be rising. Along with this increase, outcome studies reveal poor results in the treatment of ISD. Crown and D'Ardenne (1982) report difficulty in treating ISD. Their results, unfortunately, mix ISD with arousal problems, confusing any statement that might be made about the treatment of ISD. Mathews (1983) found that females complaining of low sexual interest respond “less well than those with other problems.” Mathews also notes that there may be subgroups within the population of low sexual interest that have not been adequately recognized. O'Connor & Stern (1972) found that 65% of their patients with sexual pathology had personality disorders. Kleegman (1975) found 85% of the females had neuroses. Derogatis (1981) found that women with psycho—sexual disorders presented with clinical symptoms of psychological disorders. Schmidt (1983) found 49% of sex therapy clients had a personality disorder. These studies cite relationships between psychological problems and sexual pathology. Unfortunately, these studies often group together numerous sexual dysfunctions without indicating the specific relationships between psychological variables and specific sexual dysfunctions. As Kaplan (1985) has pointed out, clients with sexual desire problems have more distinct and pervasive problems than clients with excitement and orgasmic sexual dysfunctions. An examination of the relationship of personality patterns and sexual desire may lead to information about the psychologoical profiles of desire disorder clients which can eventually aid in treatment effectiveness. The sex of a person has an impact on the etiologic factors of sexual dysfunction and the issues may vary from male to female. Braunchweig and Pain (1971) suggest that males and females have different developmental tasks and constraints. Therefore, to control for the variable of sex difference this study confined itself to investigating only females. Depression is another factor which can affect sexual functions. In depression studies, it is increasingly reported that libido is decreased (Arieti and Bemporad, 1978; Rosenthal, 1968; Feninchel, 1945; Val, Gaviria and Flaherty, 1982). Depression, in this study, may coexist with certain personality disorders. The abandonment depression that the borderline experiences when there are attempts at autonomy is an example of this coexistence. This study acknowledges the liklihood of a coexistence of depression with personality disorders. Factors which affect sexual desire may also lead to depression as well as depression leading to decreased libido. This study states that the depression of Axis-I in DSM-III may coexist with the personality disorders of Axis-II. The studies on sexual desire need to determine initially if, in fact, low sexual desire is correlated with personality patterns. After this is determined, then a move to separate out the depression variable may prove necessary. The state of the present research does not allow for this separation at this time. Why are certain personality patterns likely to be related to ISD symptoms? The following section will briefly discuss this with a more thorough investigation in Chapter II. Theory A theoretical review of the concept of sexual desire and desire phase disorders will be presented. This review will include the criteria for the determination of ISD symptoms. In addition, a discussion of object relations, ego and sexual development will follow. A beginning discussion on problems in object relations and ego development will conclude this section. As mentioned earlier, the model of ISD did not develop with the initial research of sexual dys- functions. Masters and Johnson (1966) introduced the human sexual response cycle with four phases: excitement, plateau, orgasm, and resolution. Their model did not include a pre-excitement phase. This preexcitement phase is important to examine, for unless there is a readiness for sexual activity, a psychic state (i.e., sexual desire), then it is unlikely that excitement will follow. Sexual desire, also called libido, is defined as the desire to have sex (Mathews, 1983). Levine (1984) proposes that the most critical factor in sexual desire is psychological motivation. Kaplan (1979) included the desire phase when she introduced an expanded model of Masters and Johnson's human sexual response cycle. Kaplan's model is triphasic, with desire, excitement and orgasm as the three components of the sexual response. She sees the desire phase as being an experience of specific sensations which moves a person to act out or be receptive to sexual experience. Inhibited sexual desire, in which the psychological motivation for sexual activity is not present, is defined as a minimal or lack of interest in sexual activity (Stuart, Hammond and Pett, 1986). Kolodny, Masters and Johnson (1979) define it as a state of low sexual receptivity and initiatory sexual behavior. Schover et a1., (1982) assesses sexual desire based on: 1. Client's frequency of masturbation. 2. Activity with partner. 3. Self-reported desire for spouse and other partners. 4. Frequency of fantasy. 5. Erotic dreams. 6. Seeking out erotic stimuli. These varieties of behaviors point to the multifaceted components of sexual desire. For purposes of this study, sexual desire is examined in relation to: l. Frequency--sexual activity, including intercourse, and client initiation and response to partner initiation to sexual activity. 2. Level of satisfaction--satisfaction of the client regarding the sexual relationship. 3. Subjective experience--the client's interest and/or involvement in sexual fantasy, erotic material, masturbation and feeling sexual desire. Sexual desire does not appear to be a dichotomous variable but instead lies on a continuum with a relative range from low to high sexual desire. Therefore, this study did not determine the absence or presence of ISD, but looked at that continuum. It examined the relationship of a continuum of sexual desire activities, interests and experiences. The assumption is that a low frequency of sexual activity, interest and experiences would reflect inhibited sexual desire. The causes of ISD have been hypothesized by several authors. Kaplan (1979) views problems of inhibition in the desire phase as "caused by an involuntary and unconscious but active suppression of sexual desire." Golden (1985) sees the causes as ranging from profound neurotic processes to simple perfomance anxiety. Lief (1985) examines ISD from a problematic relationship persective. Husted and Edwards (1976) found extroversion and defensiveness correlated with the quality and quantity of sexual behavior, though sexual desire was not the specific focus of their study. The reason that a person may suppress their sexual desire is that a close sexual relationship requires abilities and skills that the person develop- mentally may not have achieved. 'At no other time in the life of a couple do they confront themselves and each other in a more vulnerable way than when they are engaged in sexual pleasuring' (Talmadge and Talmadge, 1986). 10 Scharff (1982) writes that this experience provides an unconscious, symbolic 'reawakening of early child-parent interactions and all that they were and all that they were not." The unconscious symbolic reawakenings elicited in the sexual relations can be explained by a discussion of object relations and ego-psychology theory. It appears that problems in one's object relations and their ego skills can be an etiologic factor in ISD. Following will be a brief review of object relations and ego psychology theory. Chapter II will focus on the specific problems in object relations and ego development which occur in persons with low sexual desire. Object relations theory is a theory of unconscious intrapersonal (internal) object relations in dynamic interplay with current interpersonal experiences" (Ogden, 1983). Ogden further goes on to say that the internal relationship is shaped by the original object relationship. The unconscious early child-parent relations provoke the development of mental representations, (i.e., object relations) based on early experiences with primary caretakers. Fairburn (1963) states that a child internalizes the object as a defensive measure against unsatisfying experiences with the mother and that 11 the exciting and frustrating aspects of those experiences are repressed. These repressions against feared and wished for relationships later distort actual relationships. The individual is not responding to an external object, in its reality, but instead is responding to the external object based on the internal object. This inner object attempts to coerce people (the external object) into the role of that inner object. The individual is trying to change the external object into a preconceived object which may or may not be based on reality, a process Ogden (1983) calls I'interpersonal externalization (actualization) of an internal object relationship." The structures of the self and object are active in the sexual interaction of a couple when the person acts as if he/she is relating to primary persons in the past. These primary persons create a mental template for the development of the basic structure of a person's character (Ryan a Bell, 1984) and of the interaction of that indivudal's template with his/her external (real and imagined) persons (Greenberg and Mitchell, 1983). Healthy maturity, according to object relations theorists (Greenburg and Mitchell, 1983: Fairburn, 1941), is the capacity for intimate mutuality and one medium for this expression is in 12 genital functioning. Fairburn argues that intimacy must preceed the sexual expression. The development of the capacity for intimacy is mature when the child renounces both dependency on the parents with full differentation of the self along with a capability of mutual relatedness in the world. The child must also relinquish internal objects which provide security for those parts missing in the relationship with the parents. With development, this relinquishment can only occur if the child is assured that new, richer relations will occur (Greenburg and Mitchell, 1983). This sureness is dependent on the gratifying experiences which create the mental template that the world is satisfying and safe. Freud (1905) noted that sexual excitation arises as a "reproduction of satisfaction experienced in connection with other organic processes as well as through direct stimulation of organic zones.“ This stimulation of all body zones and the eventual sexual development of a child occurs in the larger context of the relationship with the mother and the family (Shariff, 1982). It begins with the physical contact of the infant with the mother. A climate is created in which the child has the chance to learn early how to care for and pleasure him/herself. Shifts from one organ 13 zone to another are due to physical maturation and cognitive changes. As the child develops the relationship with the primary caregivers, the resultant object relations development have an impact on and are affected by the ego development of the child. The love, responsiveness to needs, and quality of one's internalized images of significant persons consolidate in the child a feeling of regard toward self and others. This image and the feelings associated with it not only serve as a model for future relationships (Mackey, 1985), but also affects how the child develops certain autonomous functions. Thus, the autonomous functions, called ego functions, are affected by early object relations. It is the early object relations that provide the person with skills which allow him/her to gain increased independence from the environment and to be able to master components of the environment (Blanck and Blanck, 1974). This autonomy is achieved through ego develop- ment, the ego being the chief mediator between the person and the external world. The ego includes: 1. A defensive system—-provides for the inhibition and censoring of primary processes which protect the ego from perceived thoughts. This is unconsciously acquired through identification with introjections of others. 14 2. An executive system--provides for the process of cognitive mastery, the ability for empathy, ego-capacities, reality testing and the development of future relationships. 3. An adaptive system--provides for the constructive attempts to accomodate to reality in a manner that allows for adjustment to the environment and provides changes in the environment so that it will support the person's well-being (Mackey, 1985). Goldstein (1985) describes the specific ego functions as: 1. Functions related to reality. . Impulse control. Thought processes. Interpersonal relations. Representational images. 0‘ U1 I“ w N o . Defense mechanisms. These functions, as described by the ego psychologists, are the organizing processes of the person and allow for environmental adaption. These ego functions, in turn, affect object relations (Hartmann, 1964). The development is, therefore, circular for both object relations and ego functioning apparatuses. This circular development can be impaired. There may be (a) ego deficits due to constitutional 15 factors, (b) ego deviations which are early departures from normal development, (c) ego distortions due to faulty internalizations of self and object representations, and (d) ego regressions, regressive movements to a lower developmental level of ego functioning (Blanck and Blanck, 1974). These ego developmental problems have an impact on the interpersonal functioning for they limit the deve10pment of mature object relations. Mature object relations allow the interaction in the relationship between one's ego and the object to be appropriate and not to be affected adversely by unfinished deficient aspects of previous relationships (Mackey, 1985). Object relations are not the only factor having an impact on ego functions but their impact is significant in ego development. When object relations are experienced as excessively deprived, frustrated or gratified, then ego development becomes distorted or regressed. This results in limited ego functioning which, in turn, leads to defenses which can limit further ego development, at least, and weaken preceeding ego functioning, at best (Shapiro, 1978). Deprived object relations can lead to ego stagnation and/or regression which then prevents the integration of experiences with healthier 16 objects. This inability to integrate experiences with healthy objects then prevents change in object relations which could lead to the development of higher ego processes. One can easily see the cycle, begun by deficient objects leading to limited ego functioning, has self-perpetuating components. These inadequate object relations and deficiencies in the ability to be intimate create conflicts about dependency, identity issues, power struggles, anxiety, destructive defenses and an inability to trust and tolerate vulnerability. The above-listed deficiencies appear in persons with personality patterns who are experiencing problems in interpersonal relationships. Personality patterns are expressed in the way a person relates to others and attempts to cope with and master his/her world. These patterns exist on a continuum from normalacy to severe pathology. The forces which create normalacy are the same ones which create deviations from health (Millon, 1981). These deviations can be minor or more severe with the more severe patterns having certain characteristics. According to Millon (1981), on whose measure of psychopathology this study is based, the more pathologic personality is described as having these characteristics: 1. Adaptive inflexibility--the use of 17 alternative styles for goal attainment and c0ping with stress are minimal and the styles present are rigid. 2. Vicious circles--the pathologic personality's rigid style perpetuates and intensifies problems and limits the ability for new learning. 3. Tenuous stability--fragility under stress so that conflicts and failures create a loss of emotional control leading ultimately to distortions of reality (Millon, 1981). The specific ego deficits of each of Millon's behavioral characteristics will be discussed in Chapter II. These ego deficits will be examined in relation to their interference with the development of sexual intimacy in persons whose personality patterns hover near the pathologic end of the personality continuum. To summarize, this study was based on the assumption that the present state of knowledge about persons with ISD is limited. It is assumed that ISD may reflect more pervasive psychological problems than do other sexual dysfunctions. The previous section has pointed out that ISD clients are not responding to the traditional behavioral approaches. The reasons for this are still questionable at this time. This study examined 18 personality patterns which were possibly related to low sexual desire. With this knowledge of the relationship of personality patterns and low sexual desire, more effective therapeutic approaches can be developed. Purpose of the Study The purpose of this study was to determine the relationship of personality patterns, as measured on the Millon Clinical Multiaxial Inventory (MCMI), in women, presently in a relationship, who are experiencing low sexual desire. Specifically, the purpose of this study was to test hypotheses that assert certain personality patterns are related to sexual desire. This purpose has lead to the following research questions. Research‘guestions 1. Is there a relationship between reported symptoms of low sexual desire and certain personality patterns? 2. Is there a relationship between reported symptoms of low sexual desire and the histrionic personality pattern? 3. Is there a relationship between reported symptoms of low sexual desire and the passive- aggressive personality pattern? 4. Is there a relationship between reported —fi—-—* 19 symptoms of low sexual desire and the borderline personality pattern? 5. Is there a difference between reported symptoms of low sexual desire in a client inpatient sample versus a non-clinical sample? Summary This chapter introduced the necessity of determining personaltiy patterns which correlate with sexual desire. Chapter II will review the literature on sexual desire and present the theoretical model of the research questions in this study. CHAPTER II REVIEW OF THE LITERATURE A literature review reveals a very small number of research studies which examine a relationship between personality dynamics and sexual dysfunctions. There appears to be little actual reseach on females' sexual desire though there are articles theorizing the etiologic issues. This chapter will be a sequential examination and discussion of: 1. General research on sexual dysfunction related to psychiatric problems. 2. Psychiatric problems and ISD from an object-relations and ego-psychologic perspective. 3. The histrionic personality pattern as it relates to sexual desire. 4. The passive-aggressive personality pattern as it relates to sexual desire. 5. The borderline personality pattern as it relates to sexual desire. General Research gn_Sexua1 Dysfunctions and Personality Patterns Since the identification and treatment of 20 21 sexual dysfunction has begun, there have been arguments citing the presence and absence of psychological problems in persons presenting with sexual problems. Masters and Johnson (1970) describe their patients as being asymptomatic of psychological problems. Faulk (1973), in his review of the literature, concluded no relationship between sexual dysfunction and neurosis. Cooper (1968, 1969) studied males with sexual problems and found them relatively free of neurotic conditions. Maurice and George (1970), and Lazarus (1972) confirmed these findings. Stuart (1986) found no significant differences between ISD and non-ISD females on the ten clinical scales of the MMPI. Other researchers have identified the presence of psychological problems in persons with sexual problems. Derogatis (1979, 1981) found these persons having a distinct psychological profile, different from those without sexual problems. Kleegman (1971) found neurosis in 85% of females who were experiencing sexual dysfunction. O'Connor and Stern (1972) identified character- 1ogical and neurotic disorders in their study. Levay and Rage (1977) cite deficiencies in the area of pleasure, intimacy and cooperation in many of their sex therapy clients. 22 Studies now show early experiences with parents and later sexual adaption are correlated (Terman, 1951; Fisher, 1973). Fisher's studies found the father-daughter relationship as the variable affecting women's orgasms. He theorized that the perceived emotionally absent father causes the female to assume that her loved ones are not dependable and predictable and she then becomes chronically preoccupied with separation issues and is unable to tolerate the "letting go" during orgasm. Dunbar's (1954) and Rheingold's (1964) findings indicate that the etiology of sexual dysfunction lies in the disturbed mother-daughter relationship. Uddenberg (1974) found that mothers of women with sexual dissatisfaction and low orgasmic consistency displayed a more negative attitude toward their daughters than mothers of sexually adjusted females. These latter studies indicate that early relationships do have an impact on later sexual function and satisfaction. One of the problems in the literature is that women with sexual dysfunction are often grouped together despite the phase of the sexual problem. Arousal is often confused with desire and orgasm confused with satisfaction. Jayne's (1981) review of the literature does separate the orgasm and 23 satisfaction state into a two-dimensional model but she does not speak to the desire phase. The literature appears to reflect a deficit of investigations into sexual desire, especially in the realm of personality patterns. As Derogatis (1981) suggests, sexual disorders appear to lie on a continuum with minor conflict and conditioning problems on one end ranging to severe characterlogical disturbances on the other end. According to Kaplan (1983), persons with ISD have the tendency to lie at the more disturbed end of the continuum. This study examined the continuum and investigated whether some clients who reported low sexual desire did actually lie toward the more disturbed end of the continuum, as Kaplan and others assert. Clients with low sexual desire may be examined from an object relations framework, for it is in the sexual object relations where the client experiences the problem. Psychiatric Problems and ISD--An Object-Relations and Ego-Psychology Perspective As discussed in Chapter I, object relations and ego psychology are intertwined and both provide the organizing force behind character development (Blanck and Blanck, 1979). A review of these 24 problems which may contribute to symtoms of low sexual desire in personality disorders will be examined. Sexual activity is a physical interaction; a link between a person and his/her internalized object. It has the symbolic ability to recall an internal sense of being; the good and the bad. In order to engage in the intimacy of sexual activity, a healthy ego must be able to abandon itself (Hartmann, 1964). Hartmann further points out that the inability to engage in this abandonment is because the underlying ego functions have not achieved a sufficient degree of stability that allows for flexibility. Anxiety about the abandonment of the self is experienced by the individual without a healthy ego. When anxiety is allied to sexual functioning, especially pleasure and intimacy, it is defended against by hostility, avoidance and suppression of arousal (Hartmann, 1964). Desire also appears to be suppressed. Sexual activity is largely a nonverbal route of communication and it has important links to preverbal childhood experience of nurturance and reassurance. The opportunity for a person to explore these problems in the relationship may be minimal due to the nonverbalized component of the experiences and the anxiety these experiences elicited. 25 The question, pertinent to this study is what object-relations problems and ego-psychological deficits will be correlated with the development of low sexual desire in females? Fairburn (1954) writes that object relationship development is “a process whereby infantile dependence upon the object gradually gives place to mature dependence upon the object.” This change occurs when the original incorporating and taking aim is replaced by a mature, non- incorporating and predominantly giving aim (Fairburn, 1954). If a child feels that he/she is loved by the parents and that this love is accepted, then there is renouncement of infantile dependence with the assumption that he/she can depend safely on real objects. Fairburn states that without this renouncement of infantile dependence, there is anxiety over separation from the objects and the individual may forfeit all hOpe of obtaining satisfaction of needs. When the lack of hope is internalized, relationships are frustrating. Fairburn writes that these individuals' sexual relationships are problematic. Giovacchini (1984) notes that object relationships both gratify needs and help develop mastery techniques which lead to further gratification. Experiences with objects are 26 introjected and determine how well a child adapts. Disruptive objects, according to Glover (1930), may lead to faulty ego-structured development and the establishment of introjects that will impede the ego from acquiring satisfying, efficient and adaptive techniques. The implications of this are that the individual will be deficient in ego differentation which prevents gratification from others and thus is unable to utilize experiences in his/her world (Giovacchini, 1984). Mackey (1985) focuses on the identification process which begins with the primary caretakers who help the child develop a sense of trust and satisfaction in their association with others. Eventually the identification leads to further ego development in which the ego develops the capacity to accomodate to the environment. Without this type of contact with familiar figures, expansion to other figures does not occur in deve10pment and the person is unable to accomodate to the environment. As one recognizes the interdependent relation- ship between object relations and ego-psychological development, there is a recognition of how exces— sive frustrations can lead to a lack of development in mastery skills in an individual. Millon (1981) points out that personality pathology is noted by deficits in (a) the ability to function 27 autonomously; (b) effective and efficient adjust- ment to one's environment; (c) an inner sense of satisfaction; and (d) an ability to fulfill one's potential. These are ego deficits with an etiologic base in the faulty internalized and introjected object relations. In Chapter I, Millon's (1981) characteristics of personality disorders and Goldstein's (1985) list of ego functions were presented. A comparison between Millon's personality characters and Goldstein's ego functions will show how Millon is discussing ego deficits. Millon first asserts that the person with personality pathology has difficulty in adaptive flexibility with skills being limited in number and rigid in style. This individual is unable to adapt and make the appropriate changes. Rigidity ultimately narrows his/her world and speaks to a deficit in one of the basic ego functions; adaption to reality. Reality adaptation includes the ability to differentiate ego boundaries and determine where one's self and object differentiate. In the person with pathology, this inability limits the opportunity to enter into an intimate relationship where ego boundaries are constantly threatened with fusion. The person's response may be to either fuse with the other person, in the more severe 28 pathology, (Masterson, 1976), or to avoid the threat. Either of these methods limit the adaptive learning necessary in a relationship which requires reestablishment of boundaries (Talmadge and Talmadge, 1986). The tenuous instability, that Millon (1981) discusses, is a lack of durability under stress. Faced with failures and problems, there appears to be less control over emotions. Goldstein (1985) states that impulse control is the ability to cope with instinctual drives without symptom formation and regression. The frustration tolerance, which measures the quantity of toleration for additional anxiety,, is limited when anxiety and conflict are experienced. The discharge of impulses may be ego—dystonic or ego-syntonic (Kernberg, 1975) dependent on the severity of the pathology. Shapiro (1965) describes impulse control problems as an insufficiency in the integrative process due to the person's inability to gain stability from consistent aims and interests. Lacking in deep and consistent interests, goals and values, other than ones which meet their immediate gratification, persons with impulse control problems also lack depth and perserverance in their interpersonal relationships. Their tendency and ability to 29 sustain deep friendships or love are not evident. (Shapiro, 1965). Impulse control problems lead the person to act on the anxiety experience in a non-modulated style, without consideration of the long-term consequences. These episodes may be expressed through explosive rage, addictive behaviors, unplanned communication and unconsidered direct interaction with others (Shapiro, 1965). This style of expressing one's conflicts, along with an inability to develOp a deep and consistent relationship, limits the willingness of the person or his/her partner to share the vulnerability in a Sexual relationship. The provocation of impulsively expressed anxiety is based on early relationships which prevented the expansion of safety and trust to future relationships. Impulse control problems are also evident in the inability to talk about the internal experiences with there being, instead, an anxious desire to act on it. Millon (1981) discusses the development of verbal skills, with symbolization of objects, being a necessary process to the coordination and manipulation of the environment to gratify one's needs. The ability to recall the past and anticipate the future requires a delay in actions. A delay allows one to sacrifice 30 short-term gratification for longer-term gratification. In a sexual relationship, the ability to tolerate the anxiety of shared closeness is a short-term gratification delay in order to experience the longer-term gratification of sexual intimacy. Delay requires the frustration of one's initial desire to escape shared closeness which may be anxiety producing. The individual with low sexual desire repeatedly responds to acting on the initial anxiety of closeness and avoids, denies, withdraws or represses the desire for the long-term gratification of sexual intimacy. Millon (1981) speaks to the ”vicious circles" that the person with pathology enters and maintains. He views these circles as behavior patterns which "perpetuate and intensify preexisting difficulties“ (Millon, 1981). Anxiety is produced and immediately the person engages in activities to decrease the anxiety. These activities are patterns of behavior which shape and distort current experiences. Distortions constrict the person's world view and perpetuate the previous distortion. The anxiety and defenses it mobilizes also leads to cognitive distortion and inappropriate overt behaviors, both based on a misperception of actual events. These distortions and behaviors are likely to evoke responses which 31 reactivate early unresolved issues. This can lead to the ego developing an autonomy of its own, at times, independent of the other structures and a generalized form of problematic functioning prevails (Shapiro, 1965). Hartmann (1958) sees this form of functioning as being caused by the early internalization process which eventually creates disturbances in relation to reality. Reality testing, according to Mackey (1985), occurs when there is a congruence between a person's perception, evaluation and judgement and the actual properties of the external world. What an individual has internalized will influence the final outcome of perceptions and evaluations. These outcomes are the responses the person makes internally and externally. As Hartmann (1958) points out clearly, it is often difficult to determine exactly how realistic certain actions are but he does write that they are realistic when the actions are chosen according to goals both “subjectively and objectively reality syntonic.” Yet the question asked is, why do persons with psychopathology engage in these vicious circles? Hartmann (1958) asserts that they develop automatisms as adaptive mechanisms. These rigid apparatuses perpetuate something that was once pleasurable. The individual fails now to see how 32 conditions have changed and what is perpetuated is no longer pleasurable nor functional. The ego becomes an interlock of the early conflict and the learned adaptive response without the freedom of altering that adaptive response based on new information. This lack of freedom is based on the insecure and inadequate ego which becomes threatened by alternative responses. Conflict is provoked and confusion, helplessness, indecision and ineffectiveness prevail (Ausubel and Kirk, 1977) with the result that the examination and engagement of alternative and more effective solutions is deficient. The ego's apparatus cannot draw from memory the necessary requirements for the realistic situation (Giovacchini, 1984). The question which arises is how does this effect the intimacy necessary for a sexual experience and specifically how does it interfere with the sexual desire? According to Fairburn (1954), a person with psychopathology is constantly seeking a satisfying object yet their internalized objects have been distorted so that they expect the object to act in the same way as early frustrating objects. This expectation may either be distorted through projective identification or may actually induce the object (partner) to act in similar ways to the frustrating object. These interactions 33 result in competition, distancing or incessant anger (Levay and Kagle, 1978). The resultant lack of trust and cooperation is unlikely to create an atmosphere where there is a willingness to share vulnerability and express one's needs and fantasies. Talmadge and Talmadge (1986) state that intimate relations begin at a level where each partner regresses to the state where there is a fantasy for the ever available caretaker. There is an awareness, eventually, that the fantasy will not be realized and the couple becomes disillusioned. The person then engages in adaptive or maladaptive responses to deal with this reality. If the person's ego development has progressed to the level where intimacy is possible, then renegotiation occurs. The renegotiation requires reality awareness, impulse control, the ability to assimilate information and influence reality (Hartmann, 1958), and sublimation. These skills, which are similar to Goldstein's (1985) ego functions, are lacking in those persons with pathology who have been exposed to repeated threats and frustrations. The fantasy of the omnipotent object is replaced with a fantasy that problems are not solvable and one must either avoid them or react to them before reality tests them out (Millon, 1981). The behavior becomes inflexible 34 and the renegotiation for a separate, yet close, intimate relationship fails. Instead, anger at the frustration of the fantasy prevails. Individual and couples with this anger may experience impairment in libido (Kolodny, Masters, and Johnson, 1979). As discussed earlier, personality patterns which are less flexible in their ability to cope with internal and external objects in the environment are believed to have more problems in their interpersonal relationships. Millon (1981) has developed a paradigm of personality styles dependent on their caping styles. This paradigm is a four—by-two matrix. The theoretical model examines the reinforcements a person seeks, whom they seek it from (self or object), and what activities are pursued to achieve these goals. This model is the theoretical basis of the Millon Clinical Multiaxial Inventory (MCMI) and investigates and hypothesizes the strategies that persons with personality disorders use to cope. 35 Passive Active Detached Schizoid Avoidant Dependent Dependent Histrionic Independent Narcissistic Antisoical Ambivalent Compulsive Passive-Aggressive Millon's model includes eight of the major personality disorders from the DSM-III in which he was involved with during its development. In addition, Millon adds the more severe personality disorders of borderline, paranoid and schizotypal (which do not appear in the paradigm). He separates these latter three on the premise that 36 their ineffective attempts to mobilize defenses may lead to psychosis and severe distortions of reality due to greater developmental deficiencies. Returning to the model, the affect towards others (detached, dependent, independent and ambivalent) may be a response to Loewald's (1973) question on how psychic structure functions. Loewald asserts that the ego engages in defenses “against forces that would disrupt it but in doing so, runs the risk of limiting its domain." The affect towards others may limit the development of object relations. Asubel and Kirk (1977) would label the styles of coping with objects as being caused by developmental anxiety from personality deficits arising during ego development. The anxiety elicited is due to an attack on the person's sense of adequacy and competence as a self in relation to the object. Asubel and Kirk claim that adequacy is threatened when one's safety and security is jeopardized. Talmadge and Talmadge (1986) assert that an intimate sexual relationship provides constant threats to the self and the fantasies that one developed in early relationships and now transfers to the present relationship. The person no longer feels qualified to cOpe with the adjustive problems (in this instance, in the sexual relationship) and anxiety is provoked. The 37 anxiety, due to the perceived threat of intimacy, mobilizes the defenses. Based on the inter- nalization of the object relations and their expectations, and a lack of security the person's sense of adequacy may be readily threatened, thus causing the engagement of defenses too early to allow new internalizations to take place. The pattern then becomes repeated. Insecurity promotes a self perception of inadequacy, leading to anxiety and eventual defense. These defenses include: 1. Direct means of ego enhancement-~the active pursuit of prestige, indifference to social convention, aggressive attack of others, destructive tendencies or the obtaining of a substitute gratification (these defenses are seen in narcissistic and antisocial personality patterns). 2. Conciliatory forms of defense--the engagement of sympathy and tolerance, focus on one's own helplessness, repression of hostility, exaggerated conformity and an abandonment of one's own identity (seen in obsessive-compulsive, dependent, histrionic and borderline personality patterns). 3. Indirect and devious defenses--the rationalization and displacement of anxiety through somatization, depersonalization, displacement, regression, reliance on compulsive behavior, 38 ambivalence, inflexibility and distortment of the environment (seen in the obsessive-compulsive, histrionic, passive-agressive, borderline, schizoid, schizotypal and paranoid personality patterns). 4. Escape mechanisms--avoidance, repression, self-insulation, substance abuse and self- frustration (seen in the histrionic, avoidant, schizoid, borderline and narcissistic personality patterns) (Asubel and Kirk, 1977). All of these defenses limit one's abiliity to seek and share the self with a partner; a requirement of intimacy. The defenses in the person with psychopathology are means to either engage in a fused, symbiotic relationship (on a continuum), (Mackey, 1985), or to act on the assumption that intimacy is either not possible or must be obtained through manipulative, controlling behavior. Returning to Millon's model of psychopathology, persons with personality disorders are limited in their ability to be independent of the external object. There are problems obtaining and maintaining an optimal independence. Mahler (1963, 1977), a pioneer in the examination of the child's separation-individuation phase, views the mastery of this phase as essential to optimal 39 autonomy from the object. During this phase, autonomous achievements from the mother are the main source of narcissistic enhancement while, at the same time, the child is likely to experience separation anxiety about his/her autonomy. If the mother is emotionally available and accepting of the child's ambivalence towards separation, the child overcomes the anxiety and “is able to cathect his self-representation with neutralized energy" (Mahler, 1968). Elation occurs within the child as he/she begins to experience autonomy at new-found skills and to develop a sense of self-valuation. This self-valuation is vulnerable for it is dependent, during this phase, on the sense of magical omnipotence. Omnipotence contributes to a sense of self-worth and a belief in one's sense of capability and mastery in handling the environment (Blanck and Blanck, 1979). Since mastery is limited and the omnipotence is not based on reality, the child needs the reality of the mother in reasonable amounts. There is a shift from primary dependence on the mother-child dyad for appropriate narcissistic supplies to a greater realistic reliance on the self. The admired qualities of the primary caretaker are internalized and the interpersonal interaction begins to be replaced by the intrapersonal interaction. With 40 these changes, the self is evaluated realistically and self-love is combined with object-love (Jacobson, 1964). The object love grows into an interdependence between the self and the object. When there are significant interferences with this phase of development, the ability of the person to depend on another person apprOpriately, along with self-reliance for functioning, is limited. The person may idealize others in order to gain the protection perceived as necessary to survive. This could be evident in his/her fantasies to be taken care of and to be the omnipotent person one was not allowed to be during the separation-individuation phase. In contrast, there may be a withdrawal or contempt for others with a chronic devaluation of objects or a need to control and manipulate the object in order to fulfill the grandiose and omnipotent needs of the self. Since it is unlikely that any intimate relationship will provide for these needs, the individual becomes frustrated. As a result, the person attempts to distort reality or alter the partner ,to fulfill these dependent or grandiose needs. This attempt is apt to be either clinging or manipulative. The person may also withdraw from further attempts with that partner and reach out to others, only to be frustrated repeatedly. The 41 sexual expression that is attempted is not based on a mature interdependence (Talmadge and Talmadge, 1986) but on a demanding neediness to depend. These expressions of interactions with the object are manifested in the detached, dependent, independent or ambivalent ways of interacting with the objects. Meyers (1983) notes that the incorporation of preoedipal or oedipal psychopathology leads to impairment of sexuality. This impairment can result in sexual dissatisfaction or dysfunction. He views sexual symptoms as a means of avoiding intimacy. As Scharff (1982) points out, there may not be an exact link between the specific early experiences and the sexual problem. A specific theory does not, as yet, exist. Yet he argues that object-relation theory does contribute to an understanding on how the individual has interpreted his/her experience which may contribute to sexual problems. The state of the research, at this time, is not ready to prove specific links but to correlate personality patterns and sexual dysfunction symptoms based on the present level of knowledge. With object relations and ego pathology as a theoretical foundation, an examination of three specific personality patterns and their relationship with sexual dysfunctions will follow. 42 These three are (a) histrionic, (b) passive- aggressive and (c) borderline personality patterns. The histrionic will be the first pattern to be examined in its relationship with sexual dysfunction. Histrionic Personality The concept of hysteria goes back to early history in mankind. One of the oldest diagnostic categories, Abraham (1924), viewed repressed sexual wishes in the oedipal triangle with a fixation of the early genital experience as the cause of histrionic symptoms. Recent authors have viewed the histrionic traits as being on a continuum with the potential for preoedipal conflicts playing a greater role in the dynamics of the histrionic (Horowitz, 1977). Criteria for the histrionic were developed for the DSM—III and include the following: 1. Persistent attention-seeking--seduction and childish exhibition are a means to obtain approval. 2. Interpersonal demanding--manipulate others to get their way. 3. Overly reacting and intensely expressed affect--dramatic, superficial and short-lived emotion are expressed with rapid excitement and boredom. 43 4. Socially gregarious--pursues and attracts fleeting acquaintances. 5. Immature stimulus-seeking--impulsive activity to obtain momentary excitement and short-term hedonism. The clinical picture that one is apt to see with a histrionic will vary somewhat with the depth of pathology. Certain patterns of behavior, though, can be anticipated. One is initially struck with her flair for the dramatic, charming and attention-seeking behaviors. (Feminine pronouns will be used in this study, when apprOpriate, because all of the subjects are female). She is constantly seeking attention and approval and seems, at times, to be insatiable. Cooperation and social acceptance are primary motives. Freud (1932) saw the motive controlling the histrionic behavior as a “dread of loss of love." Leary (1957) labels the histrionic as an overconventional personality with external values governing her interactions. Krohn (1978) views her as seeking approval and provoking emotional reactions from others. There appears to be a marked attempt, on the histrionic's part, to manipulate, demand and exaggerate in order to get others to meet her needs (Kraeplin, 1964,; Millon, 1981). Seductiveness, sexual and nonsexual, 44 appears to be the interacting style in her development of relationships with others. This seductive controlling behavior is viewed by Mueller and Aniskiewicz (1986), as being due to past experiences of being controlled. Seductive- ness is a means to structure the interpersonal situation so that the histrionic can manipulate the responses of others in a manner which assures their continued interest and attention (Halleck, 1967). Sexual symbolism is often offered in the seduction with a provocativeness that erotocizes nonsexual situations. This apparent oedipal acting out may be a cover for a deeper wish to be loved and protected. Her apparent fantasy for sexual gratification is, in reality, a search for nurturance (Mueller and Aniskiewicz, 1986). Brenman (1985) writes that the histrionic uses the external object as a narcissistic relationship to prevent breakdown. Her pretense of being loving is not to achieve a deep and committed relationship but to instead be the falsely adored object of love. Brenman views her as despising and annihilating the object. This fits in with theories of the histrionic being covertly hostile toward males who are identified with the father. Brenman continues that the histrionic shows no real introjective identification of mutual sharing. 45 Instead, identifications are with fantasy objects with minimal understanding of the object. This minimal understanding of the object leads to a greedy dependency. The aim of the dependency is to change the picture of what the self and the object are and to deny the truth. Identification is shallow and the fantasy is not with a real object. The fantasy is, instead, with an infantile narcissistic love of the omnipotent false self. This false self has no real supporting objects and the introjected objects are perceived as harsh and persecutory. The harsh internalized objects result in feelings of inadequacy expressed by sexual conflicts (Giovacchini, 1984). The sexual conflict rests with the feeling of inadequacy and the incestuous wishes. Incestuous wishes represent an attempt to make a contact with the object, to elicit the object's love and to prove one's own love is acceptable. The lack of resolution of the incestuous wishes leads to a belief, in the histrionic, that her own love is bad. (Fairburn, 1954). This belief prevents the histrionic from being able to give and/or receive love in significant relationships. The incestuous wishes also threaten the capacity for sexual love by prohibitions directed against oedipal genital 46 impulses and the deeper aggressive impulses (Kernberg, 1977). The cognitive style of the histrionic has been discussed by Shapiro (1965). Impressionistic is the term Shapiro uses to describe these persons who respond quickly to input with little time spent on reflection. A weak differentation of self and the enviornment produces a global style of thinking. Berbilinger (1960) notes the vagueness and lack of precision in their communication. Mueller and Aniskiewicz (1986) use the term insubstaniality to describe the lack of depth in their thinking and affect. These writers relate it to the histrionic's feelings of dependency on others which has cost her the development of her own sense of potence, power and self-fulfillment. Insubstan- tiality is also viewed as a way to deny the intensity of affect provoked by these feelings of dependency. This global and insubstantial style may lead to weakened ego boundaries where the Opinions and feelings of others are easily merged with the histrionic's own thoughts. The potential merging is frightening to the histrionic and provokes anger at the other person she perceives as controlling her. Anger leads to defenses of avoidance, repression and boredom in the relationship. 47 This cognitive style seems to have two major consequences. First, it limits the ability of the histrionic to gain factual knowledge from her interactions with others and to learn from them. Curiosity is not a motivating factor and the satisfaction with the obvious makes the histrionic unlikely to probe the dynamics of the relationship to identify her own or partner's needs, values and fantasies. Data is not well organized so its availablity to the histrionic for future problem- solving is limited (Shapiro, 1965). This difficulty with problem-solving leads to problems in the sexual relationship. When not sexually interested, the histrionic is not likely to contemplate etiologic factors so that greater insight and apprOpriate behavior changes occur. Instead, suppression and repression occur with little opportunity for changes. With these defenses, the histrionic is unlikely to note the etiology of her affect or tension or why sexual sensations are uncomfortable. A failure to note the sensations diminishes her ability to note conscious sexual sensations and to act on these sensations. Instead, there is a vague sense of tension which is experienced as discomfort. Eventually, on an unaware level, the histrionic unconsciously relates this tension to sexual 48 sensations experienced prematurely in childhood when the oedipal triangle associated danger with the sensations (Kernberg, 1977). Therefore, the sensations are related to danger, competition with mother and submissiveness to father. All of these affects decrease the activation of the libido. The second consequence of this global style of cognition is the inability to attain and sustain a relationship with depth. A committed relationship demands a frequent awareness and analysis of the interaction. The repressive defenses and frequent forgetting are present to avoid the painful affect elicited when one is having the inevitable problems of a relationship. The diffuse style makes issues vague (Shaprio, 1965) which limits the histrionic's ability to identify and resolve the relationship's problems which would contribute to closeness with the partner. Instead, the repression defense and global thinking style leads to a vague feeling of dissatisfaction without the cognitive abilities to analyze and resolve the dissatisfaction. The dissatisfaction can also promote her already present distractibility and lead her to seek other objects to resolve her dissatisfaction rather than a recognition that the problem lies within the self. From an object-relations and ego-psychological 49 viewpoint, there appears to be an excessive reliance on external object relations in the histrionic personality. Excessive dependency appears to have its roots in the early maternal deprivation which causes the child to turn to the father as a substitute (Schariff, 1982). Unfortunately the future histrionic's father is often dominating, seductive, volatile and even narcissistic. The father views the father—daughter relationship as an extension of himself and a vehicle for his self-gratification. The daughter, seeking nurturance, becomes a confidante of the father. At the same time, the father is also disdainful of the mother who is often insecure, non-assertive and passive. The future histrionic identifies with the aggressive father and internalizes the relationship with the mother as an anti-libidinal object who is unable to rescue her from the father's narcissistic control. The internalized self and female object-representation is one of incompetence and ineffectiveness. This self-representation produces feelings of anger, helplessness and victimization in the histrionic (Mueller and Aniskiewicz, 1986). The self- representation, which produces the helpless, dependent behavior in the histrionic, makes her assume that males will victimize her. A sequel of 50 victimization gets played out in her relationships with men where she unconsciously relinquishes control in a relationship in order to be dependent. This is a continuation of the early developmental pattern with a father who had promised to take care of her if the daughter is dependent and seductive. The histrionic's beliefs about relationships with males is that dependency and seductiveness will allow her to be protected by men. She believes that male protection demands her docility. Underneath the docility the histrionic is angry about the assumption that the male's needs will dominate the relationship. She is dependent on the male, angry at him for her dependency and fearful that he may withdraw his protection. The representational image of the male is that he will withdraw his support and provider role. This image is based on the father's early rupture of the dependent relationship when the daughter reached puberty and began seeking other relationships besides the one with her father. The reuniting of the father never occurred and the histrionic is left with a sense of incompleteness. Incompleteness in her self-image is due to the histrionic feeling that the first male relationship with father was never resolved and object transference is repeated in future male 51 relationships (Mueller and Aniskiewicz, 1986). The deprivation of the mother and eroticization of the relationship by the father, with his later rejection, leaves the histrionic with feelings of being unwanted and worthless. A constant seeking out of relationships and approval from others to overcome the feelings of being unwanted provokes the manipulative and seductive skills cited earlier (Tupin, 1981). The responsiveness of the males to her seductive behavior, the internalization of a mother as an anti-libidinal object and an unresolved oedipal conflict leads the histrionic to be frequently involved with males. At the same time, the histrionic is fearful of the sexual implications of her behavior. She views sexual expression as submission to the dominating male and though she wants the dependency it may entitle her to, she also remembers the submissiveness of the mother with disdain and disgust. This self and object-representation of mother prevents the histrionic from acknowledging her own sexual feelings and limits her willingness and ability to let herself enjoy sexual expression. A lack of sexual enjoyment eventually leads to a lack of positive reinforcement from intimate interaction. The lack of enjoyment and reinforcement eventually 52 contributes to a decrease in sexual initiation and active participation. Defenses used by the histrionic are repression, denial and reaction formation. These defenses mesh with the behavioral style and self-concept of the histrionic. The repression and denial appear to be due to an inability to tolerate the anxiety created when hostile images are experienced (Andres, 1984). If the denial and repression are not maintained, then the histrionic fears the strength of her own anger and her own feelings of helplessness about that anger. Denial, repression and reaction formation against the anger help to maintain the compliance and docility in her interactions. Otherwise, the anxiety provoked by the angry feeling would be too intense. The anger also provokes the superego to inhibit and repress sexual functioning (Kernberg, 1985). This anger is not included in the histrionic's self—concept and threatens the goal of constant approval (Andres, 1984). Anger is not an affect compatible with sexual expression (Kolodny, Masters and Johnson, 1979). Instead, it promotes suppression of the libido. To summarize, the histrionic's early developmental defecits limit her ability to be involved sexually in an intimate relationship. Her 53 self and object representations, cognitive style and defenses limit the self-acknowledgement of affect in the sexually intimate components of her relationship. Moving to the next personality pattern, the passive-aggressive, the literature review will investigate how her object relations interfere with sexual desire. Passive-Aggressive Personality The passive-aggressive personality is a relatively new diagnostic category based on the work of the military in World War II (Manilow, 1981). The DSM-III (1980) describes it as an indirect resistance to external demands for adequate performance in occupational and social settings. The indirect resistance may be expressed through procrastination, stubbornness and forgetfulness. The behavior is seen in a variety of contexts and is often accompanied by feelings of dependency. Millon (1981) uses the term negativistic and considers this group as "active- ambivalent.” There is constant vascillation from seeking dependency on others through compliance to seeking satisfaction only from themselves. Millon goes on to describe the behavior and affect of the passive-aggressive as frequent irritability, easily frustrated, discontented, pessimistic, 54 unpredictable and feeling misunderstood and unappreciated. Reich (1949) labeled this personality disorder as masochistic with the person experiencing a chronic feeling of suffering. He attributes this suffering as being due to a deep disappointment in love. The passive-aggressive's provocation of others is based on past disappointments in others who did not satisfy her. The anxiety elicited by the disappointing love is defended against by courting love through provocation. A fear of losing love and guilt accompanies the provacative behavior. Horney (1939) focuses on the passive- aggressive's feelings of helplessness and self-hate at the dependency that is experienced towards others. Her hypothesis is that there are sadistic elements in the passive-aggressive who feels others should be subjected to her demands. Whitman, Trosman and Koening (1954) seem to incorporate both the sadistic and masochistic traits in their description. Aggression, acted on at times, at other times is inhibited by internal guilt or a fear of retaliation. When the aggression is inhibited, regression to dependency takes place and is expressed by passive behavior. If one examines the object relation theorists in relation to this 55 aggression, there appears to be a deficit in the neutralization of aggression in the passive- aggressive. The neutralization of aggressive energy means that the ego has the energy to dispose of the aggressive drive and to experience other affects (Greenberg and Mitchell, 1983). Neutra- lization allows the ego to develop and expand (Hartmann, 1958), and occurs when the object provides consistent gratifications. During the passive-aggressive's childhood, gratification was unstable and erratic. As a result, in this personality disorder, not only is the aggression acted out due to the lack of neutralized aggression, but also the lack of neutralization limits further ego development. Fairburn (1954) views ambivalence towards an object as originating from the late oral phase. This phase has the task of loving an object without destroying it by hate. The love and hate become intertwined and the difficulty in the relationship is due to ambivalence towards the incorporated object. A frustrating experience pulls out the hate towards the internalized object. Since relationships are inevitably frustrating at times, the hate and aggression is expressed. In the passive-aggressive, the aggression is expressed frequently but it is done so in a way that does 56 not overtly threaten the dependent relationship. Instead, the expression of the aggression in this person is nearly always done within legal limits. The active aggressive limits indicate that the ego skills of social judgement and reality testing are intact (Manilow, 1981). Yet aggression is passively expressed. Inflexibility and compul- sivity without insight for her aggressive contribution to the poor interpersonal relationship is what marks this individual. The behavior is not adaptable but ego-observing skills are not developed to the point that awareness of the maladaptive behavior is present. The acting out of the conflict of hostile dependency displaces it onto the object as a way of controlling anxiety (Manilow, 1981). Sifneos, Apfel-Savitz and Frankel (1977), in their work with alexithymic patients, noted a high frequency of passive-aggressive personality structure. These patients are unable to experience well-differentiated affect. Unpleasant sensations cannot be expressed in well-differentiated terms but instead, there is unpleasant autonomic arousal without intrapsychic connections. An inability and prohibition against the toleration of unpleasant affects is apparent. Unpleasant affect is defended against by externalization. Sudden discharges of 57 anger or depression are frequent. This inability to tolerate and sublimate affect, but instead to express is unmodulated, speaks to the absence of the ego's self-awareness and self-modulation. Anger appears to be a significant emotion underlying the passive-aggressive behavior. Rubin (1986) speaks to the autonomic arousal of anger which increases as the magnitude of threat increases. The individual who experiences the anger then takes either overt or covert aggressive action against this threat. Freud claimed that undischarged anger leads to the same excitation as fright and anxiety (Strachey, 1974). Since the passive-aggressive individual may be lacking in the ability to differentiate affect when experiencing autonomic arousal, anger and other affects can be confused with each other (Bandura, 1973). In females, the expression of anger may often be the great prohibition (Greenspan, 1983). WOmen, according to Greenspan, learn to repress their anger, initially with their father and then to other men, in order to survive. The etiology of the anger is believed to be connected to the dependency on males. The female develops “passive and indirect ways of fighting back against the code of acceptable feminine behavior” (Greenspan, 1983). It is the fear of expressing a more direct form of 58 anger along with a desire for power that is believed to lead to the passive-aggressive behavior. This behavior is an indirect communication of unconscious hostility and a way to cope with the binds of developing a feminine identity. Averill (1983) writes that anger is a response to a perceived misdeed and is an attribution of blame. The passive-aggressive individual chronically perceives misdeeds and then experiences insecurity, frustration and resentment towards the object at the same time as experiencing a dependent investment in the object (Millon, 1981). The individual is reluctant to abandon her original hate or need of the original object resulting in ambivalence (Fairburn, 1958). This ambivalence and confusion between hate and need is expressed in a vascillating style of either introjection or projection. The introjection leads to the passive, compliant behavior. The projection attributes to the object misdeeds, frustrations and self- condemnation that are experienced and is expressed through passive aggression. The passive-aggressive's primary objects are likely to have been disappointing and expressed conflictual affects and behavior towards the child. The primary caretakers vascillated in their 59 willingness to give or receive affection. With these vascillating objects, the child failed to internalize a consistent good self and good object and bonding failure resulted. A lack of bonding may contribute to the anger (Snaith and Taylor, 1985). The development of trust and belief in the primary caretakers is deficient, due to their inconsistency. The self and the object become colored with ambivalence. It is beyond the usual ambivalence one experiences in relationships. Instead, it is fraught with insecurity, resentment and limited impulse control. The ambivalence is due to being unable to predict the response of the object her own behavior will elicit. Unable to predict the object's response, either submission or covert expression of one's needs is the style of interaction perceived as safe by the passive- aggressive. Freud (1957) concluded that emotional ambivalence is due to object relationships cathected with antithetical tendencies. In a healthy sexual relationship there is a certain submission and acquiescence to the partner. Submission to the partner recreates the early submission to the primary caretakers. In the passive-aggressive, any submission to the partner becomes equated with early hostile dependence. With this hostility, sexual pleasure becomes 60 improbable. Normally, there is a sexual over- valuation which occurs in most relationships. This sexual overvaluation leads to an impoverish- ment of the self in favor of the love object (Benedeck, 1977). The passive-aggressive resents this usual overvaluation of the object and her insecurity has difficulty tolerating the impoverishment of the self; anger at the love object results. She expresses her anger covertly through a lack of sexual interest just within the legal limits of the relationship. The pleasure of the sexual relationship turns to pain because the infantile wish for a consistent object who can give and take affection becomes provoked but is not granted satisfaction. The activation of the infantile wish causes discomfort and pain (Altman, 1977). To summarize, the passive-aggressive has problems with the modulation of affect, experiences hostile pain from dependency and projects the etiology of the pain onto the partner. The ego has an inability to tolerate the frustration of the infantile wish and consolidates that failure of frustration tolerance at the level of genital primacy (Altman, 1977). The ego's deficit of frustration tolerance limits the ability of the passive-aggressive to tolerate the normal 61 ambivalence in a relationship. As discussed earlier, the passive-aggressive experiences an even greater level of ambivalence in her relationship. Thus the already weak ego apparatus is being asked to tolerate even greater amounts of ambivalence. Since ego defecits make this unlikely, there is a discharge of the ambivalence onto the partner. To guarantee that the dependent relationship can be maintained, ambivalence becomes expressed indirectly (i.e., through the conscious and unconscious suppression of sexual desire). The passive-aggressive can relinquish her responsibility in the expression of the anger component of the ambivalence and still retain her dependency. In Western society, sexual sensations, desires and fantasies are often equated with 'badness," shame, anxiety, and prohibitions (Kaplan, 1979, 1985; Masters and Johnson, 1970). The inability to tolerate these affects leads the passive-aggressive to avoid those experiences which elicit item. Sexual interaction is avoided and the sexual desire becomes suppressed. Turning to a more severe personality disorder, the borderline, the conflicts of sexual relationships cited in the histrionic and passive-aggressive are present along with early 62 developmental conflicts leading to significant sexual desire problems. Borderline Personality In the last several years much has been written about the borderline personality disorder (Kernberg, 1975, 1984; Shapiro, 1978; Frosch, 1971: Groves, 1981: Adler, 1979; Masterson, 1976, 1978; Chessick, 1977; Blanck and Blanck, 1974, 1979; Jacobson, 1964). The structural dynamics and etiologic manifestations are disagreed upon at times. A review of the literature does agree on several characteristics of behavior and defenses found in this personality disorder. DSM-III (1980) describes it in the following way: The essential feature is a personality disorder in which there is instability in a variety of areas, including interpersonal behavior, mood and self-image. No single feature is invariably present. Interpersonal relations are often intense and unstable with marked shifts of attitude over time. Frequently there is impulsive, often unpredictable, behavior that is potentially physically self- damaging. Moods are often unstable with marked shifts from a normal mood to a dysphoric mood. There is inappropriate, intense anger or a lack of control of anger. A profound identity disturbance may be manifested by uncertainty about several 63 issues relating to identity, such as self-image, gender identity or long—term goals or values. There may be problems tolerating being alone with chronic feelings of emptiness or boredom (DSM-III, 1980). Authors have focused on numerous developmental deficits, character traits, behavioral manifestations and identity issues in the borderline. The borderline's life is affected in numerous ways by her personality organization. This research will focus on those components of the borderline which have an effect on sexual desire. Kernberg (1975, 1984), a leader in the conceptualization of the borderline diagnosis, identifies three manifestations of ego weaknesses in the borderline. These are: 1. Lack of anxiety tolerance-—additional anxiety other than that usually experienced. Results in symptom formation and ego regression. 2. Lack of impulse control--an ego syntonicity in the expression of impulses which is repeatedly expressed. This occurs along with a lack of connection between the impulse expression and the rest of the self-experience. 3. Lack of developed sublimatory channels--a lack of creative enjoyment and experience 64 indicates a conflict-free ego sphere is not available. The first two have been discussed in the earlier part of Chapter II. The third component is a reflection of the borderline's inability to develop defenses which allow the anxiety and needs to be resolved in an enriching manner. The borderline's relationship rarely has an area that allows for conflict-free interaction nor can the tension of the relationship's conflicts be sublimated with other endeavors. The anxiety intolerance creates chronic conflicts and frustration. How this conflict affects the sexual arena will be discussed. Kernberg (1985), notes three levels of normal psychosexual development. First is the pre-oedipal stage when sexual excitement becomes linked with erotogenic zones. There is a polymorphous quality of sexual fantasies. The child then moves to the oedipal stage where the triangular relationship with the parents becomes a focus. In the third stage, the post-oedipal phase, the preservation of the polymorphous sexual fantasies of infancy must be translated into sexual play and fantasy. This third phase is also marked with an ability to temporarily merge with another that is derived from infantile self-object fusion. During this phase, 65 one developes the ability to achieve an object relation with enough depth to tolerate ambivalence towards the object and to empathize with another person. The integration of a normal superego, which has both regulation and tolerance characteristics, allows for the in-depth object relation. In examining the female borderline, Kernberg (1975) notes her failure to establish ego boundaries in areas where projective identification and fusion have occurred. This failure is evident in the transference of borderline. The transference, which takes place in various components of all her relationships, is especially evident in the sexual component. There is a pervasive feeling of insecurity and inferiority which Kernberg states hides narcissistic character traits. The underlying narcissism activates a fantasy of a fusion with the idealized object as a defense against the bad self and object. Splitting occurs when the good and bad object are affectively separated. This splitting prevents a fusion of the good and bad components of the object and there is a constant dissociation from the affect associated with either the good or the bad object. The borderline's relationships are built on this affective dissociation. She can dissociate from 66 sexual desire when the bad object is her awareness and the good object has been dissociated. Due to the splitting defense, the normal integration of positive and negative affects towards the self and the object is not achieved in the borderline and thus neither is one of the conditions for a sexual relationship; the integration of sexual and emotional affect. The lack of capacity for a deep object relationship "means that the sexual relation with the partner cannot be integrated with an emotional investment in the partner," (Fairburn, 1958). Sexual passion crosses the boundary of the self and into the boundary of identification with the loved object while maintaining a sense of identity (Kernberg, 1977). The ability to engage in sexual passion requires the acceptance of this danger. The danger is a) losing one's identity and; b) the liberation of aggression against internal and external objects (Kernberg, 1977). The borderline cannot tolerate this danger for her sense of identity is not intact nor is her aggression neutralized and under normal superego ego controls. Another significant point that Kernberg (1977) raises in relation to the inability to cross self-object boundaries is the eventual deterioration of excitement, pleasure and satisfaction in sexual activities. He asserts that 67 it is the boundary crossing and the world of internal and external object relations that keeps sexuality alive and gratifying. This enlivening and gratifying experience of boundary crossing in sexual activity is not available to the borderline due to the threat it would induce to the self. Thus, excitement, pleasure and satisfaction are not achieved in the sexual relationship. Severe oral pathology in the borderline causes the development of oedipal strivings prematurely in the female. This striving for the father is a search for the gratification of oral dependent needs not obtained from the 'bad' mother. The prematurity of these oedipal strivings causes the pregenital aggressive fantasies towards the mother and a pathological condensation of the mother and father (Kernberg, 1984). Genital and pregenital aims are condensed as well. The pregenital aims contain aggression, which becomes mixed with the genital sexual component of the relationship. Sexual aims, dependent fantasies and aggressive impulses become intertwined and acted out in the sexual relationship of the borderline. The aggressivization of the oedipal conflict acquires dangerous and destructive characteristics with penis envy being exaggerated and superego prohibitors against sexualized relations acquiring 68 a savage quality (Kernberg, 1984). The rage and aggression experienced by the borderline is defended against, at times, by an exaggerated yet frail idealization of the object. This idealization can be readily ruptured, resulting in extreme rage towards the partner. The pregenital aggression, severe superego prohibitions against all gential aims and the negative oedipal relation with the mother create the projection of primitive conflicts of aggression onto the sexual relationship. The borderline rage becomes mixed with sexuality and results in suppression of the desire for sexual intimacy. Anger is probably the most common cause of ISD (Kaplan, 1985). This is not only due to the difficulty in experiencing angry feelings with sexual feelings but also due to the threat of perceived hostility and withdrawal of the object the borderline experiences in her interpersonal relationships. The borderline personality experiences a) an identity diffusion; b) a lack of an integrated self-concept as defined by Erikson (1956); c) a lack of a real self. There is a poorly integrated concept of the self and others with feelings of chronic emptiness, boredom and shallowness. This identity diffusion reflects the lack of structure of the borderline and is mirrored in her object 69 relations. Normal identity integration results in stability, depth, empathy, and the ability to maintain a relationship when conflict and frustration are present (Kernberg, 1984). These characteristics allow for the development of a relationship in which there is conflict. They also allow a person to experience an understanding of the partner's needs and an ability to express one's own needs. When identity diffusion exists, as it does in the borderline, the threat of engulfment, an intermittent loss of ego boundaries and a consistent and primitive form of object relationship (Modell, 1963) limits the tolerance of intimacy in a relationship. Superficiality pervades their relationships (Gunderson and Singer, 1975). Deutsch (1942) noted the absence of empathy and a real emotional response in this personality. The lack of emotional responsiveness and empathy, caused by a deficit in the sense of one's self, promotes repeated dissloution of relationships. A lack of responsiveness also prevents the establishment of a new level of object relations (Blanck and Blanck, 1968) which would usually enhance a sense of self-identity and the relatedness of the couple. To relate to the partner requires a cohesive and coherent sense of 70 self (Meissner, 1978) which is not present in the borderline. The lack of identity in the borderline is based on a lack of libidinal object constancy (i.e., a primarily loving early object) (Mackey, 1985). A lack of libidinal object constancy creates an inability in the borderline to remain attached to the object despite a variety of affective changes. These affective changes may include gratification, frustration, disappointment and disillusionment. Instead, when these affects are experienced, the borderline looks more to the objects of the outside world to either change the affects or to provide more of the positive affects. Unfortunately, the self cannot be totally dependent on the outside world (objects) and still have a satisfying relationship. The relationship will be non-satisfying for the borderline fails to shift from a self-orientation to one of mutuality (Rapaport, 1970). This mutuality would allow for the establishing and patterning of a sexual relationship (Meissner, 1978). Without mutuality, the sexual relationship is based on a genital contact. This genital contact, without an intimate relationship, will intensify the feelings of emptiness and boredom. These feelings will be projected onto the partner and an active 71 suppression of sexual feelings will result when the partner becomes the bad object. The bad object is not desired, sexually or otherwise. Masterson (1976, 1985) focuses on a different component in the borderline than Kernberg. Masterson sees the separation-individuation stage as the critical developmental issue in the borderline personality. Basing his theory on Mahler's work, Masterson sees the mother of the borderline as fostering a continuance of the early symbiotic union during the stage when autonomy development should be fostered. The child's emerging individuality is threatening to the mother and she attempts to prevent separation by libidinal withdrawal when the child moves towards separation. The child learns to disregard herself in order to maintain libidinal supplies (Masterson, 1972). Abandonment feelings begin at this time and are defended against throughout the lifetime of the borderline. The use of the defenses used by the borderline (projective identification and splitting) effectively block the developmental move to separation-individuation. The separation-individuation phase makes an important contribution to the capacity to love. It is during this phase that the child normally intrapsychically separates from the mother. 72 Without this, the borderline fails to develop the foundation of “feeling good” and the oedipal task of adding sexual and romantic elements fails. The borderline's chronic conflict with intimacy is due to this developmental failure (Masterson, 1976). Close involvement with an object reawakens being returned to the symbiotic relationship. Distancing is mobilized to defend against the threat of symbiotic engulfment. The distancing, though, provokes fears of abandonment by the object as the borderline felt abandoned when separation/ individuation was attempted. Loss of the object is a chronic fear of the borderline for it means separating from the primary caretaker. Feelings of abandonment, elecited by the separation, then provoke a clinging defense. The clinging defense is intended to maintain an intrapsychic bond with the parents rather than with the partner (Meissner, 1978). The bond remains intact and the borderline's ties her existence with the primary caretakers. This creates an infantile dependence that then gets transferred to the partner (Meissner, 1978). Fairburn (1954) differentiates this infantile dependence from mature dependence by the incapacity of the infantile dependent person to have a cooperative, giving relationship. Infantile dependence prevents the pleasurable 73 experience of sexual activity. The loss of the ego in sexual activity is anxiety producing and the individual experiences sensations of narrowness and suffocation (Feninchel, 1945). The fear of loss of identity is significant and the borderline becomes dissatisfied with the relationship as Deutsch (1942) noted. A woman's sexual satisfaction is strongly linked with experiences with her partner (Uddenberg, 1974). An unsatisfying relationship will lead to an avoidance of sexual interaction. Uddenberg (1974) continues to point out that the sexually inadequate woman (which he fails to define specifically but appears to include women who are not sexually satisfied) had a mother who experienced ambivalence towards her daughter. This conflict and ambivalence made the maternal libidinal availablity towards the daughter limited in quality and quantity. Sexual inadequacy was correlated to limited maternal availability. This may be one of the factors contributing to the sexual problems in the borderline. Despite Uddenberg's lack of specificity of describing the sexually inadequate woman, it does appear that a similar interaction occurs between the borderline and her mother and females with low sexual desire and their mothers. Another feature of the borderline which has 74 implications in sexual activity is the chronic anxiety experienced by the borderline. As discussed earlier, borderline clients experience chronic and pervasive anxiety. The appropriate binding capacity to tolerate and sublimate the anxiety is absent due to ego deficits. Anxiety has been identified by Kaplan (1979), Masters and Johnson (1970) and Munjack and Staples (1976) as being related to sexual dysfunction. Experiences for the borderline which induce anxiety are especially prominent in those which signal progress in the life cycle development (Masterson, 1976). The challenge of intimacy is cited by Masterson as a specific separation phase. When separation is required of the borderline, anxiety prevails with an activation of the clinging and/or distancing defenses. Neither clinging nor distancing allow for the cooperation, sharing of power and balance of vulnerability necessary in a relationship. Instead, they reinforce the projection of the bad self and object and may generate feelings of depression and hopelessness. The borderline's role of chronic nurturing (clinging) or being nurtured (distancing) prevents the real exchange of adult intimate expression (Ellickson and Selas, 1986). Balint (1949) points out that genital relations are always based on a mixture of harmony and strain. 75 The borderline intolerance of this strain, which is anxiety provoking, limits her ability to express her sexual expression. Her experience of anxiety inhibits the sexual desire (Kaplan, 1977). To summarize, as a result of her ego deficits, the borderline is vulnerable to sexual conflicts. These conflicts are likely to be expressed through the inhibition of sexual desire as a defense against the anxiety provoked in a heterosexual relationship. Summary As cited earlier, the state of sexual desire research is in its beginning stages. Sexual desire problems are becoming increasingly focused upon since traditional sex therapy has not been effective in treating the problem. Various reasons for this have been postulated (Kaplan, 1979, 1985). It appears to be a multi-dimensional problem whose etiologic factors interact with early developmental deficits. Theoretical investigation has led to the hypotheses that the histrionic, passive-aggressive and borderline personality patterns are correlated with low sexual desire. This study indentifies those relationships which can direct treatment planning and future research. CHAPTER III METHODOLOGY The research design and methodologies used for the correlation of sexual desire and personality disorders are discussed in this chapter. The chapter is divided into the following sections: 1. Selection and description of the sample. a) Clinical Sample b) Non-clinical Sample 2. Measures. a) Millon Clinical Multiaxial Inventory (MCMI) b) Sexual Desire Assessment Form (SDAF) 3. Procedures for collecting data. 4. Hypotheses 5. Design. 6. Analysis. 7. Summary Selection and Description g§_the Sample The subjects in this study were females between the ages of 18 and 45 years who have been married for at least one year. 76 77 This study involved two groups. The first, which will be titled clinical, were hospitalized female patients at Pine Rest Christian Hospital, a psychiatric hOSpital in Grand Rapids, Michigan. The second group, titled non-clinical, were females who were not hospitalized and resided in the same general area of the state as the clinical sample. Clinical Sample Due to part of the focused sample of the study, female psychiatric inpatients, random selection was not possible with these clients. The admission records were reviewed two times a week by the investigator with the psychiatric team members. Those subjects who met sample criteria were contacted and given an explanation of the research. Those refusing to participate were not included (four potential subjects in the clinical population refused to participate). Thirty subjects were selected from the inpatient population. Subjects who were excluded from the study were: 1. Patients with thought disorders. 2. Patients whom the team psychiatrist or psychologist judged as being unable to provide informed consent. The mean age and years of education of the clinical sample were 32.90 and 13.43 years respectively. 78 It is acknowledged that the clinical sample is not representative of the total population of women with a potential for low sexual desire. This study has been develOped in this way because the state of the research on specific psychopathology in the ISD pOpulation is still in its infancy. This study is based on the assumption that ISD clients have more complex psychological issues than clients with other sexual dysfunctions (Kaplan, 1985). Since this is the assumption, the initial study should attempt to include those patients with known psychopathology (psychiatric inpatients). This increases the probability that if a correlation does exist, it will be found in this population. Later studies will need to compare and contrast this p0pulation with other populations of clients with sexual desire disorders. Non-Clinical Sample This group of subjects was selected in order to view a broader spectrum of females with potential symptoms of low sexual desire. These subjects were selected from the greater Grand Rapids and Lansing, Michigan area as were the clinical subjects. The mean age and years of education of the non-clinical sample were 34.17 and 13.95 age and years respectively. The 42 non-clinical subjects were university students, 79 teachers, health care workers, Pine Rest Christian Hospital employees and unemployed mothers. These women were approached at their places of employment through fellow workers. Random sampling was not used with the non-clinical sample. Four potential subjects in the non—clinical sample refused to participate in this research. Table 3.1 describes the demographic data; age and years of education, of the clinical and non-clinical sample and the t-test scores on mean differences. No significant difference was found between the clinical and non-clinical sample on age (ts .483) and years of education (t= .656). Measures The following section will provide a description of the two measures used in this study: the Millon Clinical Multiaxial Inventory (MCMI) and the Sexual Desire Assessment Form (SDAF). Millon Clinical Multiaxial Inventory The Millon Clinical Multiaxial Inventory (MCMI) is a 175-item, true-false inventory, developed by Theodore Millon. The test yields scores on 20 scales which are divided into three broad categories. These categories reflect distinction from persistent personality patterns (Scales 1 to 8) to more pathological personality patterns (Scales S, C, and P) and current symptom 80 Ho. mas mo. as oaoemm ca muoonnsm anuoa can Hmowcwaoscoz .Hmowcwao mo mOMumwuouonumco owcmmumosoo ~.m man‘s . . u. . . . a. . . . . . . :owumosem mo emo .fim m: e no on «H .mw N- e m. mm mg .mc an e m. me ma mane» new: salad oNINH cmuon omcnm coaunosom nae. .oo.en.c.m. em.mm .e¢.en.o.m. efi.em .mm.mm.c.m. m.~m use new: meumu menu” menu” omens use neuz Neuz cmuz uncut» annoy HdOfldfiHOlcoz Hn0ficwao 81 states (Scales A, H, N, D, B, T, SS, CC, PP). The 20 scales of the MCMI are listed in Table 3.2. The MCMI was developed on Millon's theory of personality and psychopathology (Millon, 1981). Millon, a contributor to the DSM-III, based the MCMI on the DSM-III distinction between enduring personality patterns (DSM-III, Axis-II) and more acute symptomatology (DSM-III, Axis-I). This study examines the personality scales which are the first eleven scales (Scales l to 8 and S, C and P) and their relationship to the measure of sexual desire as measured on the Sexual Desire Assessment Form. The Basic Personality Patterns, Scales 1 to 8, focus on usual ways of functioning that characterize these persons even when they are not experiencing acute symptoms. As discussed in Chapter II, these scales reflect the client's style of behaving, perceiving, thinking, feeling and relating (Millon, 1983). An important feature, Millon points out, is that these traits are premorbid characterological patterns. In addition to the eight basic personality patterns, the MCMI includes the Schizoid (S), Borderline (C) and Paranoid (P) Scales. These three scales measure personalities with more severe pathology in the overall personality structure. Clients with these personality patterns have more 82 TABLE 3.2 Scales of the Millon Clinical Multiaxial Inventory Scale Name Scale Name 1 Schizoid (Asocial) A Anxiety 2 Avoidant H Somatoform 3 Dependent (Submissive) N Hypomanic 4 Histrionic (Gregarious) D Dysthymic 5 Narcissistic B Alcohol Abuse 6 Antisocial (Aggressive) T Drug Abuse 7 Compulsive (Conforming) SS Psychotic Thinking 8 Passive-Aggressive (Negativistic) CC Psychotic Depression PP Psychotic Delusion S Schizotypal (Schizoid) C Borderline (Cycloid) Paranoid 83 significant and persistent problems in functioning and may also have psychotic episodes with bizarre behaviors. The clinical symptom syndromes (DSM-III, Axis—I) reflect a pathological process which is more transient, often in reaction to stress. In addition to these scales, Millon includes a 4-item validity index (Scale V) on the test which detects a failure to cooperate, an inability to comprehend and irrelevant answers in the testing situation. A Scale W, weight factor, detects excessive self- enhancement or self-depreciation and then adjusts the MCMI scales accordingly. In the MCMI, raw scores are transformed into base rate scores, a conversion determined by known personality and syndrome data. Base rate scores of 74 were set for all scales as the cutting line above which scale percentages would correSpond to the clinically judged "presence” of the personality or symptom (Millon, 1983). Scores above 84 were corresponded to the highest or most salient personality or clinical syndrome present. Scores greater than 74 are considered to be in the pathologic range. Reliability Test-retest reliability was done by Millon on two clincial populations. The first group had a test—retest interval of one week and the second, a 84 different population, had a test-retest interval of five weeks. As predicted by Millon and an important tenet of his psychopathology theory on which the MCMI is based, the test-retest showed reliability coeffecients in the range of .80 for scales one to eight. The more severe personality scales averaged in the .70 range of coeffecients. Clinical syndromes (Axis-I), anticipated to be more transient, had coeffecients in the mid-.60's. The median stability coeffecient is around .80 (Kupor and Sweetland, 1984). Piersma (1986a) examined the stability of the scales on a group of psychiatric inpatients. Test-retest reliability was higher for the personality than the symptoms scales. Piersma's results, though, were lower than Millon's with a mean of .62 on the coeffecients for Scales 1 to 8 and .48 on the symptoms scale. The severe personality scales had a mean of .43 for a coeffecient. Validity Millon (1983) engaged in a somewhat unusual strategy when he developed the MCMI. Following Loevinger's (1970) and Jackson's (1970) recom- mendation that validity determination should be an ongoing process in test construction rather than a procedure completed after a test's completion, Millon adopted ongoing testing for validity. 85 Millon used a three-stage validation process with the theoretical-substantive stage comprising the first phase. During this stage, items were written for clarity and content validity on each scale. The items were reduced and the next stage, the internal-structural validation, was tested. During this latter stage, items with high correlation to the scale and the structural model of the theory were kept (Kupor and Sweetland, 1984). Item overlap is considered theoretically congruent with items comprising each scale exhibiting their strongest but not unique association with that scale (Millon, 1983). The final stage, the external criterion phase, provided for convergent and discriminant validity. Concurrent validity was established with the Minnesota Multiphasic Personality Inventory (MMPI) including the Basic and the Wiggins Content Scales, Lanyon's (1973) Psychological Screening Inventory and Derogatis et a1., (1973) Symptom Distress Checklist (SCL-90). In order to determine the validity of using 75 and 85 as cut off scores for differential diagnosis, a cross-validation study was conducted in a population similar to the original validity study. The cross—validation of diagnostic cut off scores found the Narcissistic (5) Scale as having 86 the lowest percent (five) and the Conforming (7) Scale having the highest (fifteen) of false positive. Factor analysis, a statiStical procedure for reducing a large number of variables to a smaller number of presumed underlying unities (Thurstone, 1947, Cattell, 1952) was used by Millon in his determination of construct validity. Four factors were identified which included (a) depressive and labile emotionality, (b) paranoid thoughts and behavior with hostility and grandiosity, (c) schizoid behavioral detachment and (d) social restraint and conformity. Despite Millon's efforts to determine and validate the MCMI during the test development, it is necessary to examine external studies which investigate the validity of the MCMI. Antoni et a1., (1986) in analyzing the covariation between the MMPI's 89/98 profile and the MCMI high point scales, identified three groups of patients, the interpersonally acting out group, the interpersonally grandiose group and the emotionally acting out group. Snibbe, Peterson and Sosner (1980) found the MCMI clarifying the personality dynamics in a worker's compensation sample. This study, which also administered the MMPI, found a homogeneous population with 87 passive-dependent personalities in the Axis-II and anxious and dysthymic symptoms on the Axis-I scales which complemented and reinforced the MMPI data. Averbach (1984) found a significant correlation between the Narcissistic (5) Scale on the MCMI with the Narcissistic Personality Inventory. Flynn and McMahon (1984) investigated the factor structure of the MCMI and found a negativistic—avoidant personality style and a paranoid, cognitive and interpersonal pattern. Bartsch and Hoffman (1985), in their cluster analysis study of alcoholic clients, found significant concurrent validity in 12 of the 13 scales of the MCMI. Piersma (1986b) found a greater stability for MCMI personality scales (Scales l to 8 and S, C, P) overall than for MCMI symptom scales. The Histrionic (4) Scale was reported as having the highest correlation (r = .75) while Scale C (Borderline) reflected the lowest correlation (r = .27). The low correlation of the borderline was explained as being theoretically predictable due to the lability of the borderline characteristics. Gorp and Meyer (1986) found the MCMI detecting “fake bad” profiles but less effective with “fake good.“ Widiger et a1., (1985), based on results of their research, cautioned clinicians from assuming that the MCMI measures DSM-III, Axis-II syndromes. 88 Turning now to the other measure in this study, the Sexual Desire Assessment Form (SDAF), a description and discussion of this tool will follow. Sexual Desire Assessment Form Traditionally sexual desire has not been measured by researchers. Conte (1986), in her review of assessment of self-report questionnaires assessing sexual behaviors, reported no specific sexual desire measure. Avery-Clark (1986) also notes no specific tool to measure sexual desire. Instead, most interview and self-report measures examine a range of sexual behavior, experiences and attitudes (Conte, 1986). These constructs have been embedded into other items with no specific score available to determine the presence, absence, or a continuum of sexual desire. In 1982, Schover et a1., published the Multiaxial Problem-Oriented System for Sexual Dysfunctions. This tool separates the client's sexual problems into desire, arousal and orgasmic phases. Unfortunately, there have been no reliability or validity studies on this instrument. The instrument was developed and has been used for clinical rather than research purposes (LoPiccolo, 1986). This measure has problems in scoring for research due to its unequal number of potential responses for each item, but 89 does appear to meet the criteria for the assessment of sexual desire. Criteria are based on the following behaviors and perceptions: 1. Frequency--sexua1 interaction and desired sexual interaction less than one time every other week. 2. Dissatisfaction--the frequency and experience of the sexual interaction is experienced by the subject and/or his/her partner as unsatisfactory. 3. Subjective Experience-—a lack of interest is reported in sexual fantasy, sexual experience, sexually erotic material and/or masturbation (Masters et a1., 1983; Kaplan, 1979; Schover et a1., 1982; Avery-Clark, 1986). The Multiaxial Problem-Oriented System for Sexual Dysfunctions was the foundation of a new measure called the Sexual Desire Assessment Form (SDAF). This measure, developed specifically for this study, used the Multiaxial Problem-Oriented System for Sexual Dysfunction content as well as review of the literature content and construct to assess sexual desire. The SDAF (Appendix A) was developed for the purpose of measuring sexual desire. It is an eleven-item, self-report questionnaire measuring frequency, desired frequency, satisfaction, and 90 interest in sexual behavior and responses to partner sexual advances as perceived by the subject for the last 12 months. Each item contains seven potential responses ranging from criteria which indicate strong sexual desire to low or no sexual desire. Each item was given a score ranging from one (indicating low/absent sexual desire) to seven (indicating high/frequent sexual desire). Total scores on the SDAF range from 11 (low sexual desire) to 77 (high sexual desire). It was necessary to determine reliability and validity on this new measure. Following is a discussion of how the reliability and validity of the SDAF were determined. Reliability Test reliability indicates the extent to which individual difference in scores are attributable to "true" differences versus chance errors (Anastasi, 1976, Gay, 1981). This study examined two types of reliability for the SDAF, interitem consistency and test-retest reliability. Interitem consistency is a reliability estimate based on the average correlations among items and the total number of items in a test (Nunnally, 1967). Interitem consistency is influenced by the homogeneity of the behavioral domain, with the greater the homogeneity of the 91 behavior, the less ambiguity of the test scores (Anastasi, 1976, Cronbach, 1960). Homogeneous items are considered appr0priate when the assessment of the behavior domain is circumscribed. The SDAF appears to be circumscribed, examining one aspect of one's sexual experience, desire or the motivation to engage in sexual activities. Desire is measured by both individual behaviors, (e.g., fantasy, masturbation) and couple behaviors (heterosexual activity including intercourse) (Shover, et. a1., 1986; Avery-Clark, 1986). Sexual desire, therefore, appears to be a homogeneous construct with two methods of expression. To determine the interitem consistency of the SDAF, a pilot study on the origianl SDAF (Appendix B) was done. The original SDAF included eight items assessing sexual desire. A sample of ten from the same clinical population on which the major hypotheses were later tested was used. These were inpatient females from Pine Rest Christian Hospital, Grand Rapids, Michigan, (see Selection and Description of Sample). After data collection was completed for the pilot study, the SDAF was tested statistically for its interitem consistency using a method developed by Cronbach (1951). This method is a generalized version of the Kuder-Richardson (1937) formula, 92 called coeffecient alpha and is used for items not scored dichotomously (Nunnally, 1967). Since the SDAF is a multiple-scored inventory, it could be apprOpriately tested with Cronbach's coeffecient alpha. The pilot study determined the interitem consistency of the original SDAF. An interitem consistency of the test should fall in the .80's to .90's (Anastasi, 1976). The first pilot tested a questionnaire with eight items assessing sexual desire. Interitem consistency on the original SDAF was found to be .796 (Table 3.3). Since this did not fall in the acceptable range recommended by Anastasi, changes were made to increase interitem consistency. In reviewing the interitem consistency, it was found that item number six had a low intercorrelation with other items. This item was different from other items in that it requested that the subject respond with a perception of their mate's sexual satisfaction. Self-reported perceptions of one's partner may have had a greater chance for error than when one is reporting their own sexual satisfaction. In order to increase the interitem consistency, one can 1) increase the number of items and 2) increase the homogeneity of the items 93 (Guilford, 1954, Downie and Heath, 1970). In the second pilot study, item number six was removed from the original SDAF and four items were added which reflected more homogeneity on the SDAF (Appendix A). The interitem consistency with all 11 items was .847 (Table 3.3). Omitting item three increased the interitem consistency to .856. This item proved to be less homogeneous on the second pilot study than it had on the original pilot study where it was a high homogeneous item. After statistical consultation, it was decided to retain this item despite the lower interitem consistency. The next type of reliability determination, test-retest reliability, was examined in the formal conduction of the study with a sample of 28. (The reason that only 28 were involved with test-retest reliability, rather that all 30, was due to two subjects in the clinical sample being discharged earlier than anticipated.) Test—retest reliability is found by repeating an identical test a second time. A reliability coeffecient is determined by measuring the correlation between the scores on the test and the retest. This correlation indicates score variation that occurs between the two tests due to errors of measurement (Downie, 1967, Downie and Heath, 1970, Gay, 1981). The limited dimension of the construct of sexual desire and ways sexual 94 TABLE 3.3 Interitem Consistency of the Sexual Desire Assessment Form Pilot Study_Number One Number Number Coeffecient of subjects of items alpha lO 8 .796 Pilot Study Number Two Number Number Coeffecient of subjects of items alpha 10 11 .847 95 desire can be measured preclude the use of alternate and split half reliability. The test- retest reliability of the SDAF was found to be .966. This is significant at p (.001. For the test-retest reliability determination, (which was conducted during the formal study) female patients were asked to participate in the study within the first seven days of their hospitalization. Retest took place on the 14th to 20th day of hospitalization. The reason for this time frame is that the average length of stay at Pine Rest Christian Hospital Mulder Therapy Center is four to six weeks. In order to limit the intervening variable of psychotherapeutic treatment which the client receives during the hospitali- zation, yet to allow for an acceptable period of time before the retest, a seven to twelve day interval between test and retest was used. Another reason that the retest was not postponed until after discharge is due to the fact that the SDAF would have had to be mailed to their homes because many subjects are from outside the Grand Rapids area. The unpredictability of the willingness and motivation of the patients to complete the retest if the SDAF was mailed to their home would have limited the effectiveness of this technique. Violations of confidentiality were also 96 possible if the form was mailed to their homes. Validity The validity of a test is the degree to which a test actually measures (what it asserts it measures and how well it does this task. (Anastasi, 1976; Gay, 1981). Content validity is concerned with the determination of the test's content to determine if it covers a representative sample of the behavior (Anastasi, 1976). The content which needs to be measured is formulated and items are developed on these formulations (Thorndike and Hagen, 1961). The concept of sexual desire was investigated and develOped with the SDAF measuring the following content areas: a) Frequency--frequency or desired frequency of sexual activity (items 1, 2, 3, 11). b) Satisfaction--the subject's satisfaction with the sexual relationship (items 5, 10). c) Subjective Experience--the interest and response of the subject to sexual fantasy, sexually erotic material and to the partner's sexual advances (items 4, 6, 7, 8, 9). These three domains fit the criteria, discussed earlier, for the assessment of sexual desire. Face validity, which pertains to whether the 97 test appears valid, though less significantly important than other validity, 'is a desirable feature of tests” (Anastasi, 1976). The reason for its importance is that cooperation is likely to be greater if the test appears to the subject to measure what it purports to measure. The questions on the SDAF are specific to sexual activity, interest and experiences, thus appearing to have face validity. Criterion—related validity examines the ability of the test to measure the subject's behavior in a specified situation (Nunnally, 1967). Test performance is measured against a direct measure (criterion) (Downie and Heath, 1970). Sexual activity is primarily a private experience either occurring when one is alone or with a partner. Due to the privacy of this behavior and the probable perception of intrusiveness that any direct measure would entail, criterion-related validity is not applicable to this study. Procedures for Collecting Data The procedures for collecting data from each population varied due to the difference in the samples. The clinical sample was composed of adult female patients (age 18 to 45 years old), married at least one year and admitted to Pine Rest Christian Hospital, Grand Rapids, Michigan, in the 98 winter and spring, 1987. Implementation took place after approval for conduction of the study was received from the Research Committee at Pine Rest Christian Hospital and the University Committee Involving Research on Human Subjects at Michigan State University. After this approval was obtained, the investigator met with team psychologists, psychiatrists, social workers, nurses and activity therapists to explain the purposes and procedures of the study and to answer questions. Once the study was ready for implementation, a review of admissions on a bi-weekly basis was conducted by the investigator and team members. Both pilot studies preceeded the formal study and varied slightly from the formal study. The following is a review of procedures for the pilot studies and the formal study. In both pilot studies, where the interitem consistency was determined (as explained in the reliability discussion of the SDAF), the SDAF was administered within the first seven days after admission. At this time the patient received: 1. An Information and Participation Request Form (Appendix C) 2. A Departmental Research and Consent Form (Appendix D) 99 3. SDAF (Appendix B, first pilot study; Appendix A, second pilot study). The investigator approached each subject either individually or in groups of two or three. As stated earlier, the pilot study needed to be repeated until interitem consistency was established in an acceptable range. After the establishment of the interitem consistency, the formal study proceeded. For the formal study of the clinical sample, all hypotheses were tested and test-retest reliability was determined. Subjects were tested within the first seven days after admission. At this time the subject received: 1. An Information and Participation Request Form (Appendix E) 2. A Departmental Research and Consent Form (Appendix D) 3. SDAF (Appendix A) After the subject completed the above forms, arrangements were made with the testing office of Pine Rest Christian Hospital for each subject to take the Millon Clinical Multiaxial Inventory (MCMI). This test was also administered within seven days after the subjects' admission to Pine Rest Hospital. 100 In the retest of the SDAF, the subject received another c0py of the SDAF (Appendix A) after the 14th day, but before the 20th day of hospitalization. Each subjects' therapist was notified if their client (in the clinical sample) was involved in the research, though no test findings were made available to them due to confidentiality reasons. Two persons in the clinical sample requested that the MCMI and SDAF be made available to their therapist. This request was added to the consent form and results were given to the therapist. The collection of data for the non-clinical was discussed earlier in this chapter. The investigator made contact with women employed in private and public agencies. These contacts were made through the agency's administration and the employees. Employees at Pine Rest Hospital were approached in order to have a representation in the non-clinical sample which may be similar to the clinical sample in cultural and religious background. The majority of the non-clinical sample were other professional and non-professional women in the greater Grand Rapids and Lansing, Michigan area. These persons were approached with the: 101 1. Information and Participation Request Form (Appendix F) 2. A Departmental Research and Consent Form (Appendix G) 3. SDAF (Appendix A) 4. MCMI Test Booklet and Answer Sheet Some persons chose to return the measures to the investigator in person and others chose to mail the measures. Most subjects preferred to separate the consent form from the test data for confi- dential purposes. Others were unconcerned about the confidentiality issue and mailed the signed consent form with the test results. Hypotheses There were three major and seven exploratory hypotheses tested in this study. As stated in the first two chapters, the principal objective of this study was to determine the presence of a relation- ship between low sexual desire and the histronic, passive-aggressive and borderline personality, as measured by the MCMI. The following are the three major hypotheses tested in this study. Hypothesis I The Histrionic (4) Scale of the Millon Clinical Multiaxial Inventory will show a Hypothesis II Hypothesis III 102 significant negative relation- ship with scores on the Sexual Desire Assessment Form. The Passive-Aggressive (8) Scale of the Millon Clinical Multiaxial Inventory will show a significant negative relationship with scores on the Sexual Desire Assessment Form. The Borderline (C) Scale of the Millon Clinical Multiaxial Inventory will show a significant negative relationship with scores on the Sexual Desire Assessment Form. In addition to the three major hypotheses, a number of exploratory items have been examined. The previous chapters reported that the present state of the research on sexual desire is minimal. The exploratory hypotheses, though not the major thrust of this study, can provide direction for future research along with the major hypotheses. The following are seven exploratory hypotheses. Hypothesis A Hypothesis B Hypothesis C Hypothesis D Hypothesis E 103 Selected Scales 1, 2, 3, 5, 6, 7 and S and P of the Millon Clinical Multiaxial Inventory will show a significant relationship with scores on the Sexual Desire Assessment Form. There will be a significant relationship between each item of the Sexual Desire Assessment Form. There will be a significant relationship between age and scores on the Sexual Desire Assessment Form. There will be a significant relationship between years of education and scores on the Sexual Desire Assessment Form. There will be a significant difference in the scores on the Sexual Desire Assessment Form 104 between the clinical and non-clinical sample. Hypothesis F There will be a significant difference in the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory between the clinical and non-clinical sample. Hypothesis G There will be a significant difference in the correlation of the Histrionic (4), Passive— Aggressive (8) and Borderline (C) Scales on the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form between the clinical and non- clinical sample. sense The general design of the study is descriptive in nature. The design used in this research is a 'data analysis" design (Campbell and Stanley, 1963). Causal connections between personality patterns and sexual desire cannot be demonstrated in a non-experimental study. 105 The purpose was to explore whether the reported presence of sexual desire (as measured on the SDAF) is correlated with personality patterns (as measured by the MCMI). In this study, it was hypothesized Scale 4 (Histrionic), Scale 8 (Passive-Aggressive) and Scale C (Borderline) of the MCMI would be correlated with scores on the SDAF. This study attempted to verify the existing theory through descriptive research methodology. Descriptive research is appropriate to the investigation because of its heuristic value. It was hoped that this research would also generate further questions, increase knowledge about personality patterns of women with reported low sexual desire and provide possible direction to further inquiry and theory development of sexual desire. A correlational design is appropriate when there is a need to quantify the degree of association between variables (Hopkins and Glass, 1978). The dependent variable (score on the SDAF) was correlated with the independent variables (scores on Scales 1 to 8, and S, C and P of the MCMI). The application of this statistical technique attempts to identify a relationship between self-reported experiences of sexual desire and personality patterns. Each subject received a 106 score on the SDAF and Scales 1 to 8 and S, C, and P of the MCMI. Analysis Statistical analysis was performed at Calvin College, Grand Rapids, Michigan, using the Statistical Package for Social Sciences (Nie, Hull, Jenkins, Steinbrenner and Bent, 1986). The Pearson product-moment correlation was used to test Hypothesis I, II, III, A, B, C, and D. This test was used to analyze the data on the total population as well as the clinical and non-clinical groups separately. This parametric test was chosen because it can summarize the magnitude and direction of the relationship (HOpkins and Glass, 1978) between the dependent variable (scores on the SDAF) and the independent variables (scores on Scales 1 to 8 and S, C and P of the MCMI). The Pearson product-moment correlation measures the goodness of fit of a linear regression line to the data and the strength of the linear relationship existing between two variables (Klecka, Nie and Hull, 1975). Scores on the SDAF were correlated with scores on Scales 1 to 8, S, C and P of the MCMI. The level of significance, which is the probability of a Type-I error, for the correlation coefficient was established at p (.01. This level 107 was determined due to the nature of correlational research. The coeffecient of determination (r) is most informative when it is squared (r2) which is the proportion of variance in the dependent variable that is predictable from the independent variable. The larger the correlation required for significance the larger the porportion of the SDAF is predictable from the MCMI Scales. An alpha level of .01 can limit the power of the test, 1-B. The power of the correlation test can be increased by N, the sample size. The sample size of 72 provides the power for this level of significance. To further explore Hypotheses I, II, III and A, additional testing was computed after the results of the Pearson product-moment correlations were reviewed. These included a multiple regression, a simple regression and a partial correlation, on Hypotheses I, II and III to maximize the accuracy of predicting sexual desire from the personality patterns as measured on the MCMI. A multiple regression was also computed on Hypothesis A. Regression is a statistical method which allows for prediction of a dependent variable from one (simple regression) or more than one (multiple regression) independent variables. The fundamental task of regression is to explain the variance of a dependent variable (Kerlinger and 108 Pedhazur, 1973) and to describe the nature of a relationship (Kachigan, 1986). It is a method of analyzing the collective and separate contributions of one or more independent variables to the variation of a dependent variable (Kerlinger and Pedhazur, 1973). A simultaneous multiple regression is recommended when no single independent variable is anticipated to be a better predictor than other variables (Cohen and Cohen, 1976). In this study no personality pattern was anticipated to be a qualified predictor and a simultaneous multiple regression was computed. Another test that was computed for this study, was a partial correlation. This is a reduced correlation used as a form of statistical control (Kerlinger and Pedhazur, 1973; Edwards, 1979). This control is suggested when multicollinearity exists between two independent variables in a multiple regression equation. Multicollinearity exists when two or more variables have high intercorrelations, indicating a redundancy in the prediction provided to the dependent variable (Neter and Wasserman, 1974). Highly correlated variables add little predictive power (Nunnally, 1967; Kelly, Beggs, McNeil, Eichelberger and Lyon, 1969). When multicollinearity is present, the regression coefficient of any independent variable 109 depends on which other independent variables are included in the equation (Neter and Wasserman, 1974). The partial correlation considers this in its analysis. After the correlations were computed for Hypotheses I, II, and III an intercorrelation of .783 was computed between the Passive-Agressive (8) and Borderline (C) Scales of the MCMI. The significance of a .783 correlation affecting the prediction of the dependent variable is questionable. Even though a partial correlation is not mandated by the size of this intercorrelation, it was computed to obtain a more complete picture of the independent variables effect on the dependent variable. This correlation, which is a Pearson r, provides information on the relationship between the dependent variable and independent variable, having controlled for the influence of the other independent variables in the equation (H0pkins and Glass, 1978). It is calculated using a regression analysis. A second-order partial correlation was computed for this study due to the number of independent variables. For Hypothesis E and F, a mean and standard deviation were determined and a t—test was computed to determine differences in means of independent observations. Hypothesis G compared correlational coeffecients. The z-test for testing independent 110 correlation coefficients was computed for Hypothesis G. A significance level of p (.05 was determined for the t and z-test. The N of each group was less than the N for the correlation studies which limits the power of the test. The power of the test may be increased by increasing alpha which was done for the t and z-tests. Before closing the analysis discussion, it is necessary to review the assumptions for statistical testing. Assumptions of the statistical tests used in this study include: 1) Independence of observation, 2) Linear regression, 3) Homoscedasticity, 4) Normal distribution, 5) Random sample, 6) Equal variance in the population, Assumptions one through three were met in this study. Assumption number four, that of a normal distribution, may be violated, according to the central limit thereom, when there is a larger number in the sample. The size of this sample, 72, is considered an adequate number to meet the central limit thereom's demands. Assumption number five deals with random sampling. The samples were not randomly selected in this study. Tukey and Cornfield (Glass and Stanley, 1970) argue the issue 111 of generalization when random sampling is not used. They assert that generalization may be made to a ”like" pOpulation as those chosen in the study. In this study a “like” population would be females, clinical and non-clinical, age 18 to 45 years of age who have been married for at least a year and reside in the midwest section of this country. In the t-test for mean differences (Hypotheses E and F) assumption number six was violated. That assumption is that the variance observations in both pOpulations are equal (HOpkins and Glass, 1978). This assumption can be violated when the sample size is equal in number or if the greater variance is in the larger sample. (Glass and Stanley, 1970). In this study neither of these criteria were met; variances were assumed to be greater for the smaller clinical group as well there being an unequal number in the groups. This can result in the probability of a Type I error being greater than alpha. With a Type I error, the Null Hypothesis would be rejected when it is correct. The SPSS (1986) statistically controls for these violations by computing a separate variance estimate for the violations of these assumptions. The test results reported in this study reflect that statistical control. 112 Summary Using a sample of 72 women (30 clinical and 42 non-clinical), self—reported data on the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form was collected. The variables in this study are the dependent variables (scores on the SDAF) and the independent variables (Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the MCMI. The sample and procedure for collecting data were described. Reliability and validity on the MCMI and SDAF were established. Statistical tests of correlation, regression, t-test for mean score differences and the z-test for differences in correlations of the two samples were discussed. The results of the above analysis are reported in Chapter IV. CHAPTER IV ANALYSIS In Chapter IV the results of the hypotheses are set forth. The results of the testing of the major hypotheses correlating MCMI Histrionic (4), Passive—Aggressive (8) and Borderline (C) Scales and scores on the Sexual Desire Assessment Form are presented in the first section. In the second section, the results of further exploratory testing of Hypotheses A through G are presented. The third section summarizes the results. Results 23 Major Hypotheses The initial research plan provided for the use of 30 subjects for both the clinical and non—clinical groups in testing all hypotheses. The final data gathering included 30 subjects in the clinical group and 42 subjects in the non-clinical group. The availability and response of non- clinical subjects proved to be greater than initially anticipated resulting in a total number of 72 subjects for the testing of the hypotheses. Statistical conclusions for the hypotheses were based on the total number of both samples. The 113 114 findings of each sample (clinical and non-clinical) are also reported. Following is a report on the major hypotheses. Major Hypotheses Hypothesis‘l The Histrionic Scale (4) of the Millon Clinical Multiaxial Inventory will show a significant negative relationship with scores on the Sexual Desire Assessment Form. The first hypothesis, stating that the Histrionic (4) Scale of the MCMI will show a significant negative relationship to scores on the SDAF, was tested using the Pearson product-moment correlation. The correlation was found to be significantly positive (r = .412, p (.001) for the total group (clinical and non-clinical) (Table 4.1). A positive correlation indicates that persons with higher scores on Scale (4) also scored higher on the SDAF, reflecting greater sexual desire than low scores. When each group was correlated separately neither the clinical group nor the non-clinical group were found to have a significant correlation. The clinical group had an r=.238, p=.107 and the non-clinical group had an 115 r=.219, p=.08l. The r2 is also reported in the major hypotheses. r2, the coefficient of determination, expresses the proportion of variance of the dependent variable (SDAF) determined by the independent variable (MCMI Scale) (Kerlinger and Pedhazur, 1973). r2 = .169 for Hypothesis I. A significant positive relationship was found between scores on the Histrionic (4) Scale of the MCMI and scores on the SDAF. Therefore, Hypothesis I was rejected. Hypothesis 1; The Passive-Aggressive (8) Scale of the Millon Clinical Multiaxial Inventory will show a significant negative relationship with scores on the Sexual Desire Assessment Form. The second research hypothesis, stating that the Passive-Aggressive (8) Scale of the MCMI will show a significant negative relationship with scores on the SDAF, was tested using the Pearson product-moment correlation. The correlation for the total group was found to be a significant negative correlation (r=-.526, p (.001) (Table 4.2). A negative correlation indicates that a person with high scores on Scale (8) scored lower 116 on the SDAF, reflecting low sexual desire. The clinical group showed a significant negative correlation (r = —0.515, p (.01). The non-clinical group showed no significant relationship (r = -0.028, p = .431). r2 = .277 for Hypothesis II. A significant negative relationship was found between scores on the Passive-Aggressive (8) Scale of the MCMI and scores on the SDAF. Therefore, Hypothesis II was confirmed. Hypothesis III The Borderline (C) Scale of the Millon Clinical Multiaxial Inventory will show a significant negative relationship with scores on the Sexual Desire Assessment Form. The third research hypothesis, stating that the Borderline (C) Scale of the MCMI will show a significant negative relationship with scores on the SDAF, was tested using the Pearson product-moment correlation. The correlation for the total group showed a significant negative correlation (r = -0.435, p (.001) (Table 4.3). In the clinical pOpulation, a negative correlation (r = -.377 p = .02) was found but is not considered significant for this study. In the non-clinical 117 TABLE 4.1 Correlation of Scores on the Millon Clinical Multiaxial Inventory Histrionic (4) Scale and Scores on the Sexual Desire Assessment Form B a £3 Clinical 30 .238 .057 Non-Clinical 42 .219 .048 TOTAL 72 .412** .169 *p<.01 **p<.001 118 TABLE 4.2 Correlation of Scores on the Millon Clinical Multiaxial Inventory Passive- Aggressive (8) Scale and Scores on the Sexual Desire Assessment Form B .1; r_’ Clinical 30 -.515* .265 Non-Clinical 42 .028 .001 TOTAL 72 -.526** .277 *p<.01 **p<.001 119 TABLE 4.3 Correlation of Scores on the Millon Clinical Multiaxial Inventory Borderline (C) Scale and Scores on the Sexual Desire Assessment Form I! .2 £3 Clinical 30 -.377 .141 Non-Clinical 42 .064 .004 TOTAL 72 -.435** .189 *p<.01 **p<.001 .8 120 population no signficant correlation was found (r = 0.064, p = .346). r2 = .187 for Hypothesis III. A significant negative relationship was found between scores on the Borderline (C) Scale of the MCMI and the SDAF. Therefore, Hypothesis III was confirmed. As discussed in Chapter III, to further explore Hypothesis I, II, and III, additional statistical investigation was conducted. A multiple regression was computed to predict the SDAF from the three scales of the MCMI. Table 4.4 reports the results of the multiple regression analysis of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the MCMI and the SDAF. When all independent variables are simultaneously entered into the equation, a significant level was computed (F = 12.1699, p (.001). Multiple R= .5911 and R2= .3493. The R2 signifies the prOportion of the variance in the criterion variable (SDAF) predictable from variation in the derived variable of composite scores. The derived variable is the weighted combination of the other variables (Kachigan, 1986). The adjusted R2 = .3206 is the R2 compensated, based on the number of variables and the number of observations in the study. To the extent that the adjusted R2 and R2 are similar 121 Hoc.va.. Ho.va. «anon.» Hmfic. “UV madaumvuom «cvom.n meme.) .m. o>wmmoumm¢ Io>fimmom mac. hvmw. Avv OficOwHumwm mmwmwlm doom moanmwum> cOwummmm on» ca moannflum> ..mmo.~a mo.m emfio. sewn. moan. “Ham. means a gaseous «m cmumsmaa «m eosmsnea ~m m camauaaz mo mooumoa mscws um .mhuzv Euom ucoEmmomm< daemon Hosxom on» can mucuco>cH Howxmfiuaaz Hooficwau coda“: on» no moanom “UV ocHHuoouom can Am. o>wmmouomanmnm .Avv owcoauumwm onu mo mamaamc< cowmmouoom onfiuHs: ¢.¢ manta 122 there can be confidence that the real relationship between the independent and dependent variable was measured (Kachigan, 1986). In this regression, the difference between the two R2 is .0187. Beta weights, also called the regression weights, are the slope of the regression lines reported in standard score form. These weights are the function of l) the correlations of the individual predictor (independent) variables with the criterion (dependent) variable and 2) the correlations that exist among the predictor variables themselves (Draper and Smith, 1966; Kachigan, 1986). The Beta weights are .2847 for the Histrionic (4), -.4563 for the Passive- Aggressive (8) and .0181 for the Borderline (C) Scales. The findings on the multiple regression directed the decision to compute a simple regression and partial correlation as discussed in Chapter III. A simple regression was computed between the SDAF and each personality pattern, Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the MCMI. The results (Table 4.5) were all three personality patterns, when analyzed separately, had a significant F (p (.001). The simple regression revealed the 123 aoo.va.. acmon.u~ op.n hon..l undo. «cach.u~ on." mmNm.u mono. «conn.vu on.” «mac. cane. canes m sooooum noun «a vounaficc no noouuoo use“! «a Amhuzv Euom ucoEmmomm< oufimoo Hosxom ac.vac nhhn. Gama. omen. «OBN. comm. oaou. as eouuafiec «a bvnv. mama. «saw. a Ouuuunal was one muoucmecH Hangmauas: Hmoacaao :oHHa: on» we museum .0. ocwauocuom can Am. o>fimmoummwmmnm ..v. cacofiuumfim on» no mamaamc< :ofimmoumom oamswm m.v mdm<9 .0. Godunovuon .0. osunnouuo< ioaunnsm .v. vascuuunwa codename; 124 Histrionic (4) Scale F = 14.326, the Passive- Aggressive (8) Scale F = 26.708 and the Borderline (C) Scale F = 16.305. The R2 for these three scales are .1698, .2761 and .1889 (Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales respectively). The adjusted R2's are reported in Table 4.5. The differences between the R2 and adjusted R2 are .0118, on the Histrionic (4) Scale, .0103 on the Passive-Aggressive (8) Scale and .0116 on the Borderline (C) Scale. Beta weights of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales are .4122, -.5255 and -.4347 respectively. Thus, the simple regression adds to the correlation data, that is, Scale 4, 8 and C of the MCMI not only correlated with the SDAF but also predict the SDAF score. In addition to the regression, a partial correlation was computed. The partial correlation examined the correlation of the dependent variable and each independent variable while the other two variables' influence on the dependent variable and the independent variable under study was removed. Table 4.6 reports the results of the partial correlation analysis. The Histrionic (4) and Passive-Aggressive (8) Scales of the MCMI had significant correlations with the SDAF (r = .3152, p (.01, r = .3315, p (.01 respectiveIY). while the 125 TABLE 4.6 Partial Correlation of Scores on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72) Variables Degrees of Variable Controlled Freedom r Histrionic (4) 8,10 3,68 .3152* Passive- Aggressive (8) 4,10 3,68 .3315* Borderline (C) 4,8 3,68 .0137 *p<.01 **p<.001 126 influence of the other variables was controlled. The Borderline (C) Scale of the MCMI did not show a significant correlation (r =.0137, p =.46) with the SDAF when the influence of the Histrionic (4) and Passive-Aggressive (8) Scales were removed. Results of Exploratory Hypotheses In addition to the major hypotheses, Hypotheses A through G were tested in the interest of exploration. Exploratory Hypotheses Hypothesis'A Selected Scales l, 2, 3, 5, 6, 7, S and P of the Millon Clinical Multiaxial Inventory will a show a significant relationship with scores on the Sexual Desire Assessment Form. Hypothesis A, stating that selected Scales 1, 2, 3, 5, 6, 7, S and P of the MCMI will show a significant relationship to scores on the SDAF, was tested using a Pearson product—moment correlation. In the total group, it was found that there is a significant negative relationship between the Schizoid (1), Avoidant (2), Dependent (3) and Schizotypal (S) Scales on the MCMI and scores on the SDAF (Table 4.7). A significant positive relationship was found in the total group on the 127 Narcissistic (5), Antisocial (6), and Conforming (7) Scales of the MCMI and scores on the SDAF. In the clinical group, a significant negative correlation was found between scores on the Schizoid (1) and Avoidant (2) Scales and the SDAF. Also in the clinical group a significantly positive relationship was present on the Narcissistic (5) Scale of the MCMI and scores on the SDAF. No significant relationship was found in the non-clinical group. Based on the significant results found in the total group, Hypothesis A was partially confirmed. To further explore this hypothesis, a simultaneous multiple regression was computed. Table 4.8 reports these results. When all scales were entered into the regression, a significant F 86.3080 (p (.001) was found. The R2 was found to be .4447, and the difference between the R2 and the adjusted R2 =.0705. Beta weights and F values for each Scale are: Schizoid (l) B= -.4948, Fa 7.176; Avoidant (2), B= -.1596, F= .592; Dependent (3), B= .0067, F= .002; Narcissistic (5), B= .1899, F= .871; Antisocial (6),B= .1075, F8 .494; Conforming (7), B= .1588, F= 2.227; Schizotypal (S), B- .3123, F8 2.759; and Paranoid (P), B= .0856, F- .556. The Schizoid (1) Scale of the MCMI was the only scale found to be a significant predictor (F: 7.166, 128 TABLE 4.7 Correlation of the Schizoid (l), Avoidant (2), Dependent (3), Narcissistic (5). Antisocial (6), Conforming (7), Schizotypal (5). and Paranoid (P) Scales of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form Clinical Clgggcal Total Total N=30 N=42 N=72 N=72 r r2 r r2 Schizoid (1) -.466* -.297 -.573** .328 Avoidant (2) -.510** -.127 -.569** .324 Dependent (3) .210 ~ -.029 -.375** .141 Narcissistic (5) .426* .234 .507** .251 Antisocial (6) .323 .040 .392** .154 Conforming (7) .299 .012 .289* .084 Schizotypal (S) -.352 -.046 -.428** .183 Paranoid (P) .305 .315 .158 .025 *p<.01 **p<.001 129 TABLE 4 . 8 Multiple Regression Analysis of Scales 1, 2, 3, 5, 6, 7, S and P of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form (N=72) R2 minus Degree of Multiple R R2 Adjusted R2 Adjpsted R Freedom F value .6668 .4447 .3742 .0705 8,63 6.3077** Variables in the Equation Variables Beta F. Value Schizoid (1) -.4948 7.176** Avoidant (2) -.1596 .592 Dependent (3) w .0067 .002 Narcissistic (5+ .1899 .871 Antisocial (6) .10755 .494 Conforming (7) .1588 2.227 Schizotypal (S) .3123 2.759 Paranoid (P) .0856 .556 *p<.01 **p<.001 130 p (.001) in this multiple regression analysis. Compared with the three variables of Hypotheses I, II, and III, these eight variables have an F value of approximately half the size of the other three independent variables. Hypothesislg There will be a significant relationship between each item on the Sexual Desire Assessment Form. Hypothesis B, stating that there will be a significant relationship between each item on the SDAF, was tested using a Pearson product-moment correlation. Table 4.9 summarizes the results. In examining the correlation matrix, it appears that item number three, dealing with masturbation, was the most poorly correlated item with other items on the SDAF with correlations ranging from .059 to .257. Number nine, which assesses the frequency of sexual fantasy, was correlated with a lower number of items as well with correlations ranging from .059 to .331. Item number four, a direct question about the respondents' frequency of sexual desire, correlated most frequently with other items with correlations ranging from .319 to .679. This item correlated at p (.01 with at least nine other items. Therefore, the Hypotheses B was confirmed. 13]. Scene. 37a. ccuvh. ccQOB. cunn. ccnnc. ccmflh. ccono. ccono. ccnhw. hm“. ccunh. ccflnh. Huumm ccovh. cchom. «nu. no". cconv. ccuov. chmc. cchov. own. ccnon. ccufln. «a ccneb. ccbnm. an". new. ccmuv. ccnhn. ccnon. ccouv. who. cconm. ccvvn. an cunn. «nu. mnN. boo. «co. hvc. .vmo. cnun. «no. non. 699. n ccnuv. non. con. #09. can. and. non. ccvnn. and. cnnn. son. a ccnuh. cconv. ccmuv. «co. can. ccnbm. ccnoo. cmnn. «cu. ccuon. ccoov. s cccnm. ccnnv. ccnhn. 6.0. «ha. ccnhm. cccmv. can". Qua. can. fins. w ccooo. chmv. ccnom. two. men. ccnoo. cconv. coon. and. ccnnn. ccnno. n ccnho. cchov. cconv. cunn. ccvon. coun. conN. cnon. new. ccnvw. ccnmv. v nmn. can. aha. nmc. and. awn. coo. can. ova. «no. wcu. n ccnnb. ccnwm. cconm. nun. ccnnn. ccnwn. can. ccnnn. chvo. «no. cconh. N ccumh. ccuno. ccvvm. hnc. non. cconv. hnu. ccnnw. ccunv. man. ccnnh. u hum” S 3 a a e e m c n a. a so”: Amwnzv Euom ucoEmmomm¢ ouwmoa Hmsxom on» no EouH come no Ramon: cowunaouuou m.v mqm<9 132 Hypothesis‘g There will be a significant relationship between age and scores on the Sexual Desire Assessment Form. Hypothesis C, stating that there will be a relationship between age and scores on the SDAF, was tested using a Pearson product-moment correlation. The correlation between age and scores on the SDAF for the total sample was r = -.021, p =.429 (Table 4.10). The clinical sample's relationship between age and scores on the SDAF was r =.072, p =.353. The non-clinical sample's relationship between age and score on the SDAF was r =-.234, p =.07. No significant relationship was found in either group. Therefore, Hypothesis C was rejected. Hypothesis‘g There will be a significant relationship between years of education and scores on the Sexual Desire Assessment Form. Hypothesis D, stating there will be a significant relationship between years of education and scores on the SDAF, was tested using a Pearson product-moment correlation. No significant relationship (r 8.219 p =.032) was found in the 133 TABLE 4.10 Correlation of Age and Scores on the Sexual Desire Assessment Form B .5 I3. Clinical 30 .072 .005 Non-Clinical 42 .234 .055 TOTAL 72 .021 .000 *p<.01 **p<.001 134 TABLE 4.11 Correlation of Years of Education and Scores on the Sexual Desire Assessment Form .1! r 5.3 Clinical 30 .264 .070 Non-Clinical 42 .123 .048 TOTAL 72 .219 .048 *p<.01 **p<.001 135 total group (Table 4.11). Neither the clinical nor the non-clinical groups were found to have significant relationships, r=.264, r=.123, respectively. Therefore, Hypothesis D was rejected. Hypothesis‘g There will be a significant difference in the scores on the Sexual Desire Assessment Form between the clinical and the non—clinical sample. Hypothesis E, stating that there will be a significant difference in the scores on the SDAF between the clinical and non—clinical sample, was tested for level of significance using a t-test on the mean scores of each item of the SDAF. Table 4.12 reflects the results of the t-test for mean scores on each item of the SDAF for the clinical and non-clinical sample. The clinical sample consistently scored significantly lower on nine of the eleven items of the SDAF reflecting a lower sexual desire than the non-clinical group. A significant level of difference (p (.001) was found on the total score of the SDAF and on item number seven. Item seven assesses the frequency of the subjects' response to sexual advances by the mate. Item numbers 1, 2, 3, 5, and 10, nearly half of the TABLE 4.12 t-test Mean Score Differences on all Items of the Sexual Desire Assessment Form in the Clinical (N830) and Non-Clinical (N=42) Samples Clinical Non-Clinical N=30 N=42 Mean S§:3?ard Mean S;23?ard t-test Item 1 3.43 1.68 4.64 1.25 3.35** 2 4.07 1.78 5.07 1.05 2.77** 3 1.27 .52 1.76 1.05 2.63“ 4 4.27 2.13 5.19 1.37 2.09* 5 4.00 2.32 5.50 1.61 3.05** 6 4.47 2.19 5.40 1.75 1.94 7 3.80 2.04 5.95 1.32 5.06*** 8 3.50 2.29 4.69 1.57 2.47* 9 3.40 2.24 3.02 1.94 -0.74 10 3.87 1.89 4.93 1.09 2.77** 11 2.87 1.90 3.76 1.32 2.22* ggigl 38.47 12.81, 49.90 7.73 4.71*** *p=<.05 **p= <.01 ***p= <.001 137 SDAF items were found to be significantly different (p <.01) between the clinical and non-clinical groups. These items assessed the frequency and desired frequency of sexual activity (1 and 2), frequency of masturbation (3), satisfaction of the sexual relationship (5) and the importance of sexual activity (10). Item number four and eight were found to have a significant difference at p (.05. These items assessed the frequency of feeling sexual desire (4) and the subjects' reaction to erotic materials such as movies, books, (8). Item numbers six and nine were not significantly different (r= .194, p= .06 and r= -0.74, p =.46 respectively). Item number six assesses the frequency of feeling uncomfortable about sexual activity and number nine assesses the frequency of imagining sexual activity. Item number nine is the only item of the SDAF in which the clinical sample had a greater mean score than the non-clinical sample, though the difference was not statistically significant. A significant difference (p (.05) in means was found between the clinical and non-clinical samples on the total SDAF scores and nine of the eleven items of the SDAF. Two items were not signifi- cantly different. Therefore, Hypothesis D was partially confirmed. 138 Hypothesis‘g There will be a significant difference on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales on the Millon Clinical Multiaxial Inventory between the clinical and non-clinical sample. Hypothesis E, stating that there will be a significant difference on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales on the MCMI between the clinical and non-clinical sample, was tested for level of significance using a t-test on the mean of the base rate scores of the MCMI. (Table 4.13). There is a significant difference (p <.001) between the clinical and non- clinical scores on the Histrionic (4) (t= 3.59), Passive-Aggressive (8) (ts -8.57), and Borderline (C) (t= -5.90) Scales of the MCMI. The non- clinical sample scored significantly higher (3‘ =65.26) on the Histrionic (4) Scale of the MCMI than the clinical sample (i =4l.26). On the Passive-Aggressive (8) Scale of the MCMI the clinical group scored significantly higher, with a (§_=78.93) for the clinical sample and a (§—=28.61) for the non-clinical sample. The clinical group also scored significantly higher (§-=7B.l3) than TABLE 4 . 13 139 t-test Mean Score Differences on the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory in the Clinical (N=30) and Non-Clinical (N=42) Samples Clinical Non-Clinical (N=30) (N=42) Standard Standard Mean . Deviation Mean Deviation t test “”3?“ 41.267 32.097 65.262 21.313 3.57*** Passive- Aqqrmive 78.933 25.223 28.619 23.624 -8.57*** m ”"3“" 78.133 24.836 45.571 20.391 -5.90*** *p<.05 **p<.01 ***p<.001 140 the non—clinical group (i =45.57) on the Borderline (C) Scale of the MCMI. Therefore, Hypothesis F was confirmed. Hypothesis'g There will be a significant difference in the correlation of the Histrionic (4), Passive- Aggressive (8) and Borderline (C) Scales scores of the Millon Clinical Multiaxial Inventory and the Sexual Desire Assessment Form between the clinical and non-clinical sample. Hypothesis G, stating that there will be were a significant correlation of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scale of the MCMI with the SDAF, was tested using a z-test for differences in correlation. Results (Table 4.14) reflect that there is a significant difference in the correlations between the clinical and non-clinical samples on the correlation of the Passive-Aggressive (8) Scale of the MCMI and the SDAF (z 82.16, p (.05). No significant difference was found between the two groups on the correlation of the Histrionic (4) Scale of the MCMI and the SDAF (z =.0779) or the 141 TABLE 4.14 Differences in the Correlation Scores of the Histrionic (4), Passive-Aggressive (8) and Borderline (C) Scales of the Millon Clinical Multiaxial Inventory and Scores on the Sexual Desire Assessment Form . . Non- Clinical Clinical (N=30) (N=42) r r z-scores Variables Histrionic (4) .2380 .2195 .0739 Passive- _ _ * Aggressive (8) .5152 .0298 2.167 Borderline (C) -.3766 .0640 1.7460 *p<.05 **p<.01 142 Borderline (C) Scale (z 81.74) of the MCMI and the SDAF. Therefore, Hypothesis G was partially confirmed. M The results of this study are reported in two sections. First, the major hypotheses relating to sexual desire and personality patterns, as measured by the SDAF and the MCMI respectively, were tested and results were reported. Chapter III included the discussion of additional statistical tests of regression and partial correlation, which were computed after the results of the Pearson- product moment correlation were reviewed. These were reported in Chapter IV. Second, the results of the exploratory hypothesis were presented, including the correlation, t-test and z-test findings. The following chapter will summarize the results from this study. Chapter V will also include a discussion and the conclusions of this study. CHAPTER V SUMMARY AND CONCLUSIONS The major purpose of this study was to provide information about the relationship between sexual desire and personality patterns. In this chapter a summary of the study will be presented. Conclusions based on the results of the analysis of the data will be included. Limitations of this study and implications for future research and therapy will conclude this chapter. Review of the Study Sexual desire remains a largely unexplored area of organized research, although theoretical discussions have increased in the last decade. The greater number of discussions, compared with the sparse research, appear to be due to l) the present conceptual limitations on sexual desire; 2) the difficulty in measuring a concept that has biologic, sex-role, intimacy, perceptual, temporal and developmental variables (to cite but a few); and 3) the tendency of the sexual research to focus on observable responses, i.e. preorgasmia, impotence. This descriptive study has attempted to 143 144 examine correlations of sexual desire and to predict relationships between low sexual desire and personality characteristics. Relationships between sexual desire and personaltiy patterns from an object-relations, ego-psychologic perspective were hypothesized from the review of the literature. Specifically, it was predicted that the histrionic, passive-aggressive and borderline personalities would have low sexual desire. The study developed a Sexual Desire Assessment Form (SDAF). The SDAF was then correlated with' personality scores on the Millon Clinical Multiaxial Inventory (MCMI). Specifically, scales on the MCMI measuring histrionic, passive- aggressive and borderline personality patterns were correlated with the SDAF. The research hypotheses were tested on women, age 18-45 years and married for at least one year. These women included two groups, 30 hospitalized clinical subjects and 42 non-clinical subjects. The hypotheses that were generated assumed that relationships would be found between low sexual desire and psychopathology. These hypotheses, which were developed by a theoretical review of the literature, examined physical intimacy toleration, enjoyment and satisfaction by the histrionic, passive-aggressive and borderline 145 personality patterns. In addition, an investigation was conducted to determine differences in the clinical and non-clinical sample. Although other studies examined the relationship between sexual dysfunction and psychopathology, the relationship between sexual desire disorders and DSM-III, Axis-II personality diagnoses had not been investigated. In the present study, relationships between sexual desire and three specific personality patterns were investigated. Hypotheses about these relationships and differences in the clinical and non-clinical groups were based on theoretically derived explanations of specific ego defecits in persons with lower sexual desire. Hypotheses were divided into main Hypotheses (I, II, III) and Exploratory Hypotheses (A, B, C, D, E, F and G). Pearson product-moment correlations, multiple and simple regression, partial correlations, t-tests and z-tests were conducted to test the hypotheses. A summary of the results of the hypotheses tests is presented below. Items number one through four summarize the major hypotheses. Numbers five through eleven report the exploratory hypotheses. 1. Correlations were found to be 146 significantly positive (p <.001) between the SDAF and the Histrionic (4) Scale. Significant negative correlations (p <.001) were found between the SDAF and the Passive—Aggressive (8) and Borderline (C) Scales of the MCMI and the SDAF. When the above three MCMI variables were combined, the multiple regression analysis revealed them to be significant predictors (p <.001) of scores on the SDAF. In a simple regression analysis, all three scales were found to be significant predictors of the SDAF (p <.001). In response to the .783 intercorrelation found between the Passive-Aggreséive (8) and Borderline (C) Scales, a partial correlation was computed on all three variables. It was discovered that the Histrionic (4) and Passive—Aggressive (8) Scales had a significant correlation (p (.01) when the influence of the other variables were controlled. The Borderline (C) Scale did not significantly correlate with the SDAF when Scales Four and Eight were controlled. The first exploratory hypothesis examined the other eight personality scales of the 147 MCMI and found significant positive corre- lation (p <.001) between the Narcissistic (5), Antisocial (6) and Conforming (7) Scales of the MCMI and the SDAF. Signifi— cant negative correlations were found between the Schizoid (l), Avoidant (2), Schizotypal (S), (p <.001), and the Dependent (3), Scales (p (.01), of the MCMI and the SDAF. A multiple regression predicted that, when combined, the other eight personality scales of the MCMI were a significant predictor (p (.001) of the SDAF. Further examination revealed that only the Schizoid (1) Scale was a significant predictor (p <.001) of the SDAF. Demographic variables of age and years of education were examined in order to deter— mine a relationship between each of these variables and the SDAF. No significant relationships were found. Significant differences varied from p (.05 to p (.001 on nine of the eleven items and the total score of the SDAF between the clinical and non-clinical groups. Items six and nine did not show significant differences. Item number nine was the 10. 11. 148 only item in which the clinical group's mean score was higher (though not significant) than the non-clinical group's mean score. This item assesses the frequency of sexual fantasy by the respondent. Significant differences (p <.001) were found between the clinical and non- clinical groups on the Histrionic (4) Scale of the MCMI with the greater mean score in the non-clinical group. The mean score of the non-clinical group was not in the pathological range of the MCMI. Significant differences (p (.05) were found between the clinical and non- clinical groups on the Passive-Aggressive (8) and Borderline (C) Scales of the MCMI with the greater mean score in the clinical group. The mean scores of both of these scales were in the pathological range for the clinical group. Significant differences (p (.05) were found in the correlation of the Passive- Aggressive (8) Scale of the MCMI and the SDAF between the clinical and non-clinical groups. No significant differences were found between the two groups when the 149 Histrionic (4) or Borderline (C) Scales were correlated with the SDAF. Conclusions Major Hypotheses Hypothesis I was not supported by correlation nor regression analysis. Hypothesis II and III were supported by both of these statistical procedures. These hypotheses represented aspects of an object-relations and ego development perspective on personality patterns which might affect a female's sexual desire. The personality patterns specified in persons with lower sexual desire was hypothesized to be histrionic, passive-aggressive and borderline. These three personalities were assumed to have physical intimacy problems based on ego deficits and object—relational deve10pment. This was based on the theoretical explanation that the defenses, coping styles, impulse control problems and expression of affect would interfere with the experience and expression of sexual desire. Hypothesis I which predicted a negative relationship between the histrionic personality and the SDAF was rejected. Instead, this scale was found to be positively correlated with higher levels of sexual desire and the regression analysis supported this finding. The prediction of a 150 negative relationship was not confirmed but instead, testing found a significant positive relationship between the histrionic and sexual desire. Explanations for this unexpected finding are unclear at this time, but an expanded or different theoretical perspective may offer some explanation. The first explanation may be found in examining the description of the histrionic in Chapter II of this study. This chapter described a primitive histrionic whose defenses of denial and manipu- lation are rigid. The primitive histrionic would be less able to use alternative styles of meeting goals and controlling impulses than a histrionic who has greater ego development. This primitive histrionic would have ego arrest in the first four years of her life and would not have success- fully mastered the separation—individuation phase which leads to autonomy and relatedness with others, including the opposite sex. These problems with relatedness to males would be expressed in a withdrawal from sexual intimacy. In contrast, a less primitive histrionic would have more successfully developed ego strengths in the first four years of life and have primarily unresolved Oedipal issues which would stimulate a desire for sexual activity in order to resolve the feelings of 151 rejection by the father. Separation-individuation would have been resolved so the toleration for closeness with a male would be present. Perhaps the histrionic females measured in this sample reflect this higher level of functioning. If the MCMI does not capture the characteristics of the more primitive histrionic than the hypothesis would not be confirmed. The positive correlation between the Histrionic (4) Scale and the SDAF, can perhaps be also understood by reviewing Millon's presentation of the characteristics of the Histrionic (4) Scale (Millon, 1983). The histrionic is described as frequently engaging in exciting and seductive behavior. A flight into sexual activity may be a way for the histrionic to express the need for seduction and excitement. A significant part of the identity of a female histrionic is being considered a sexual object by males as she was considered to be by her father. This sexual seductiveness is a means to attain the closeness and feeling of being valued that she felt deprived of in her childhood. Being an attractive, seductive female is a coping style she developed to defend against the feeling of deprivation from her objects. Her sexual behavior may not be a desire for mature sexual intimacy but instead maybe an 152 attempt to obtain closeness without intimacy. If one considers the frequency of multiple partners that the histrionic may have, (Kernberg, 1985; Krohn, 1978; Mueller and Aniskiewicz, 1986), there appears to be an attempt to obtain intimacy without experiencing the depth of the relationship that is demanded by intimacy. In fact, there may be an illusion of intimacy without true intimacy. The sexual activity would be part of the symptomotology of the histrionic. The desire to be a valued, sexually attractive object may be inaccurately labeled as sexual desire. The ability to differentiate between being considered a sexual object and experiencing sexual desire is not possible at this time. A final possible explanation for the positive relationship between the histrionic personality and sexual desire may be found in a review of the mean scores of Scales l - 8, S, C and P of the MCMI. The Histrionic (4) Scale was one of four scales (the others being the Narcissistic (5), Antisocial (6) and Conforming (7) Scales of the MCMI) in which the non-clinical sample scored in a normal range yet scored higher than the clinical sample (Table 5.1). In a certain range these scales may be measuring psychological health. Low scores (which Millon does not interpret) or pathological scores 153 TABLE 5.1 t-test Mean Score Differences between the Clinical (N=30) and Non-Clinical (N=42) Samples on the Scales 1-8, S, C and P of the Millon Clinical Multiaxial Inventory Clinical Non-Clinical Scale N=30 N=42 t-test 3:322:42. 3:322:12. 3°93?“ 67.90 29.20 33.79 18.94 -5.61*** “it?“ 77.60 29.35 31.29 20.53 -7.44*** “9‘3?“ 82.83 22.85 51.31 21.48 -5.92*** ““3?“ 41.27 32.09 65.26 21.31 3.57*** ”mg?” 40.50 27.71 66.19 16.68 4.63*** ”it?“ 39.33 24.12 58.21 13.22 3.89*** “”1317“? 57.33 19.99 69.14 17.94 2.58** Passive- Nam-1v- 78.93 25.22 28.62 23.62 -8.57*** “Mtg???“ 64.43 19.85 42.76 15.43 -5.000*** ”“311" 75.13 24.84 45.57 20.39 -5.9o*** "5:3?“ 58.86 12.92 53.12 17.62 -l.60 *p<.05 **p<.01 ***p<.001 154 may be better predictors of low sexual desire. In a normal range of these scales, there appears to be a positive relationship with sexual desire. An explanation on why mean scores in the pathological range were not found in the clinical sample may be that females with these personality disorders (specifically the histrionic) do not present for hospitalization and are able to function in their daily activities. The non-clinical sample was not expected to have means in the pathological range due to the probable dispersion of personality disorders in the general population. Since neither the clinical nor non-clinical sample scored a mean in the pathological range for Scale 4, the hypothesis about the Histrionic (4) Scale may not have been adequately tested due to the study's failure to capture a sample of the histrionic population. Means in the normal range on this scale prevent any assertion about histrionic psychopathology and sexual desire. Turning to the other two scales of the MCMI investigated in this study, the passive-aggressive and borderline personality patterns were both found to have negative correlations with sexual desire as theoretically hypothesized. WOmen who scored higher on the Passive-Aggressive (8) and Borderline 155 (C) Scales of the MCMI were found to have lower sexual desire. Though both scales were significant predictors of lower scores on the SDAF, the Passive-Aggressive (8) Scale proved to be a better predictor when each scale was an independent SDAF predictor. Summarizing the reasons discussed in Chapter II, the passive-aggressive and borderline personality styles both reflect lability in affect, deficiencies in self—regulation and chronic interpersonal and affective ambivalence. The instability of their moods not only limits their ability to experience and express pleasurable affect to their partner but it may have implications in their partners' response to them. Men who are married to these women are likely to be either confused or angry at the unpredictability and hostility evident in the female's behavior. The male is likely to feel rejection or to coerce the female into sexual activity. Any of these behaviors in the male partner will increase the withdrawal of sexual feelings by the female. Thus, a cycle will have begun and would be perpetuated by the interaction of the two people in the relationship. Whether the sexual problems initiate with the pathology of the passive-aggressive or borderline personality, whether they choose male 156 partners who have their own pathology or whether the passive-aggressive or borderline's pathology maintains the problem in the relationship, at this time, is unknown. It does appear that low sexual desire is correlated with passive-aggressive and borderline pathology as measured by the MCMI. Kaplan (1985) asserted that low sexual desire is related to significant psychological and relationship problems. This study appears to confirm her assertion. In the multiple regression analysis, the Borderline (C) Scale did not add a significant amount to the prediction SDAF scores. Instead it was found that Histrionic (4) and Passive- Aggressive (8) Scale scores best predicted the SDAF. The inabililty of the Borderline (C) Scale to add to the prediction of the SDAF may be partially explained by its intercorrelation with the Passive-Aggressive (8) Scale reported in Chapter IV. The intercorrelation, which is discussed later in this section, would limit the Borderline (C) Scale's additional contribution to the SDAF after the removal of the Histrionic (4) and Passive-Aggressive (8) variables. Another possible explanation on why the Borderline (C) Scale does not add to the prediction of the SDAF may be that this scale is not measuring 157 what it states that it measures. The instability of the Borderline (C) Scale (Piersma, 1986b) may point towards its tendency to measure crisis responses rather than a true personality disorder. The crisis may be that which precipitated hospitalization instead of the borderline personality dynamics discussed in Chapter II of this study. In addition, factors which differentiate the passive-aggressive from the borderline personality may ultimately affect sexual desire. The borderline flucuates significantly in affect whereas the passive-aggressive seems to have a more stable mood. Both personalities have a considerable amount of anger. The borderline also has times of idealization of the objects and grandiose feelings about the self. The passive- aggressive has a chronic pervasive anger with less rigid defenses against the anger. In contrast, the borderline's defense of splitting in which the object can be both all bad and all good creates flucuation in moods. When the object and self are good, idealization and grandiosity are present. Sexual desire may be a way to express these idealizations. This sexual desire is likely to be a behavioral response to the splitting defense 158 rather than the sexual desire discussed in Chapters I and II. Despite the inabililty of the borderline to add to the prediction of the SDAF, this scale was found to have a significant negative correlation with the SDAF along with the Passive-Aggressive (8) Scale. Chapter II discusses the issues of each personality in detail but a brief review and explanation of why these two personalities are negatively correlated, while the histrionic is positively correlated, may be summarized by inspecting the personalities from a clinical perspective. Clinically, when examining their negative relationship with sexual desire, both the passive- aggressive and borderline personality appear to be more difficult to please, more apt to complain overtly or covertly of their dissatisfaction and both seem to have a greater amount of hostility than the histrionic personality either has or is able to express. This tendency, to act out their hostility, may be an additional explanation on why the passive—aggressive and borderline are highly correlated with each other, and correlate in the opposite direction of the histrionic. The desire to please and gain attention (found in the histrionic) appears to be less intense or even 159 absent in the passive-aggressive and borderline relationships. Instead, their anger seems to take precedence. A powerful way to express this anger in their relationship is to withdraw or deny sexual expression to and from the partner and thus to covertly express dissatisfaction without taking the responsibility for expressing the anger. This discussion is a tentative explanation for the unexpected findings of Hypotheses I and the findings of Hypotheses II and III. The impli- cations for research and therapy will suggest directions to study further explorations of these findings and conclusions. Turning now to the exploratory hypotheses, following is an analysis of the findings. Exploratory Hypotheses Other Scales of the MCMI. The first exploratory hypotheses investigated the correlation of Scales l, 2, 3, 5, 6, 7, S and P of the MCMI between the SDAF with significant correlations found on these other scales. Four other scales were found in the MCMI which negatively correlate with scores on the SDAF. Negative correlations were discovered between the SDAF and the Schizoid (l), Avoidant (2), Dependent (3) and Schizotypal (S) Scales of the MCMI. Thus, the exploratory Hypothesis A provided information 160 that the Passive—Aggressive (8) and Borderline (C) Scales were only two of six Scales of the MCMI negatively correlated with the SDAF. In order to obtain more information about this finding, a simultaneous multiple regression was computed. From the regression analysis, only the Schizoid (1) Scale was found to be a statistically significant predictor of SDAF scores with the other Scales being correlated but not significant predictors. An examination of the schizoid's charac- teristics may both explain this finding and present an issue that demands discussion. The schizoid is described as having affective deficits, weak affectionate needs, inapprOpriate social communication, interpersonal indifferences and perceptual insensitivity (Millon, 1981). The schizoid would be unlikely to feel a need or engage in behavior which reflects closeness to another person, sexually or otherwise. Due to her limited perception of her own and others' feelings, she may be less likely to label the low sexual desire as unsatisfactory. Unlike the passive-aggressive and borderline personalities, who Millon (1983) labels as "moving towards" other people, the schizoid “moves away“ from others. This “moving away“ makes her less likely to have relationships or to experience discomfort with sexual problems in a 161 relationship. The ”moving away" tendency also points towards an assumption in this study that needs discussion when making conclusions about test results. An assumption of this study was that the personality disorders under investigation would be negatively correlated with sexual desire and these persons would also be dissatisfied with their desire level. This study, developed from a clinical and theoretical perspective, sought to find more information about sexual desire and personality patterns. From the clinician's perspective, information was needed about the dynamics of women who seek sex therapy. Though personality patterns may be correlated with low sexual desire, dissatisfaction with it may be minimal in certain personality disorders with little interest in seeking therapy for the problem. The conclusion about this finding and discussion is that, though the Schizoid (1) Scale is negatively correlated with sexual desire, the schizoid seems to be less apt to seek therapy since awareness of and dissatisfaction with sexual desire is unlkely. Intercorrelation of the SDAF The testing of Hypothesis B, regarding the intercorrelation of all of the items on the SDAF, points toward some possible conclusions. Items 162 number three and nine correlated the least with the other items on the SDAF as well as the total SDAF score. Item number three assesses the frequency of masturbation. It has been documented (Masters and Johnson, 1970; Jayne, 1981;) that females are less likely to masturbate and when they do engage in this behavior, the onset is likely to be later in life for a female than it is for a male. In fact, a lack of masturbation in a male during adolescence. is considered a possible sign of sexual problems, whereas, this is not a diagnostic indicator for the female. Jayne, (1981), proposes that, despite the greater intensity of the orgasm for the female on masturbation, the preferred choice of sexual activity is with a partner. Married females in this study may prefer sexual activity with a partner over masturbation, which is a self-focused sexual activity. Whether this is a developmental, cultural or biologic issue is unclear. The results of this finding may indicate that masturbation may not be a criteria for sexual desire in married females. Item number nine of the SDAF assessed the frequency of fantasizing sexual behavior. This item correlated poorly with other items on the SDAF as well as with the total score of the SDAF. Item number nine provided examples of sexual fantasy. 163 These examples included fantasies of sex with one's partner or other partner(s), and coercion in sexual activity. The examples, attempting to help the respondent, may have limited the view of fantasy. Respondents may have a wider range of erotic fantasy (sexual and non-sexual) which were not considered because of the limiting effects of the examples. Fantasy, in the examples, was confined to imagining various sexual activities. It may be that other types of fantasy that are not specifically sexual in content or nature may be erotic for females. Nutter and Condron (1983) found the frequency of sexual fantasy during sexual activity to be less frequent in women with ISD. Their findings were not confirmed in this study. This points towards the need of both refinement in the assessment of sexual fantasy as well as further study. Demographic Relationships Hypotheses C and D examined two demographics of the samples used in this study: age and years of education and their relationships with sexual desire. No significant relationship was found between either demographic variable, age or years of education and sexual desire. The relationship between age and sexual desire was examined because is was thought that sexual desire may be affected 164 by the develOpmental tasks or physical changes of a certain age. It was also believed that sexual desire would be related to years of education. It has been theoretically hypothesized that females with higher amounts of education are more likely to acknowledge and express their sexual feelings. WOmen with less education are believed to not feel that sexual expression is a necessary and desirable component of their identity. These hypotheses were not confirmed in this study. Reasons for this may be that the range for both age (28 years) and years of education (12 years) is smaller than it is for scales on the MCMI (115 points). The variance and the number of persons in a sample affect a correlation. In this study, the variance is limited due to the age confines and realistic limitation on years of education. The sample size may have limited the likelihood of finding a correlation suggesting a larger sample size for studying these variable in the future. Differences in the Clinical and Non-Clinical Samples In relation to the hypotheses that suggest there is a difference in the clinical and non-clinical sample, the results seem to affirm what was stated in the first two chapters of the study. Those chapters argued that women with 165 psychOpathology would be more likely to have a lower sexual desire. It was found that women in the clinical sample did score significantly lower on nine of the eleven items of the SDAF as well as on the SDAF total score reflecting a lower sexual desire. There was one item on which the clinical sample scored higher (though not significantly) than the non-clinical sample, item number nine. This item, which dealt with fantasy, had a slightly greater mean in the clinical sample (X'= 3.40) than the non-clinical sample (§'= 3.02). This non- statistical difference and opposing direction from other items on the SDAF may be understood if one considers the purpose of fantasy. Sexual fantasy is used to both erotocize and to add excitement and variety to the sexual experience. It allows an individual to orchestrate mentally what she feels to be an exciting or ideal sexual situation (Masters, 1983). Sexual fantasy is also used as an escape from boring or unsatisfying experiences. An escape can be either a coping response or a pathological withdrawal. For the clinical group, the purpose and use of sexual fantasy may be appropriate or problematic. Since the coping styles of the clinical sample are often problematic in other areas of their life, it is possible that fantasy may be an escape from the problems in the 166 sexual relationship. Unfortunately, the data assessment in this study do not allow for any definite conclusions about this behavior. Item number six also did not reveal a significant difference between the clinical and non—clinical groups. Unlike number nine, the clinical sample did not have a greater mean than the non-clinical sample. Item number six assesses the frequency in which the idea of sexual activity is considered unpleasant or uncomfortable. The non-clinical sample found the idea uncomfortable slightly less often than the clinical group, indicating that the difference was in the anticipated direction but was not significant. This item may not be a sensitive indicator of the absence of presence of sexual desire or it may need refinement in its wording. Further testing of this item would be necessary to draw any conclusions. The clinical sample scored significantly higher on both the Passive-Aggressive (8) and Borderline (C) Scales of the MCMI than the non-clinical sample, with a mean score in the pathological range. The non—clinical sample scored significantly higher on the Histrionic (4) Scale but did not score in the pathological range. The conclusions of these findings were discussed 167 earlier in this section when the unanticipated results of Hypothesis I were reviewed. Differences in correlation were found between the clinical and non-clinical sample on the Passive-Aggressive (8) Scale of the MCMI when it was correlated with the SDAF (p (.05). The Histrionic (8) and Borderline (C) Scales' correlations with the SDAF did not show a significant difference between the two samples. This confirms the finding that characteristics of the passive-aggressive personality are more prevalant in the clinical sample. These traits have a significantly greater correlation with low sexual desire in the clinical sample than the non-clinical sample. In this section conclusions about the results found in this study were discussed. These potential explanations must be considered with caution as the limitations of this study are reviewed. Limitations The findings of this study are to be considered in the light of its limitations. Limitations of this study are divided into 1) sampling limitations, 2) assumptions about other MCMI Scales and 3) measurement limitations. 168 Sampling Limitations The first limitation may be found in the choice of a Christian hospital for selection of the clinical sample. This group may have a higher percentage of people with religious backgrounds. It is known that religious orientation and values have an effect on sexual function (Masters and Johnson, 1970). The effect of religious orientation on sexual desire in a marital relationship is unclear at this time. In addition, the selection of clinical subjects in the inpatient psychiatric hospital and the lack of random selection in the non—clinical sample prevented the use of random sampling. Since random sampling did not occur and religious background may be a component of some clinical and non-clinical subjects, the generalizability of this study is limited. Chapter III reviewed the Tukey and Cornfield arguement (Glass and Stanley, 1970). Their discussion is a logical argument for inferences to be made from a non-randomized sample to pOpulations of interest. Thus, results of both the clinical and non-clinical sample must be considered with regards to their special characteristics, i.e. hospitalized or non- hospitalized married females, age 18 to 45 years, residence in the midwest region of the country and 169 a large representation with a religious orien- tation. Assumptions regarding other MCMI Scales Hypothesis A found four other scales of the MCMI negatively correlated with the SDAF. These were the Schizoid (l), Avoidant (2), Dependent (3) and Schizotypal (S) of the MCMI. The Schizoid (1) Scale of the MCMI was found also to be a predictor of low scores on the SDAF. An earlier section of this chapter examined the theoretical reasons that a schizoid would be unlikely to present for sex therapy. Yet, this assertion is only hypothetical. The reasoning that persons with this personality diagnosis would not be dissatisfied with their lower level of sexual desire is tentative and based only on clinical observation, not on research. Therefore, though this study may have correlated relationships between personality patterns and sexual desire, it cannot predict which personality is most likely to present for sex therapy. Measurement Limitations Another limitation, which needs to be addressed, is the Sexual Desire Assessment Form, an unproved instrument, used in this correlation study. Two factors that can affect correlation values are 1) measurement error and 2) variability in samples (HOpkins and Glass, 1978). This section 170 will initially discuss potential measurement error of the SDAF and the MCMI. It will then review the sample variability. Measurement error can reduce the value of the observed correlation. In this study, the correlation and regression were most likely to be affected by errors in the SDAF. The SDAF measured a relatively new concept, sexual desire. This concept is presently limited to theoretical as well as proven research content. There is likely to be a large number of components to sexual desire not measured by the SDAF. These may include more behaviors in relationship to the partner, a greater variability on the type of fantasy and the experiences in previous sexual activity, to cite but a few of other variables which may affect sexual desire. These variables need to be investigated in order to deliniate and measure a larger number of the behaviors which reflect sexual desire. Another source of measurement error is the limited validity of the SDAF. Interitem consistency and test—retest correlations, both reliability measures, were determined for the SDAF. Validity determination for this measure were confined to content and face validity. The validity of this test to measure actual sexual desire rather than what the respondents' view as socially 171 desirable is questionable. This can be quite important in that sexual desire is susceptible to social desirability. Social desirability contains two sources of error in measurement 1) the tendency to describe one's self in a socially desirable manner and 2) the tendency to say good things about one's self, i.e. individual differences (Edwards, 1957; Nunnally, 1967). The major componenets of social desirability are 1) knowledge that the person has about what is socially desirable, 2) knowledge the person has about his/her own traits and 3) frankness in the individual in stating what he/she knows (Nunnally, 1967; Loevinger, 1972). All three of these factors are susceptible to violation when examining the sensitive area of sexual desire. Many persons would not be comfortable labeling themselves as having no sexual interest. This is particularly true in the last two decades when social mores have encouraged the development of one's sexual identity. Thus, a “fake good" profile would be possible for the samples' response on the SDAF. In contrast, there is also possibility that certain women in the sample, especially those in the clinical sample, would respond with a “fake bad“ response set. Persons who are hospitalized for psychiatric problems have a variety of feelings regarding their 172 hospitalization. In order to convince themselves and/or family of the necessity of psychiatric hospitalization, a tendency to complain unduly about minor difficulties may be present (Millon, 1983). It is possible that the “fake bad' phenomena contributed to some of the excessively low scores on the SDAF. In this study, the range of scores obtained on the SDAF (from 13 indicating low desire to 67 indicating high desire) speaks to the fact that the respondents were willing to acknowledge the absence or presence of sexual desire but the specific accuracy for each individual continues to be questionable. There are validity checks that would have improved the ability of this study to determine if social desirability or other interfering variables (e.g. memory) affected the SDAF scores. These may have included, 1) interviewing the spouse of each subject to confirm appropriate items on the SDAF; 2) having each subject keep a daily record of her sexual activity and thoughts; 3) the addition of an outpatient sample which may have verified the validity of the SDAF scores, if they would have scored a mean score on the SDAF between the clinical and non-clinical sample; 173 4) having the subjects complete two SDAF's, one describing their own sexual desire and one describing what they perceive as “normal“ sexual desire. The first two recommendations for improving validity may be perceived as intrusive by research subjects. Despite this potential for intrusiveness, verification of actual sexual behavior would add to the assessment of sexual desire. The MCMI does not theoretically appear to have the measurement errors as did the SDAF. This is primarily because it is a more tested tool for validity and reliability. There has been a critique, in this study, of its accuracy regarding the Borderline (C) and the Histrionic (4) Scales. In the literature review, the borderline personality is defined and described from a variety of perspectives; the sense of self, separation- indviduation, ego developmental skills, acting-out behaviors, and defense mechanisms. The statistical results of the Borderline (C) Scale of the MCMI and the SDAF may reflect the MCMI's inability to capture a more thorough measurement of this broad diagnostic category. As discussed earlier, the MCMI may be capturing crisis behaviors rather than the more enduring characteristics of the 174 borderline. The early section of this chapter also discussed the possibility that the MCMI may assess the higher functioning histrionic rather than the more primitive histrionic. A second major influence on statistical correlation is the variance in the sample. If other things are held constant, the greater the variability among the observations, the larger will be the correlation. A more homogeneous sample is likely to produce a smaller variance. In this investigation, there were components of hetero- geneity and homogeneity. Heterogeneity was found in clinical versus non-clinical subjects as well as different community sources. The age ranged from 18 to 45 years, a limitation put on by the study in order to control for menOpausal changes which could affect sexual desire. Educational backgrounds revealed a smaller variance than anticipated though 5 it did range from high school dropouts to women with Ph.D's but the majority of the sample fell towards the mean in years of education. A greater heterogeneity (variability) in the sample may have increased the correlations. In order to make the group more heterogeneous, additional variables may have been added to the sample. These could have included women from 1) both larger and smaller 175 communities, 2) outside the Michigan area and 3) in outpatient psychotherapy. Turning now to the conclusion of this study, the implications both for future research and therapy are considered. Implications for Research and Therapy The findings of the present study imply that there are correlations between sexual desire and personality patterns. As in all correlational studies no causal implications can be made from these findings. Yet this study did identify implications for future research. One of the first implications of this study is that the pathological histrionic personality needs to be assessed for sexual desire. This study's findings did not result in a mean score in a pathological range for either the clinical or non-clinical sample. Assessing women with histrionic pathology for sexual desire would determine if the theoretical assertions of Chapter II are accurate. This study also points toward the fact that other personality pathology needs to be investigated for its relation to sexual desire. Issues which need to be addressed are further affirmative studies in which personality patterns coexist with low sexual desire and which 176 personality patterns are most likely to seek therapy for a change in sexual desire. Is sex therapy for low sexual desire more successful with certain personality patterns? Can sex therapy, in its cognitive-behavioral model, change sexual feelings and sexual behavior for those persons with less ego development and more rigid and primitive object relations? Another direction for future research, addressed in Chapter I, was depression's contri- bution to low sexual desire in persons with personality disorders. Separating the depression from personality pathology when it is a component of that pathology may be difficult. Personality patterns are more enduring than a DSM-III, Axis-I diagnosis of depression. Sexual desire could be measured in the individual with a coexisting personality disorder and depression when the symptoms of depression are being experienced by the client and again when they are absent without the intervening variable of sex therapy. Obviously, this suggested study would require significant time. In examining the two personality diagnoses (passive-aggressive and borderline personality disorders) which correlated with a lower score on the SDAF, some of the similarities between the 177 diagnosis have been discussed. Labile affect, self-regulation difficulties, ambivalence and frequent experiences of anger and hostility have been cited as similar characteristics. A factor analysis of these behaviors and feelings in examining sexual desire may point toward the fact that these behaviors are the contributers to low sexual desire rather than the diagnosis of passive-aggressive or borderline personality in themselves. This could be difficult to differ- entiate since the behaviors are imbedded in the diagnoses. Identifying women who experience these behaviors and affects but who do not score in the pathological range of the scales on the MCMI may determine the difference in correlation between the affects and behavior and sexual desire versus the personality diagnoses and sexual desire. Turning to implications for therapy, this study seems to point out the need for sex therapists to develop a diagnostic tool for sexual desire which covers a greater variety of behaviors and experiences. The SDAF, developed for this study, needs refinement, additional criteria and further exploration. Its applicability to males has not even been investigated. If therapists are going to treat the client with low sexual desire with success, it is mandatory that the clinician be 178 able to identify what components of sexual desire are most problematic for each client. Another implication for therapy that needs to be examined from this study is the therapeutic prognosis of these passive-aggressive and border- line clients who enter sex therapy. The success of treating low sexual desire is lower than the treatment of other dysfunctions. According to the literature review, this lower success with desire disorders has been attributed to the absence of ego skills necessary for therapy. Sex therapy is a short-term, intensive type of therapy which rapidly analyzes and alters previously destructive behavior. It can also rapidly mobilize unhealthy defenses. Before sex therapy begins with desire disorder clients perhaps assessment of and treat- ment for the necessary skills for sex therapy would be mandatory. This is likely to mean that individual therapy would be a requirement for some seeking sex therapy. Skills which would be necessary before sex therapy began would include the ability to: 1. Experience and express a reasonable amount of care and committment to the partner. 2. Control defensive behavior, especially blaming and projection. an" .151— _- Tr “.55'.“ ~. I m‘ ‘ 179 3. Be introspective and aware of the impact of one's behavior on the relationship. 4. Express positive and negative affect overtly to the partner in a manner productive to the relationship. 5. Tolerate frustration and control impulses. Sex therapy assists the couple to develop these skills but the underlying abilities must be there in order to proceed through the therapy with a successful outcome. To summarize, this study found that sexual desire is correlated with psychopathology and found a specific correlation with passive-aggressive and borderline personalities. Further study is necessary in order to expand the clinician's knowledge of the dynamics of sexual desire and other personality disorders. Expansion of therapists' knowledge about sexual desire can assist in the provision of more successful outcomes in the treatment of low sexual desire. APPENDICES APPENDIX A Sexual Desire Assessment Form The following questionnaire, Sexual Desire Assessment Form, is to determine the level of sexual desire in your present relationship. First,please fill out the top righthand corner which requests information about your age and education. Then respond to the questions as you feel best provides information about your relationship in the past year. It is recognized that sexual patterns do fluctuate at times during the year so some questions may be difficult to answer. Please respond by circling only one answer to each item. Complete each item as best you can. Please consider the usual pattern of your sexual relationships for the past year. - A a 533‘ ‘Tfi -A -_.‘.... _,.__. 181 PLEASE NOTE: Copyrighted materials in this document have not been filmed at the request of the author. They are available for consultation, however, in the author's university library. These consist of pages: P. 182-1811 P. 185-186 University Microfilms lntemational 300 N. ZEEB RD, ANN ARBOR, MI 48106 (313) 761-4700 SEXUAL DESIRE ASSESSMENT FORM Age: Years of Education (Circle Highest Grade Completed) Grade School: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 Graduate: 1 2 3 4 Highest Degree Attained Please find the most appropriate response for each question when considering your sexual relationship for the past year (Circle most appropriate answer). 1. How frequently do you and your mate have sexual intercourse or activity? a.‘ b. C. d. e. f. d. 2. How once a day or more 3 or 4 times per week twice a week once a week once every 2 weeks once a month or less not at all frequently would you like to have sexual intercourse or activity? a. b. c. d. e. f. g. 3. How a. b. c. d. e. f. g. 4. How not at all once a month or less once every 2 weeks once a week twice a week 3 or 4 times a week once a day or more often do you masturbate? once a day or more 3 or 4 times a week twice a week once a week once every 2 weeks once a month or less not at all frequently do you feel sexual desire? This feeling may include wanting to have sex, 182 planning to have sex, fantasizing about having sex, feeling frustrated due to lack of sex, etc. a. once a day or more b. 3 or 4 times a week c. twice a week d. once a week e. once every 2 weeks f. once a month or less 9. not at all Overall, how satisfactory to you is your sexual relationship with your mate? a. extremely unsatisfactory b. moderately unsatisfactory c. slightly unsatisfactory d. slightly satisfactory e. satisfactory f. moderately satisfactory g. extremely satisfactory How frequently do you find the idea of sexual activity uncomfortable or unpleasant? a. once a day or more b. 3 or 4 times a week c. twice a week d. once a week e. once every two weeks f. once a month or less 9. not at all When your mate makes sexual advances, how do {I you usually respond? i a. almost always refuse b. often refuse c. sometimes refuse d. accept reluctantly e. sometimes accept with pleasure f. often accept with pleasure 9. almost always accept with pleasure ’ l‘ D" What is your usual reaction to erotic materials (pictures, movies, books)? a. almost always extremely aroused b. often aroused c. sometimes aroused d. often not aroused e. usually not aroused 183 10. 11. f. g. rarely aroused negative - feel repulsed, disgusted How frequently do you imagine sexual activity and/or encounters (e.g., sexual interactions with your mate or others, having more than one sexual partner, forcing or being forced by a sexual partner)? a. b. c. d. e. f. 9. not at all once a month or less once every two weeks once a week twice a week 3 or 4 times a week once a day or more Overall, in the last year, where would you rate the importance of sexual activity in your life? a. extremely important b. very important c. moderately important d. important e. slightly important f. rarely important 9. not important at all How frequently do you approach your mate for sexual activity and/or intercourse? a. b. c. d. e. f. 9. once a day or more 3 or 4 times a week twice a week once a week once every two weeks once a month or less not at all 184 ‘1 Ilium-t- Azure}! anon-99‘3”" .‘ I.‘ A 1721“: 4 APPENDIX B Sexual Desire Assessment Form The following questionnaire, Sexual History germ, is to determine the level of sexual desire in your present relationship. Please, please respond to the questions as you feel best provide information about your relationship in the past year. It is recognized that sexual patterns do fluctuate at times during the year so some questions may be difficult to answer. Please do your best and consider the usual pattern of your sexual relationships for the past year. i.— -— ‘fii‘ ‘ Int-K 184 .A SEXUAL DESIRE ASSESSMENT FORM Age: Years of Education (Circle Highest Grade Completed) Grade School: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 Graduate: 1 2 3 4 Highest Degree Attained Please find the most appropriate response for each question when considering your sexual relationship for the past year (Circle most apprOpriate answer). 1. How frequently do you and your mate have sexual intercourse or activity? a. once a day or more b. 3 or 4 times per week c. twice a week d. once a week e. once every 2 weeks f. once a month or less d. not at all 2. How frequently would you like to have sexual intercourse or activity? a. not at all b. once a month or less c. once every 2 weeks d. once a week e. twice a week f. 3 or 4 times a week 9. once a day or more 3. How often do you masturbate? a. once a day or more b. 3 or 4 times a week c. twice a week d. once a week e. once every 2 weeks f. once a month or less 9. not at all 4. How frequently do you feel sexual desire? This feeling may include wanting to have sex 185 w ”91148.! .S'AUJ'» n . , 33:41- plan sex, etc. a. b. c. d. e. f. 9. Over ning to have sex, fantasizing about having feeling frustrated due to lack of sex, once a day or more 3 or 4 times a week twice a week once a week once every 2 weeks once a month or less not at all all, how satisfactory to you is your sexual relationship with your mate? a. b. c. d. e. f. 9. Over sexu a. b. c. d. e. f. 9. When you a. b. c. d. e. f. g. extremely unsatisfactory moderately unsatisfactory slightly unsatisfactory slightly satisfactory satisfactory moderately satisfactory extremely satisfactory all, how satisfactory do you think your al relationship is to your mate? extremely satisfactory moderately satisfactory slightly satisfactory satisfactory slightly unsatisfactory moderately unsatisfactory extremely unsatisfactory your mate makes sexual advances, how do usually respond? almost always accept with pleasure often accept with pleasure sometimes accept with pleasure accept reluctantly sometimes refuse often refuse almost always refuse What is your usual reaction to erotic materials (pictures, movies, books)? a. b. almost always extremely aroused often aroused sometimes aroused often not aroused usually not aroused rarely aroused negative - feel repulsed, disgusted 186 APPENDIX C Information and Participation Request Form My name is Marty Whipple and I am a doctoral student at Michigan State University. I am conducting a research project that is being jointly sponsored by Michigan State University and Pine Rest Christian Hospital. I have trained in helping couples with sexual problems at the Masters and Johnson Institute in St. Louis, Missouri. Many people experience sexual difficulties in their relationships. Sometimes this is embarrassing or confusing to them. Often people are afraid to talk about it with other peOple. Yet it can cause a person loneliness, shame and unhappiness in their relationships. In the field of psychology, we are trying to learn it more about sexual problems. This reasearch is 1 trying to understand what kinds of sexual problems women experience in their relationships. I realize that this may be uncomfortable for 1 you. Please remember that there are no 'right' answers. It can be helpful to you by perhaps identifying some areas of concern you have about your sexual relationship. After completing this questionnaire, if you have any questions or 187 concerns about your sexual relationship, it would be helpful to discuss this with your therapist. This research is not part of the usual treatment program. If, at any time, you choose to withdraw from this study, you may do so with no penalty. As you can see, your name is not written on the Sexual Desire Assessment Form (SDAF). The results of this study are held in strict confidence and you will remain anonymous. At the end of my study, if you are interested, you may recieve results of this study. I sincerely thank you for your cooperation and appreciate your input. 188 1. APPENDIX D MICHIGAN STATE UNIVERSITY Department of Psychology DEPARTMENTAL RESEARCH CONSENT FORM I have freely consented to take part in a scientific study being conducted by: Martha Whipple under the supervision of: William C. Hinds, Ed.D. Academic Title: Professor of Counseling Psychology The study has been explained to me and I understand the explanation that has been given and what my participation will involve. My participation in this research is completely voluntary. I am aware that responding to the instruments in this research might lead to negative and unpleasant emotions. I understand that I am free to discontinue my participation in the study at any time without penalty. I understand that the results of the study will be treated in strict confidence and that I will remain anonymous. Within these restrictions, results of the study will be made available to me at my request. I understand that my participation in the study does not guarantee any beneficial results to me. I understand that involvement in this study is not part of the usual treatment program at this hospital. I understand that, at my request, I can receive additional explanation of the study after my participation is completed. Signed: Date: APPENDIX E Information and Participation Request Form My name is Marty Whipple and I am a doctoral student at Michigan State University. I am conducting a research project that is being jointly sponsored by Michigan State University and Pine Rest Christian Hospital. An area of psychology in which I have been trained at the Masters and Johnson Institute in St. Louis, Missouri, is in helping couples with sexual problems. Many peOple experience sexual difficulties in their relationships. Sometimes this is embarrassing or confusing to them. Often people are afraid to talk about it with other people. Yet it can cause a person loneliness, shame and unhappiness in their relationships. In the field of psychology, we are trying to learn more about sexual problems. This reasearch is trying to understand what kinds of sexual problems women experience in their sexual relationships. I realize that this may be uncomfortable for you. Please remember that there are no "right” answers. It can be helpful to you by perhaps identifying some areas of concern you have about your sexual relationship. After completing this questionnaire, if you have any questions or concerns about your sexual relationship, it would be helpful to discuss this with your therapist. 190 As you can see, your name is not written on the Sexual Desire Assessment Form (SDAF). The results of this study are held in strict confidence and you will remain anonymous. In approximately two weeks, you will be asked to take this test again so that the reliability of the test can be determined. At that time, I will again go over, with you, the information about taking the test. Your participation will also involve completing another test called the Millon Clinical Multiaxial Inventory (MCMI). This test is frequently used by the psychology staff at Pine Rest in order to obtain information which will be helpful to you in your therapy at Pine Rest. When the MCMI is requested by your therapist, the results will be available to her/him. If the test is not requested but is administered for the purposes of this study, then it will only be used for the purposes of this study. Your therapist will only review the results of the MCMI if it is a part of his/her assessment for your treatment plan. This research is not part of the usual treatment program. If, at any time, you choose to withdraw from this study, you may do so with no penalty. At the end of my study, if you are interested, you may receive results of this study. I sincerely thank you for your cooperation and appreciate your input. 191 I.- APPENDIX 1? Information and Participation Request Form My name is Marty Whipple and I am a doctoral student at Michigan State University. I am conducting a research project in the Department of Counseling Psychology, Michigan State University, East Lansing, Michigan. I have trained in working with couples on sexual issues at the Masters and Johnson Institute in St. Louis, Missouri. Many people have concerns about their sexual relationships. Sometimes this is embarrassing or confusing to them. Often people are afraid to talk about it with other people. Yet it can cause a person loneliness, shame and unhappiness in their relationships. In the field of psychology, we are trying to learn more about sexual issues. This reasearch is trying to understand what kinds of sexual problems and concerns women experience in their relationships. I realize that this may be uncomfortable for you. It can be helpful to you by perhaps identifying some areas of concern you have about your sexual relationship. After completing this questionnaire, if you have any questions or concerns about your sexual relationship, it may be helpful to discuss them with your spouse or a 192 1 T5 T7. _m:;THli6.il~-m—9flm .-_ v—‘f I 1 1 r' professional (therapist, physican or minister). Please remember that there are no I‘right" answers. As you can see, your name is not written on the Sexual Desire Assessment Form (SDAF). The results of this study are held in strict confidence and you will remain anonymous. Your participation will also involve completing another test called the Millon Clinical Multiaxial Inventory (MCMI). This test is a personality inventory and helps us to understand an individual's characteristics. This inventory also is confidential and your name is not on the form. You will see a number on each questionnaire. This is only for statistical purposes. Again, please remember there are no right answers. Just answer each question as best as you can. If you would like to receive the results of this study, please sign a paper with your name and address and I will be happy to send the results to you when the research is completed. I sincerely thank you for your cooperation and appreciate your input. Marty Whipple 193 1. APPENDIX G MICHIGAN STATE UNIVERSITY Department of Psychology DEPARTMENTAL RESEARCH CONSENT FORM I have freely consented to take part in a scientific study being conducted by: Martha Whipple under the supervision of: William C. Hinds, Ed.D. Academic Title: Professor of Counseling Psychology The study has been explained to me and I understand the explanation that has been given and what my participation will involve. My participation in this research is completely voluntary. I am aware that responding to the instruments in this research might lead to negative and unpleasant emotions. I understand that I am free to discontinue my participation in the study at any time without penalty. I understand that the results of the study 2 will be treated in strict confidence and that I will remain anonymous. Within these restrictions, results of the study will be made available to me at my request. I understand that my participation in the study does not guarantee any beneficial L results to me. 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