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Incorporating Mindfulness Into an Internet-Based Intervention for Female Sexual Dysfunctions

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Incorporating Mindfulness Into an Internet-Based Intervention for Female Sexual Dysfunctions i Incorporating Mindfulness into an Internet-Based Intervention for Female Sexual Dysfunctions by Alice Lee Hucker, BA (Hons) Submitted in partial fulfilment of the requirements for the degree of Doctor of Psychology (Clinical) Deakin University December, 2012 iv Acknowledgements I would like to acknowledge Professor Marita McCabe for her supervision and guidance in preparing this thesis, and for her clinical guidance throughout the implementation of the PursuingPleasure program. Marita approached supervision with a rigidity that kept me on track, and a sense of humour that kept me sane. I would also like to thank her for the support she gave me in following my research passions, her encouragements for my future career in this field, and her expertise in conference networking. I would like to thank Nathan for his abundant patience and support, for his sense of playfulness and perspective, and for his willingness to pick me up on his shoulders during times of low morale. I would also like to acknowledge my parents – Teena and Neil – for instilling in me a deep sense of curiosity and ambition, and my sisters – Danyelle and Kelly - for being my personal cheer squad. Thank you to Margaret, Bruce, Siobhan and Paul for your support and consistent faith in me. And to my good friends - Jessie-Ra, Julia, Anthony, Aaren, Georgie and Libby – thank you for believing in me and reminding me that it is always necessary to take time out. Finally, I would like to acknowledge all of my peers in the DPsych at Deakin University who have worked so hard alongside me for the past three years. In particular, thank you to Kechi, Defne, Sarah, Joey and Luke, and I wish those still completing the DPsych all the best of luck! v List of Contents Title page………………………………………………………………….…….…...i Access to Thesis – A………………………………………………………………... ii Candidate declaration……………………………………………………….…..….. iii Acknowledgements……………………………………………………….……..…. iv List of Contents…………………………………………………………….…..….....v List of Appendices……………………………………………………………………x Abstract…………………………………………………………………….….…….xii Chapter 1 - Classification, Prevalence and Etiology of Female Sexual Dysfunctions…………………………………………………………………………1 1.1 Female Sexual Response…………………………………………………………1 1.2 Classification and Diagnosis of FSDs……………………………………………2 1.3 Prevalence of FSDs………………………………………………………………4 1.4 Etiology of FSDs…………………………………………………………………5 1.4.1 Biological factors…………………………………………………………….6 1.4.2 Psychological factors………………………………………………………...7 1.4.2.1 Intergenerational factors……………………………………………………..7 1.4.2.2 Individual factors…………………………………………………………….8 1.4.2.3 Relationship factors………………………………………………………….9 Chapter 2 - Treatment Approaches for Female Sexual Dysfunctions……………...11 2.1 Issues in Assessing the Effectiveness of FSD Treatments……………………...11 2.2 Medical Treatments for FSDs…………………………………………………..12 vi 2.2.1 Hormone treatments………………………………………………………...12 2.2.2 Peripherally and centrally acting agents……………………………………13 2.3 Psychological Treatments for FSDs……………………………………….……15 2.3.1 Face-to-face psychological treatment………………………………………16 2.3.1.1 Cognitive-behavioural therapy interventions……………………….………16 2.3.1.2 Mindfulness-based interventions…………………………………………...17 2.3.1.3 Other considerations…………………………………………………...…...19 2.3.2 Self-help interventions……………………………………………….…….20 2.3.3 Internet-based interventions………………………………………….…….21 2.4 Factors Related to FSD Treatment Outcomes……………………………….…21 2.4.1 Characteristics of the dysfunction………………………………….………21 2.4.2 Motivation to change……………………………………………………….22 2.4.3 Compliance…………………………………………………………………22 2.4.4 Partner characteristics………………………………………………………23 2.4.5 Relationship quality………………………………………………………...23 Chapter 3 - Internet-Based Interventions for Female Sexual Dysfunctions………..25 3.1 Internet-Based Approaches to Mental Health………………………….……….24 3.1.1 Synchronous and asynchronous methods…………………………….…….26 3.1.2 Therapeutic techniques………………………………………………….…..26 3.1.3 Interactivity and usability…………………………………………….……..27 3.2 Advantages of Internet-Based Interventions………………………….….……...28 3.3 Disadvantages of Internet-Based Interventions……………………….…….…..28 3.4 Ethical Considerations and Suitability of Clients………………………….……29 3.5 Internet-Based Interventions for Sexual Dysfunctions…………………………30 vii 3.5.1 Male sexual dysfunctions…………………………………………………...31 3.5.2 Female sexual dysfunctions………………………………………………...33 3.5.2.1 Attrition……………………………………………………………………..35 3.5.2.2 Cognitive therapy…………………………………………………………...37 3.5.2.3 Psychoeducation…………………………………………………………….38 3.5.2.4 Mindfulness training…………………………………………………….…..39 3.5.2.5 Partner involvement………………………………………………………...39 3.6 Summary………………………………………………………………………..41 Chapter 4 – Description of Publications……………………………………………42 4.1 The PursuingPleasure Program………………………………………………...42 4.2 Article 1: Manualised Treatment Programs for Female Sexual Dysfunction: Research Challenges and Recommendations…………………………………..44 4.3 Article 2: Effectiveness of Cognitive Behavioral Therapy Incorporating Mindfulness Training in the Online Treatment of Female Sexual Dysfunction..45 4.4 Article 3: An Online, Mindfulness-Based, Cognitive-Behavioral Therapy for Female Sexual Dysfunction: Impact on Relationship Functioning…………….46 4.5 Article 4: A Qualitative Evaluation of Online Chat-Groups for Women Completing a Psychological Intervention for Female Sexual Dysfunction….…47 Chapter 5 - Article 1: Published in the Journal of Sexual Medicine……….……….48 Chapter 6 - Article 2: Resubmitted After Reviews for Publication in the Journal of Sexual Medicine…………………………………………………………………….69 viii Chapter 7 - Article 3: Resubmitted After Reviews for Publication in the Journal of Sex & Marital Therapy……………………………………………………………107 Chapter 8 - Article 4: Online Preview of Article Accepted for Publication in the Journal of Sex & Marital Therapy………………………………………………...138 Chapter 9 – Discussion………………………………………………………...….157 9.1 Evaluation of the PursuingPleasure Program………………………………...157 9.1.1 Female sexual functioning…………………………………………….…..157 9.1.2 Male sexual functioning…………………………………………………..159 9.1.3 Distress associated with sexual functioning………………………………159 9.1.4 Relationship functioning…………………………………………………..160 9.1.5 Effectiveness of PP at 3-month follow-up………………………………...160 9.1.6 Observations between treatment groups……………………………….…..161 9.2 Qualitative Feedback and Recommendations…………………………..……..162 9.2.1 Challenges during treatment and barriers to change……………….….…..162 9.2.1.1 Mindfulness-related challenges………………………………………..…..162 9.2.1.2 Partner-related challenges……………………………………………….....163 9.2.2 Most helpful and least helpful components of treatment……………….…164 9.2.3 Recommendations for improvements………………………………….…..165 9.3 Challenges in the Delivery of PursuingPleasure…………………….…….…..167 9.3.1 Technical challenges………………………………………………….……167 9.3.2 Participant engagement and motivation……………………………….…...168 9.3.3 Treatment timing………………………………………………………..….169 9.3.4 Couple dynamics………………………………………………………..….170 9.4 Implications for the Treatment of FSDs……………………………….………171 ix 9.4.1 Internet-based interventions for FSD……………………………….……..171 9.4.2 Mindfulness training for FSD……………………………………….……..172 9.4.3 Online chat-groups as an adjunct to internet-based FSD treatment…….….174 9.4.4 The online therapeutic relationship………………………………………...176 9.4.5 Etiological factors…………………………………………………….……177 9.4.6 Involvement of partners in treatment…………………………………..…..178 9.4.7 Manualised treatments for FSDs……………………………………….…..180 9.5 Limitations and Recommendations for Future Research………………….…...183 9.6 Conclusion………………………………………………………………….….187 References……………………………………………………………………….…190 x List of Appendices Appendix 1: Human Ethics Research Approval………………………………..…218 Appendix 2: Advertisement for Recruiting PP Participants…………………..….219 Appendix 3: Plain Language Statement for Females Interested in PP………..…..220 Appendix 4: Plain Language Statement for Partners Interested in PP………..…..225 Appendix 5: Example of PP Website Layout……………………………….……229 Appendix 6: PP Online Content (as Word Document)…………………………...230 6.1 Welcome Ladies………………………………………………….……………230 6.2 Module 1………………………………………………………………………233 6.3 Module 2………………………………………………………………………241 6.4 Module 3………………………………………………………………………253 6.5 Module 4………………………………………………………………………264 6.6 Module 5………………………………………………………………………274 6.7 Module 6………………………………………………………………………283 6.8 Resources……………………………………………………………………...294 6.9 Sample Letter…………………………………………………………….……297 6.10 Sharing Feelings……………………………………………………………...298 6.11 Getting in the Mood…………………………………………………….……300 Appendix 7: Psychoeducation Handouts for Partners (as Word Documents)….....301 7.1 What’s it all about?………………………………………….………………...301 7.2 Module 1………………………………………………………………………303 7.3 Module 2………………………………………………………………………308 7.4 Module 3………………………………………………………………………314 7.5 Module 4………………………………………………………………………319 xi 7.6 Module 5………………………………………………………………………324 7.7 Module 6………………………………………………………………………330 Appendix 8: Female questionnaire (as Word document)…………………………336 Appendix 9: Partner questionnaire (as Word document)………………………….348 Appendix 10: Email Therapy and Chat-Groups: Further Details……….………...353 Appendix 11: Picture of Chat-Room………………………………………….…..356 xii Abstract This thesis explores the use of manualised treatments for female sexual dysfunctions (FSDs), with a particular focus on internet-based treatments. Due to the embarrassment that can surround FSDs, online interventions offer an anonymous and private treatment alternative. To date, only
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