Name:

Date of Birth:
Today’s Date:

SMI (Version 1.1)

INSTRUCTION: Listed below are statements that people might use to describe themselves. Please
rate each item based on how often you believe or feel each statement in general using the
frequency scale.

FREQUENCY: In general
1= Never or Almost Never 4= Frequently
2= Rarely 5= Most of the time
3= Occasionally 6= All of the time

In general...
1. I demand respect by not letting other people push me around.
2. I feel loved and accepted.
3. I deny myself pleasure because I don’t deserve it.
4. I feel fundamentally inadequate, flawed, or defective.
5. I have impulses to punish myself by hurting myself (e.g., cutting myself).
6. I feel lost.
7. I’m hard on myself.
8. I try very hard to please other people in order to avoid conflict, confrontation, or
rejection.
9. I can’t forgive myself.
10. I do things to make myself the center of attention.
11. I get irritated when people don’t do what I ask them to do.
12. I have trouble controlling my impulses.
13. If I can’t reach a goal, I become easily frustrated and give up.
14. I have rage outbursts.
15. I act impulsively or express emotions that get me into trouble or hurt other people.

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 FREQUENCY: In general
1= Never or Almost Never 4= Frequently
2= Rarely 5= Most of the time
3= Occasionally 6= All of the time

In general...
16. It’s my fault when something bad happens.
17. I feel content and at ease.
18. I change myself depending on the people I’m with, so they’ll like me or approve of me.
19. I feel connected to other people.
20. When there are problems, I try hard to solve them myself.
21. I don’t discipline myself to complete routine or boring tasks.
22. If I don’t fight, I will be abused or ignored.
23. I have to take care of the people around me.
24. If you let other people mock or bully you, you’re a loser.
25. I physically attack people when I’m angry at them.
26. Once I start to feel angry, I often don’t control it and lose my temper.
27. It’s important for me to be Number One (e.g., the most popular, most successful, most
wealthy, most powerful).
28. I feel indifferent about most things.
29. I can solve problems rationally without letting my emotions overwhelm me.
30. It’s ridiculous to plan how you’ll handle situations.
31. I won’t settle for second best.
32. Attacking is the best defense.
33. I feel cold and heartless toward other people.
34. I feel detached (no contact with myself, my emotions or other people).
35. I blindly follow my emotions.
36. I feel desperate.
37. I allow other people to criticize me or put me down.
38. In relationships, I let the other person have the upper hand.
39. I feel distant from other people.
40. I don't think about what I say, and it gets me into trouble or hurts other people.
41. I work or play sports intensively so that I don’t have to think about upsetting things.

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 FREQUENCY: In general
1= Never or Almost Never 4= Frequently
2= Rarely 5= Most of the time
3= Occasionally 6= All of the time

In general...
42. I’m angry that people are trying to take away my freedom or independence.

43. I feel nothing.

44. I do what I want to do, regardless of other people’s needs and feelings.
45. I don’t let myself relax or have fun until I’ve finished everything I’m supposed to do.
46. I throw things around when I’m angry.
47. I feel enraged toward other people.
48. I feel that I fit in with other people.
49. I have a lot of anger built up inside of me that I need to let out.
50. I feel lonely.
51. I try to do my best at everything.
52. I like doing something exciting or soothing to avoid my feelings (e.g., working,
gambling, eating, shopping, sexual activities, watching TV).
53. Equality doesn’t exist, so it’s better to be superior to other people.
54. When I’m angry, I often lose control and threaten other people.
55. I let other people get their own way instead of expressing my own needs.
56. If someone is not with me, he or she is against me.
57. In order to be bothered less by my annoying thoughts or feelings, I make sure that I’m
always busy.
58. I’m a bad person if I get angry at other people.
59. I don’t want to get involved with people.
60. I have been so angry that I have hurt someone or killed someone.
61. I feel that I have plenty of stability and security in my life.
62. I know when to express my emotions and when not to.
63. I’m angry with someone for leaving me alone or abandoning me.
64. I don’t feel connected to other people.
65. I can’t bring myself to do things that I find unpleasant, even if I know it’s for my own
good.
66. I break rules and regret it later.
67. I feel humiliated.
68. I trust most other people.
69. I act first and think later.

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 FREQUENCY: In general
1= Never or Almost Never 4= Frequently
2= Rarely 5= Most of the time
3= Occasionally 6= All of the time

In general...
70. I get bored easily and lose interest in things.
71. Even if there are people around me, I feel lonely.
72. I don’t allow myself to do pleasurable things that other people do because I’m bad.
73. I assert what I need without going overboard.
74. I feel special and better than most other people.
75. I don’t care about anything; nothing matters to me.
76. It makes me angry when someone tells me how I should feel or behave.
77. If you don’t dominate other people, they will dominate you.
78. I say what I feel, or do things impulsively, without thinking of the consequences.
79. I feel like telling people off for the way they have treated me.
80. I’m capable of taking care of myself.
81. I’m quite critical of other people.
82. I’m under constant pressure to achieve and get things done.
83. I’m trying not to make mistakes; otherwise, I’ll get down on myself.
84. I deserve to be punished.
85. I can learn, grow, and change.
86. I want to distract myself from upsetting thoughts and feelings.
87. I’m angry at myself.
88. I feel flat.
89. I have to be the best in whatever I do.
90. I sacrifice pleasure, health, or happiness to meet my own standards.
91. I’m demanding of other people.
92. If I get angry, I can get so out of control that I injure other people.
93. I am invulnerable.
94. I’m a bad person.
95. I feel safe.
96. I feel listened to, understood, and validated.
97. It is impossible for me to control my impulses.
98. I destroy things when I’m angry.

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 FREQUENCY: In general
1= Never or Almost Never 4= Frequently
2= Rarely 5= Most of the time
3= Occasionally 6= All of the time

In general...
99. By dominating other people, nothing can happen to you.
100. I act in a passive way, even when I don’t like the way things are.
101. My anger gets out of control.
102. I mock or bully other people.
103. I feel like lashing out or hurting someone for what he/she did to me.
104. I know that there is a ‘right’ and a ‘wrong’ way to do things; I try hard to do things
the right way, or else I start criticizing myself.
105. I often feel alone in the world.
106. I feel weak and helpless.
107. I’m lazy.
108. I can put up with anything from people who are important to me.
109. I’ve been cheated or treated unfairly.
110. If I feel the urge to do something, I just do it.
111. I feel left out or excluded.
112. I belittle others.
113. I feel optimistic.
114. I feel I shouldn’t have to follow the same rules that other people do.
115. My life right now revolves around getting things done and doing them ‘right’.
116. I’m pushing myself to be more responsible than most other people.
117. I can stand up for myself when I feel unfairly criticized, abused, or taken advantage
of.
118. I don’t deserve sympathy when something bad happens to me.
119. I feel that nobody loves me.
120. I feel that I’m basically a good person.
121. When necessary, I complete boring and routine tasks in order to accomplish things I
value.
122. I feel spontaneous and playful.
123. I can become so angry that I feel capable of killing someone.
124. I have a good sense of who I am and what I need to make myself happy.

© 2008 Young, J., Arntz, A., Atkinson, T., Lobbestael, J., Weishaar, M., van Vreeswijk, M and Klokman, J.
Unauthorized reproduction without written consent of the authors is prohibited. This version is equivalent to
the Dutch 1.0 version. For more information, write: Schema Therapy Institute, 130 West 42nd St., Ste. 501,
New York, NY 10036, or for the Dutch version: J. Lobbestael, Clinical Psychological Science, PO Box 616, 6200
MD Maastricht, the Netherlands ([email protected]).

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