SASB/Intrex
University of Utah
Department of Psychology
390 South 1530 East, Rm 502
Salt Lake City UT 84112-0251
Sample questionnaires. Not to be used without written
permission from SASB /Intrex at the University of Utah. Complete questionnaires
and accompanying answer sheets are available to qualified professional users by
ordering SASB Intrex processing software from
Note: It is recommended that you use the Medium Form rather
than the Short Form. The Short Form shows good structural validity and has
proven very useful in a number of contexts (see list of known publications).
However it only provides one item to sample each SASB model point, while the
Medium Form provides two. This increase in sampling permits the Medium Form to
report internal reliability for each administration, an advantage appreciated
by many clinicians and researchers. The Long Form provides 4 or 5 items per
model point and, of course, also provides a measure of internal validity for
each administration.
Here are general instructions for setting up the series
suitable for your clinical/ research situation.
Intrex Short Form Questionnaires
and Answer Sheets
Please note: You may form your “administration:” to suit
your own research or clinical needs.
The standard series is:
Introject at BEST (Form A)
Introject at WORST (Form A)
Significant other at Best (Form B = He; Form C = She)
Significant other at WORST ( Form B = He; Form C = She)
Mother when the rater was age 5-10 (Form E)
Father when the rater was age 5-10 (Form D)
Mother and Father when the rater
was age 5-10 (Form I)
Here are printed headings for question and answer booklets
that you can use in setting up your Master Copy sheets after you have paid
appropriate royalties to the University of Utah.
YOUR
SIGNIFICANT OTHER PERSON AT HER BEST
YOUR
SIGNIFICANT OTHER PERSON AT HIS WORST
YOUR
SIGNIFICANT OTHER PERSON AT HER WORST
YOUR
SIGNIFICANT OTHER PERSON AT HIS/HER BEST
YOUR
SIGNIFICANT OTHER PERSON AT HIS/HER WORST
YOURSELF
YOURSELF
AT YOUR BEST
YOURSELF
AT YOUR WORST
YOUR
MOTHER
YOUR
FATHER
YOUR
MOTHER WHEN YOU WERE AGE 5-10
YOUR
FATHER WHEN YOU WERE AGE 5-10
YOUR
MOTHER WITH YOUR FATHER
YOUR
FATHER WITH YOUR MOTHER
YOUR
MOTHER WITH YOUR FATHER WHEN YOU WERE AGE 5-10
YOUR
FATHER WITH YOUR MOTHER WHEN YOU WERE AGE 5-10
Instructions are continued on the next page:
This
questionnaire asks about your attitudes and feelings toward yourself and
others.
Please answer the questions for how you really think or
feel. Your initial reaction to each
question will most often be your best answer.
There are no “right” or “wrong” answers. It’s your view that is important – not necessarily what is
“true,” “false,” or what someone else might think you should say. If part of a question seems to fit while
part does not fit it all, you should give the question a lower score because of
the “spoiling” part.
For the BEST/WORST series (strongly recommended):
Rate this person and yourself twice: when the relationship
is best, and when it is worst. First,
try to remember a specific time a few days/weeks/months ago when she and you
were at your best, and while thinking of that time, rate the best version. Then, think of a specific time a few days/weeks/months ago when
she and you were at your worst, and rate the worst version. Please do
not go back in time further than one year.
Now indicate what percent of the time he/she was:
AT HIS/HER BEST ______
AT HIS/HER WORST ______
NEITHER
______
Now indicate what percent of the time you were:
AT YOUR BEST ______
AT YOUR WORST ______
NEITHER
______
Finally, indicate what percent of the time you feel you can
control whether you are in your best or your worst state. ______
INTREX Short Form A /Introject./Version 1. Copyright
1995, University of Utah
-------------------------------------------------------------------------------------------------
Please use an answer sheet marked "introject" and
indicate how well each question describes
YOURSELF.
Rate yourself twice: at your best, and at your worst.
First, try to remember a specific
time a few days/weeks/months ago when you were at your
best, and while thinking of that time,
rate the best version. Then think of a specific time a few
days/weeks/months ago when you were at your worst, and rate the worst version.
Please do not go back in time further than one year.
Use the scale
that appears at the top of the answer sheet.
-------------------------------------------------------------------------------------------------
1. Without concern
or thought, I let myself do and be whatever I feel like.
2. Without
considering what might happen, I hatefully reject and destroy myself.
3. I tenderly,
lovingly cherish myself.
4. I put energy
into providing for, looking after, developing myself.
-------------------------------------------------------------------------------------------------
5. I punish myself
by blaming myself and putting myself down.
6. Aware of my
personal shortcomings as well as my good points, I comfortably let myself
be "as is".
7. I am recklessly
neglectful of myself, sometimes completely "spacing out".
8. To make sure I
do things right, I tightly control and watch over myself.
-------------------------------------------------------------------------------------------------
Now change
to rating:
YOURSELF AT YOUR WORST
Use the scale that appears at the top of the answer sheet.
-------------------------------------------------------------------------------------------------
1. Without concern
or thought, I let myself do and be whatever I feel like.
2. Without
considering what might happen, I hatefully reject and destroy myself.
3. I tenderly,
lovingly cherish myself.
4. I put energy
into providing for, looking after, developing myself.
-------------------------------------------------------------------------------------------------
5. I punish myself
by blaming myself and putting myself down.
6. Aware of my
personal shortcomings as well as my good points, I comfortably let myself be
"as is".
7. I am recklessly
neglectful of myself, sometimes completely "spacing out".
8. To make sure I do things right, I tightly control and watch over
myself.
Note: Copying of the INTREX Short form without written permission from University of
Utah is a violation of copyright law
INTREX Short Form
B:/He/Present./Version 1
Copyright 1995, University of Utah
-------------------------------------------------------------------------------------------------
Please use an
answer sheet marked "interpersonal" and
indicate how well
each question describes: YOUR SIGNIFICANT OTHER PERSON AT HIS BEST
Use the scale
that appears at the top of the answer sheet.
---------------------------------------------------------------------------------------------------------------------
1. He lets me speak
freely, and warmly tries to understand me even if we disagree.
2. He walls himself
off from me and doesn't react much.
3. He puts me down,
blames me, punishes me.
4. Without giving it
a thought, he uncaringly ignores, neglects, abandons me.
---------------------------------------------------------------------------------------------------------------------
5. He learns from
me, relies upon me, accepts what I offer.
6. He happily,
gently, very lovingly approaches me, and warmly invites me to be as close as I
would like.
7. With much sulking
and fuming, he scurries to do what I want.
8. He clearly and
comfortably expresses his own thoughts and feelings to me.
---------------------------------------------------------------------------------------------------------------------
9. To keep things in
good order, he takes charge of everything and makes me follow his rules.
10. He thinks, does, becomes whatever I want.
11. He knows his own mind and "does his own thing"
separately from me.
12. Without thought about what might happen, he wildly,
hatefully, destructively attacks me.
---------------------------------------------------------------------------------------------------------------------
13. With much kindness, he teaches, protects, and takes care
of me.
14. Without much worry, he leaves me free to do and be whatever
I want.
15. He relaxes, freely plays, and enjoys being with me as
often as possible.
16. With much fear and hate, he
tries to hide from or get away from me.
YOURSELF IN THIS RELATIONSHIP AT BEST
---------------------------------------------------------------------------------------------------------------------
17. I let him speak freely, and warmly try to understand him
even if we disagree.
18. I wall myself off from him and don't react much.
19. I put him down, blame him, punish him.
20. Without giving it a thought, I uncaringly ignore,
neglect, abandon him.
---------------------------------------------------------------------------------------------------------------------
21. I learn from him rely upon him, accept what he offers.
22. I happily, gently, very lovingly approach him, and
warmly invite him to be as close as he would like.
23. With much sulking and fuming, I scurry to do what he
wants.
24. I clearly and comfortably express my own thoughts and
feelings to him.
---------------------------------------------------------------------------------------------------------------------
25. To keep things in good order, I take charge of
everything and make him follow my rules.
26. I think, do, become whatever he wants.
27. I know my own mind and "do my own thing"
separately from him.
28. Without thought about what might happen, I wildly,
hatefully, destructively attack him
---------------------------------------------------------------------------------------------------------------------
29. With much kindness, I teach, protect, and take care of
him.
30. Without much worry, I leave him free to do and be
whatever he wants.
31. I relax, freely play, and enjoy being with him as often
as possible.
32. With much fear and hate, I try
to hide from or get away from him.
INTREX Medium Form A
/Introject. Copyright 1995, University of Utah
-------------------------------------------------------------------------------------------------
Please use an answer sheet marked "introject" and
indicate how well each question describes
YOURSELF.
Rate yourself twice: at your best, and at your worst.
First, try to remember a specific
time a few days/weeks/months ago when you were at your
best, and while thinking of that time,
rate the best version. Then think of a specific time a few
days/weeks/months ago when you were at your worst, and rate the worst version.
Please do not go back in time further than one year.
Use the scale
that appears at the top of the answer sheet.
-------------------------------------------------------------------------------------------------
1. Without concern
or thought, I let myself do and be whatever I feel like.
2. Without
considering what might happen, I hatefully reject and destroy myself.
3. I tenderly,
lovingly cherish myself.
4. I put energy
into providing for, looking after, developing myself.
-------------------------------------------------------------------------------------------------
5. I punish myself
by blaming myself and putting myself down.
6. Aware of my
personal shortcomings as well as my good points, I comfortably let myself
be "as is".
7. I am recklessly
neglectful of myself, sometimes completely "spacing out".
8. To make sure I
do things right, I tightly control and watch over myself.
-------------------------------------------------------------------------------------------------
9. I let myself do
whatever I feel like and don't worry about tomorrow.
10. Without thought
about what might happen, I recklessly attack and angrily reject myself.
11. I very tenderly
and lovingly appreciate and value myself.
12. I take good care
of myself and work hard on making the most of myself.
-------------------------------------------------------------------------------------------------
13. I accuse and
blame myself for being wrong or inferior.
14. With awareness
of weaknesses as well as strengths, I like and accept myself "as is."
15. I carelessly let
go of myself, and often get lost in an unrealistic dream world.
16. To become
perfect, I force myself to do things correctly.
-------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------
Now change to rating YOURSELF
AT YOUR WORST
-------------------------------------------------------------------------------------------------
Use the scale that appears at the top of the answer sheet.
1. Without concern
or thought, I let myself do and be whatever I feel like.
2. Without
considering what might happen, I hatefully reject and destroy myself.
3. I tenderly,
lovingly cherish myself.
4. I put energy
into providing for, looking after, developing myself.
-------------------------------------------------------------------------------------------------
5. I punish myself
by blaming myself and putting myself down.
6. Aware of my
personal shortcomings as well as my good points, I comfortably let myself be
"as is".
7. I am recklessly
neglectful of myself, sometimes completely "spacing out".
8. To make sure I
do things right, I tightly control and watch over myself.
-------------------------------------------------------------------------------------------------
9. I let myself do
whatever I feel like and don't worry about tomorrow.
10. Without thought
about what might happen, I recklessly attack and angrily reject myself.
11. I very tenderly
and lovingly appreciate and value myself.
12. I take good care
of myself and work hard on making the most of myself.
-------------------------------------------------------------------------------------------------
13. I accuse and
blame myself for being wrong or inferior.
14. With awareness
of weaknesses as well as strengths, I like and accept myself "as is."
15. I carelessly let
go of myself, and often get lost in an unrealistic dream world.
16. To become
perfect, I force myself to do things correctly.
-------------------------------------------------------------------------------------------------
Note: Copying of the Intrex
Medium form without written permission from University of Utah is a
violation of copyright law
Intrex Medium Form B:
He/Present. Copyright 1995,
University of Utah.
-------------------------------------------------------------------------------------------------
Please use an
answer sheet marked "interpersonal" and
indicate how well
each question describes: YOUR
SIGNIFICANT OTHER PERSON AT HIS BEST
Use the scale that appears at the top of the answer sheet.
-------------------------------------------------------------------------------------------------
1. He lets me speak freely, and warmly tries to understand
me even if we disagree.
2. He walls himself
off from me and doesn’t react much.
3. He puts me down,
blames me, punishes me.
4. Without giving it
a second thought, he uncaringly ignores, neglects, abandons me.
-------------------------------------------------------------------------------------------------
5. He learns from
me, relies upon me, accepts what I offer.
6. He happily,
gently, very lovingly approaches me, and warmly invites me to be as close as I
would like.
7. With much sulking
and fuming, he scurries to do what I want.
8. He clearly and
comfortably expresses his own thoughts and feelings to me.
-------------------------------------------------------------------------------------------------
9. To keep things in
good order, he takes charge of everything and makes me follow his rules.
10. He thinks, does, becomes whatever I want.
11. He knows his own mind and "does his own thing"
separately from me.
12. Without worrying about the effect on me, he wildly,
hatefully, destructively attacks me.
-------------------------------------------------------------------------------------------------
13. With much kindness, he teaches, protects, and takes care
of me.
14. Without much worry, he leaves me free to do and be
whatever I want.
15. He relaxes, freely plays, and enjoys being with me as
often as possible.
16. With much fear and hate, he tries to hide from or get
away from me.
-------------------------------------------------------------------------------------------------
17. He likes me and
tries to see my point of view even if we disagree.
18. He closes off
from me and mostly stays alone in his own world.
19. He tells me my
ways are wrong and I deserve to be punished.
20. Without giving
it a thought, he carelessly forgets me, leaves me out of important things.
-------------------------------------------------------------------------------------------------
21. He trustingly
depends on me, willingly takes in what I offer.
22. With much love
and caring, he tenderly approaches if I seem to want it.
23. He bitterly,
resentfully gives in, and hurries to do what I want.
24. He peacefully
and plainly states his own thoughts and feelings to me.
-------------------------------------------------------------------------------------------------
25. To make sure
things turn out right, he tells me exactly what to do and how to do it.
26. He defers to me and conforms to my wishes.
27. He has a clear sense of what he thinks, and chooses his
own ways separately from me.
28. Without caring what happens to me, he murderously
attacks in the worst way possible.
-------------------------------------------------------------------------------------------------
29. In a very loving way, he helps, guides, shows me how to
do things.
30. Without much concern, he gives me the freedom to do
things on my own.
31. He is joyful and comfortable, altogether delighted to be
with me.
32. Filled with disgust and fear, he tried to disappear, to
break loose from me.
-------------------------------------------------------------------------------------------------
For questions #33 through 64, change from rating him to
rating
YOURSELF IN THIS RELATIONSHIP.
-------------------------------------------------------------------------------------------------
33. I let him speak
freely, and warmly try to understand him even if we disagree.
34. I wall myself
off from him and don't react much.
35. I put him down,
blame him, punish him.
36. Without giving
it a second thought, I uncaringly ignore, neglect, abandon him.
-------------------------------------------------------------------------------------------------
37. I learn from
him, rely upon him, accept what he offers.
38. I happily,
gently, very lovingly approach him, and warmly invite him to be as close as he
would like.
39. With much
sulking and fuming, I scurry to do what he wants.
40. I clearly and
comfortably express my own thoughts and feelings to him.
-------------------------------------------------------------------------------------------------
41. To keep things
in good order, I take charge of everything and make him follow my rules.
42. I think, do,
become whatever he wants.
43. I know my own
mind and "do my own thing" separately from him.
44. Without worrying
about the effect on him, I wildly, hatefully, destructively attack him.
-------------------------------------------------------------------------------------------------
45. With much
kindness, I teach, protect, and take care of him.
46. Without much
worry, I leave him free to do and be whatever he wants.
47. I relax, freely
play, and enjoy being with him as often as possible.
48. With much fear
and hate, I try to hide from or get away from him.
-------------------------------------------------------------------------------------------------
49. I like him and try to see his point of view even if we
disagree.
50. I close off from him and mostly stay alone in my own
world.
51. I tell him his ways are wrong and he deserves to be
punished.
52. Without giving it a thought, I carelessly forget him,
leave him out of important things.
-------------------------------------------------------------------------------------------------
53. I trustingly depend on him, willingly take in what he
offers.
54. With much love and caring, I tenderly approach if he seems
to want it.
55. I bitterly, resentfully give in, and hurry to do what he
wants.
56. I peacefully and plainly state my own thoughts and
feelings to him.
-------------------------------------------------------------------------------------------------
57. To make sure things turn out right, I tell him exactly
what to do and how to do it.
58. I defer to him and conform to his wishes.
59. I have a clear sense of what I think, and choose my own
separate ways.
60. Without caring what happens to him, I murderously attack
him in the worst way possible.
-------------------------------------------------------------------------------------------------
61. In a very loving way, I help, guide, show him how to do
things.
62. Without much concern, I give him the freedom to do
things on his own.
63. I am joyful and comfortable, altogether delighted to be
with him.
64. Filled with disgust and fear, I try to disappear, to
break loose from him.
-------------------------------------------------------------------------------------------------
Note: Copying of the Intrex‚ Medium form without written permission from University of
Utah is a violation of copyright law.
INTREX Long Form A. Copyright
1995, University of Utah
Please use the answer sheet marked A and indicate how well
each question describes YOURSELF AT YOUR
BEST.
Use the scale which appears at the
top of the answer sheet.
1.
I neglect myself, don’t try to develop good skills, ways of
being.
2.
Because I want to help myself, I try to figure out what is
really going on within me.
3.
Instead of getting around to doing what I really need to do
for myself, I let myself go and just daydream.
4.
I just let important personal matters, choices, thoughts,
issues slip by without paying much attention.
5.
Knowing both my faults and strong points, I comfortably let
myself be “as is”.
6. I let
myself feel glad about and pleased with myself just as I am.
7.
I accuse and blame myself until I feel guilty, bad and
ashamed.
8.
I practice and work on developing worthwhile skills, ways of
being.
9.
I tenderly, lovingly, cherish and adore myself.
10.
I naturally and easily provide for, nurture and take care of
myself.
11.
I angrily and harshly reject myself as worthless, and leave
what happens to me to fate.
12. I ignore
and don’t bother to know my real self.
13.
I like myself very much, and feel very good when I have a
chance to be with myself.
14.
I very carefully watch, hold back and restrain myself.
15.
I have the habit of keeping very tight control over myself.
16.
I let myself murder, kill, destroy and reduce myself to
nothing.
17.
I tear away at and empty myself by greatly overburdening
myself.
18. I gently
and warmly stroke and appreciate myself for just being me.
19.
I keep an eye on myself to be sure I am doing what should
and ought to be done.
20.
I try very hard to make myself be like an ideal.
21.
I comfortably let myself hear and go by my own deepest inner
feelings.
22.
Even when it means harming myself greatly, I let my own
sickness and injury go unattended.
23.
I put all kinds of energy into making sure I follow the
right standards and am proper.
24.
I harshly punish, torture myself; I “take it out” on myself.
---------------------------------------------------------------------------------------------------------------------25. I make myself do and be things which are
known not to be right for me. I fool myself.
26.
I just let myself go along with today as it is and don’t
plan for tomorrow.
27.
I comfortably look after my own interests and protect
myself.
28.
I let myself drift with the moment; I have no internal
direction, goals or standards.
29.
I put a lot of energy into figuring out what I’m going to
need for myself and how to get it.
30.
I freely, easily and
confidently let myself do whatever comes naturally.
---------------------------------------------------------------------------------------------------------------------
31.
1 understand and like myself just as I am. I feel solid, “together”.
32.
Without concern, I just let myself be free to turn into
whatever I will.
33.
I am reckless; I carelessly let myself end up in
self-destructive situations.
34.
I keep myself open to connecting with people, places or
things which would be very good for me.
35.
I put myself down, tell myself that I have done everything
wrong and that others can do better
36. I think up
ways to hurt and destroy myself. I am my own worst enemy.
Note: Copying of the Intrex‚
Long form without written permission from University of Utah is a
violation of copyright law.
INTREX Long Form A. Copyright
1995, University of Utah
Please use the answer sheet marked A and indicate how well
each question describes YOURSELF AT YOUR
WORST.
Use the scale which appears at the
top of the answer sheet.
1.
I neglect myself, don’t try to develop good skills, ways of
being.
2.
Because I want to help myself, I try to figure out what is
really going on within me.
3.
Instead of getting around to doing what I really need to do
for myself, I let myself go and just daydream.
4.
I just let important personal matters, choices, thoughts,
issues slip by without paying much attention.
5.
Knowing both my faults and strong points, I comfortably let
myself be “as is”.
6. I let myself
feel glad about and pleased with myself just as I am.
7.
I accuse and blame myself until I feel guilty, bad and
ashamed.
8.
I practice and work on developing worthwhile skills, ways of
being.
9.
I tenderly, lovingly, cherish and adore myself.
10.
I naturally and easily provide for, nurture and take care of
myself.
11.
I angrily and harshly reject myself as worthless, and leave
what happens to me to fate.
12. I ignore
and don’t bother to know my real self.
13.
I like myself very much, and feel very good when I have a
chance to be with myself.
14.
I very carefully watch, hold back and restrain myself.
15.
I have the habit of keeping very tight control over myself.
16.
I let myself murder, kill, destroy and reduce myself to
nothing.
17.
I tear away at and empty myself by greatly overburdening myself.
18. I gently
and warmly stroke and appreciate myself for just being me.
19.
I keep an eye on myself to be sure I am doing what should
and ought to be done.
20.
I try very hard to make myself be like an ideal.
21.
I comfortably let myself hear and go by my own deepest inner
feelings.
22.
Even when it means harming myself greatly, I let my own
sickness and injury go unattended.
23.
I put all kinds of energy into making sure I follow the
right standards and am proper.
24. I harshly
punish, torture myself; I “take it out” on myself.
25. I make myself do and be things which are known not to be
right for me. I fool myself.
26. I just let myself go along with today as it is and don’t
plan for tomorrow.
27.
I comfortably look after my own interests and protect
myself.
28.
I let myself drift with the moment; I have no internal
direction, goals or standards.
29.
I put a lot of energy into figuring out what I’m going to
need for myself and how to get it.
30.
I freely, easily and
confidently let myself do whatever comes naturally.
---------------------------------------------------------------------------------------------------------------------
31.
1 understand and like myself just as I am. I feel solid, “together”.
32.
Without concern, I just let myself be free to turn into
whatever I will.
33.
I am reckless; I carelessly let myself end up in
self-destructive situations.
34.
I keep myself open to connecting with people, places or
things which would be very good for me.
35.
I put myself down, tell myself that I have done everything
wrong and that others can do better
36. I think up
ways to hurt and destroy myself. I am my own worst enemy.
Note: Copying of the Intrex‚
Long form without written permission from University of Utah is a
violation of copyright law.
INTREX Long Form C. Copyright
1995, University of Utah
Please use the answer sheet marked C and indicate how well
each question describes YOUR SIGNIFICANT
OTHER PERSON AT HER BEST.
Use the scale which appears at the
top of the answer sheet.
1.
With much kindness and good sense, she figures out and
explains things to me.
2.
She has a clear sense of who she is separately from me.
3.
Makes me follow her rules and ideas of what is right and
proper.
4.
Puts me down, tells me my ways are wrong and her ways are
better.
5.
Learns from me, comfortably takes advice and guidance from
me.
6. Gives up,
helplessly does things my way without feelings or views of her own.
7.
Angrily leaves me out.
Completely refuses to have anything to do with me.
8.
Warmly, comfortably accepts my help and caregiving.
9.
To do her own thing, she does the opposite of what I want.
10.
Is straightforward, truthful and clear with me about her own
position.
11.
Is joyful, happy and very open with me.
12. Murders,
kills, destroys and leaves me as a useless heap.
13.
Reacts to what I say or do in strange, unconnected,
unrelated ways.
14.
Joyfully, lovingly, very happily responds to me sexually.
15.
Warmly, cheerfully invites me to be in touch with her as
often as I want.
16.
Warmly, happily stays around and keeps in touch with me.
17.
Freely comes and goes; does her own thing separately from
me.
18. With
gentle, loving tenderness, she connects sexually if I seem to want it.
19.
Gets me interested and teaches me how to understand and do
things.
20.
Accuses and blames me. She tries to get me to believe and
say I am wrong.
21.
Full of happy smiles, she lovingly greets me just as I am.
22.
Trustingly depends on me to meet every need.
23.
Harshly punishes and tortures me, takes revenge.
24. Clearly
understands me and likes me even when we disagree.
25.
Is trusting with me. Comfortably counts on me to come
through when needed.
26.
Willingly accepts, goes along with my reasonable
suggestions, ideas.
27.
In pain and rage, she screams and shouts that I am
destroying her.
28.
Gently, lovingly strokes and soothes me without asking for
anything in return.
29.
Butts in and takes over, blocks and restricts me.
30. Full of
doubts and tension, she sort of goes along with my views anyway.
31.
Mindlessly obeys my rules, standards, ideas about how things
should be done.
32.
Rips me off, tears, steals, grabs all she can from me.
33.
Checks with me about every little thing because she cares so
much about what I think.
34.
Is very tense, shaky, wary, fearful with me.
35.
Misleads me, disguises things, tries to throw me off track.
36. Bitterly,
hatefully, resentfully chooses to let my needs and wants count more than her
own.
37.
Provides for, nurtures, takes care of me.
38.
Lets me speak freely and hears me even if we disagree.
39.
Just doesn’t notice or pay attention to me at all.
40.
Without concern, she lets me do and be anything at all.
41.
Furiously, angrily, hatefully refuses to accept my offers to
help out.
42. Boiling
over with rage and/or fear, she tries to escape, flee, or hide from me.
43.
Believing it’s really for my own good, she checks often on
me and reminds me of what ought to be done.
44.
Leaves me free to do and be whatever I think is best.
45.
Forgets all about me, our agreements, plans.
46.
Caves in to me and does things my way, but sulks and fumes
about it.
47.
Gives in to me, yields and submits to me.
48. Looking
very mean, she follows me and tries to hurt me.
49.
Controls me in a matter-of-fact way. She has the habit of
taking charge of everything.
50.
Believing I do things well, she leaves me to do them my own
way.
51.
Expresses herself clearly in a warm and friendly way.
52.
Feels, thinks, does, becomes what she thinks I want.
53.
Angrily leaves me to go without what I need very much even
when she easily could give it to me.
54. Really
hears me, acknowledges my views even if we disagree.
55.
Bitterly, angrily detaches from me and doesn’t ask for
anything. She weeps alone about me.
56.
Pays close attention to me so she can figure out all of my
needs and take care of everything.
57.
Whines, unhappily protests, tries to defend herself from me.
58.
Speaks up, clearly and firmly states her own separate
position.
59.
Is too busy and alone with her “own thing” to be with me.
60. Likes me
and thinks I’m fine just as I am.
61.
Walls herself off from me; doesn’t hear, doesn’t react.
62.
Relaxes, lets go, enjoys, feels wonderful about being with
me.
63.
Believing she really knows what’s best for me, she tells me
exactly what to do, be, think.
64.
To avoid my disapproval, she bottles up her rage and
resentment.
65.
Ignores the facts and offers me unbelievable nonsense and
craziness.
66. Goes her
own separate way apart from me.
67.
Lovingly looks after my interests and takes steps to protect
me. She actively backs me up.
68.
Freely and openly talks with me about her innermost self.
69.
Is very happy, playful, joyful, delighted to be with me.
70.
Just when she is needed most, she abandons me, leaves me
alone with trouble.
71.
Neglects me, my interests, needs.
72. Peacefully
leaves me completely on my own.
For questions #73 through
#144 change from rating him to rating;
YOURSELF IN THIS RELATIONSHIP.
Continue using the same scale at
the top of the answer sheet marked C..
73.
With much kindness and good sense, I figure out and explain
things to her.
74.
I have a clear sense of who I am separately from her.
75.
Make her follow my rules and ideas of what is right and
proper.
76.
I put her down, tell her her ways are wrong and my ways are
better.
77.
I learn from her, comfortably take advice and guidance from
her.
78. I give up,
helplessly do things her way without feelings or views of my own.
79.
I angrily leave her out.
I completely refuse to have anything to do with her.
80.
I warmly, comfortably accept her help and caregiving.
81.
To do my own thing, I do the opposite of what she wants.
82.
I am straightforward, truthful and clear with her about my
own position.
83.
I am joyful, happy and very open with her.
84. I murder,
kill, destroy and leave her as a useless heap.
85.
I react to what she says or does in strange, unconnected,
unrelated ways.
86.
I joyfully, lovingly, very happily respond to her sexually.
87.
I warmly, cheerfully invite her to be in touch with me as
often as she wants.
88.
I warmly, happily stay around and keep in touch with her.
89.
I freely come and go; do my own thing separately from her.
90. With
gentle, loving tenderness, I connect sexually if she seems to want it.
91.
I get her interested and teach her how to understand and do
things.
92.
I accuse and blame her. I try to get her to believe and say
she is wrong.
93.
Full of happy smiles, I lovingly greet her just as she is.
94.
I trustingly depend on her to meet every need.
95.
I harshly punish and torture her, take revenge.
96. I clearly
understand her and like her even when we disagree.
97.
Am trusting with her. Comfortably count on her to come
through when needed.
98.
I willingly accept, go along with her reasonable suggestions,
ideas.
99.
In pain and rage, I scream and shout that she is destroying
me.
100.
I gently, lovingly stroke and soothe her without asking for
anything in return.
101.
I butt in and take over, block and restrict her.
102.
Full of doubts and tension, I sort of go along with her
views anyway.
103.
Mindlessly obey her rules, standards, ideas about how things
should be done.
104.
I rip her off, tear, steal, grab all I can from her.
105.
Check with her about every little thing because I care so
much about what she thinks.
106.
I am very tense, shaky, wary, fearful with her.
107.
I mislead her, disguise things, try to throw her off track.
108.
I bitterly, hatefully, resentfully choose to let her needs
and wants count more than my own.
109.
I provide for,
nurture, take care of her.
110.
I let her speak freely and hear her even if we disagree.
111.
I just don’t notice or pay attention to her at all.
112.
Without concern, I let her do and be anything at all.
113.
I furiously, angrily, hatefully refuse to accept her offers
to help out.
114.
Boiling over with rage and/or fear, I try to escape, flee,
or hide from her.
115.
Believing it’s really for her own good, I check often on her
and remind her of what ought to be done.
116.
I leave her free to do and be whatever she thinks is best.
117.
I forget all about her, our agreements, plans.
118.
I cave in to her and do things her way, but sulk and fume
about it.
119.
I give in to her, yield and submit to her.
120.
Looking very mean, I follow her and try to hurt her.
121.
I control her in a matter-of-fact way. I have the habit of
taking charge of everything.
122.
Believing she does things well, I leave her to do them her
own way.
123.
I express myself clearly in a warm and friendly way.
124.
I feel, think, do, become what I think she wants.
125.
I angrily leave her to go without what she needs very much
even when I easily could give it to her.
126.
I really hear her, acknowledge her views even if we
disagree.
127.
I bitterly, angrily detach from her and don’t ask for
anything. I weep alone about her.
128.
I pay close attention to her so I can figure out all of her
needs and take care of everything.
129.
I whine, unhappily protest, try to defend myself from her.
130.
I speak up, clearly and firmly state my own separate
position.
131.
I am too busy and alone with “my thing” to be with her.
132.
I like her and think she is fine just as she is.
133.
I wall myself off from her; don’t hear, don’t react.
134.
I relax, let go, enjoy, feel wonderful about being with her.
135.
Believing I really know what’s best for her, I tell her
exactly what to do, be, think.
136.
To avoid her disapproval, I bottle up my rage and
resentment.
137.
I ignore the facts and offer her unbelievable nonsense and
craziness.
138.
I go my own separate way apart from her.
139.
I lovingly look after her interests and take steps to
protect her. I actively back her up.
140.
I freely and openly talk with her about her innermost self.
141.
I am very happy, playful, joyful, delighted to be with her.
142.
Just when I am needed most, I abandon her, leave her alone
with trouble.
143.
I neglect her, her interests, needs.
144.
I peacefully leave her completely on her own.
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