SVQ

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SVQ

Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.

Birthday *

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Name *

INSTRUCTIONS:

Think back over the past four months and try to remember the time you felt the worst about yourself. It may be a time you felt shame more intensely than any other time. If you did not feel shame during this period of time, it may be a time you felt your lowest self-esteem or thought about something you didn't like about yourself, even if it was for only a brief moment. Try to remember the specific event and its circumstances. The following are some statements that may describe how you felt AT THE EXACT TIME you felt the worst about yourself. Please rate each statement using the 5-point scale below. Remember to rate each statement based on how you felt right at that worst moment.

Please rate each statement using the 5-point scale below. Remember to rate each statement based on how you felt right at that worst moment.

1=NOT AT ALL- I did not feel this way

3= I felt this way somewhat

5 = COMPLETELY - I felt this very strongly

I experienced shame

I felt good about myself

I hated myself

I wanted to hide from other people

I felt inadequate

I felt disgusted with myself

I felt worthless

I felt that I was a bad person

I had trouble thinking about anyone other than myself

I felt I deserved to be punished

I felt I was a failure as a person

I blamed myself for bad things that happened

I felt like a worthy or valuable person

I felt inferior to others

I felt like a burden to others

1=NOT AT ALL- I did not feel this way

3= I felt this way somewhat

5 = COMPLETELY - I felt this very strongly

I experienced shame

I felt good about myself

I hated myself

I wanted to hide from other people

I felt inadequate

I felt disgusted with myself

I felt worthless

I felt that I was a bad person

I had trouble thinking about anyone other than myself

I felt I deserved to be punished

I felt I was a failure as a person

I blamed myself for bad things that happened

I felt like a worthy or valuable person

I felt inferior to others

I felt like a burden to others

Clear selection

How long did you feel bad about yourself (i.e., how long until you felt like your normal self again or until you got your mind onto something else)?

5- Nearly the whole rest of the day

4- Longer than 1 hour, but not most of the rest of the day

3- Longer than 10 minutes, less than 1 hour

2- Longer than 1 minute, Less than 10 minutes

1- Less than 1 minute

Clear selection

On average, how often did you feel bad about yourself this strongly over the past four months?

5 - Nearly every day

4- Several times per week

3- Once per week

2- 1-3 times per month

1- One or two times only (i.e., less than once per month)

Clear selection

On average, how often did you feel good about yourself (or at least not feel bad about yourself) over the past four months? In other words, how many days did you NOT suffer from shame, hate yourself, feel inadequate/inferior, feel worthless, feel like a failure or a burden, or think you were a bad person.

1- Nearly every day

2- Several days per week

3- One day per week

4- 1-3 days per month

5- One or two days only (i.e., less than once per month)

6- No days

Clear selection

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