SCHEMA MODE QUESTIONNAIRE (SMI 1.

1)
Jeffrey Young, Ph.D.
(Translated and adapted officially for use in Brazil by Elisa Steinhorst Damasceno, Lauren Heineck de Souza and Margareth
da Silva Oliveira. Exclusively authorized by Schema Therapy Institute.)

Name: Date:

Instructions

This questionnaire contains statements that people might use to describe themselves. Based on the frequency scale
below, rate each
1 – Never item by
or almost choosing the number between 1 and46–that
never best describes how often you feel each statement
Frequently
2 – Rarely
applies to you; then write the number to the left of each statement.
5 – MostAsofyou
timeanswer each question, ask yourself, "In
3 – Occasionally
general, how often does this phrase apply to me." 6 – All of the time

1 – Never or almost never

2 – Rarely
3 – Occasionally
4 – Frequently
5 – Most of the time
6 – All of the time

In general, how often do you feel...

1 I demand respect by not letting others intimidate me or boss me around.

2 I feel loved and accepted.

3 I don’t allow myself to feel 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 am hard on myself.

8 I try very hard to please other people, thereby I 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.

Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

12 I have trouble controlling my impulses.

13 If I cannot reach an objective, I become easily frustrated and give up.

14 I have outbursts of rage.

15 I act impulsively or express emotions that hurt others or get me into trouble.

16 When something bad happens, it is my fault.

17 I feel happy and at ease.

18 I change myself depending on who I am with so they will 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’ discipline myself to complete boring or routine tasks.

22 If I do not fight people will take advantage of me or ignore me.

23 I have to take care of the people around me.

24 If you let other people make fun of you or mess you around, you are a loser.

25 I physically attack people when I am angry with them.

26 When I start to feel angry, I often can’t control it and lose my mind.

27 It’s important for me to be Number One (e.g., the most popular, most successful, wealthiest,
most powerful.)
28 I feel indifferent about most things.

29 I can solve problems rationally without letting my emotions overcome me.

Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

30 It’s ridiculous to plan how you will handle situations.

31 I will not settle for second best.

32 Attacking is the best defense.

33 I feel cold and emotionally distant towards other people.

34 I feel disconnected (no contact with myself, my emotions and other people).

35 I follow my emotions blindly.

36 I feel desperate.

37 I allow other people to criticize me or put me down.

38 In relationships, I let the other person make the decisions.

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 do physical exercises intensively, so I don’t have to think about things that upset me.

42 I am angry because people are trying to take away my freedom or independence.

43 I feel nothing.

44 I do what I want to, regardless of other people’s feelings or needs.

45 I do not let myself relax or have fun until I have finished everything I’m supposed to.

46 I throw things everywhere (far, on the floor, against the wall, etc.) when I’m angry.

47 I feel anger towards other people.

Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

48 I feel accepted by other people.

49 I have so much anger built up inside me that I have to release it.

50 I feel lonely.

51 I try to do my best in everything.

52 I like to do something exciting or relaxing to avoid my feelings (e.g.: working, gambling, eating,
shopping, sexual activities, watching TV, etc).
53 Equality doesn’t exist, so it’s better to be superior to other people.

54 When I get angry, I often lose control and threaten people.

55 Instead of expressing my own needs, I let other people get their own way.

56 If a person does not agree with me, he or she is against me.

57 I try to be always busy, so that I am less bothered by my annoying thoughts and feelings.

58 When I get angry at others, I consider myself a bad person.

59 I don’t want to get involved with people.

60 I feel so angry that I've even hurt or killed someone.

61 I feel that I have a lot of stability and security in my life.

62 I know when to express my emotions and when not to.

63 I feel angry with someone for leaving me alone or abandoning me.

64 I don’t feel connected to other people.

65 I can’t discipline myself to do things that I find unpleasant, even if I know it’s for my own good.
Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

66 I break the rules and later regret it.

67 I feel humiliated.

68 I trust most people.

69 I act first and think later.

70 I get bored easily and lose interest in things.

71 Even with people around me, I feel lonely.

72 I do not allow myself to do pleasurable things that other people do because I am a bad person.

73 I express or say what I need without going overboard (not requiring too much from others).

74 I feel special and better than most other people.

75 I don’t care about anything; nothing makes a difference to me.

76 I get angry when someone tells me how I should feel or behave.

77 If you don’t dominate others, they will dominate you.

78 I say what I feel, or act impulsively, without thinking of the consequences.

79 I feel like screaming at/fighting with people for the way they treat me.

80 I am capable of taking care of myself.

81 I am quite critical in relation to others.

82 I am under constant pressure to achieve my goals and handle things.

83 I am trying not to make mistakes otherwise I will heavily/strongly criticize myself.

Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

84 I deserve to be punished.

85 I can grow, learn and change.

86 I want to distract myself from thoughts and feelings that might make me feel upset.

87 I am angry at myself.

88 I feel indifferent and emotionless.

89 I have to be the best in everything I do.

90 I sacrifice pleasure, health and happiness to meet my own standards.

91 I demand a lot from other people.

92 If I get angry, I sometimes get so out of control that I physically assault or injure other people.

93 I am invulnerable.

94 I am a bad person.

95 I feel safe.

96 I feel listened to, understood and accepted/welcomed.

97 It’s impossible for me to control my impulses.

98 I destroy things when I’m angry.

99 If you dominate 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.

Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

102 I mock or intimidate other people.

103 I feel like verbally or physically assaulting someone for what he/she did to me.

104 I know there is a right way or wrong way to do things. I try to do the right things the right way
otherwise I start criticizing myself.
105 I often feel alone in the world.

106 I feel weak and helpless.

107 I am lazy.

108 I can put up with anything that comes from people who are important to me.

109 I have been betrayed 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 or despise others.

113 I feel optimistic.

114 I feel that I don’t have to follow the same rules that other people do.

115 Right now, my life comes down to starting and completing tasks the right way.

116 I push myself to be more responsible than most other people.

117 I can defend myself properly when I feel unfairly criticized, abused, or when taken advantage
of.
118 I do not deserve pity, or that others be sympathetic when something bad happens to me.

119 I feel that nobody loves me.

 Based on the frequency scale below, choose the statement which best represents how well each one applies to
you.

1 – Never or almost never 4 – Frequently

2 – Rarely 5 – Most of time
3 – Occasionally 6 – All of the time

In general, how often do you feel...

120 I feel that I am fundamentally a good person.

121 When necessary, I complete boring and routine tasks to accomplish the things I value.

122 I feel spontaneous and cheerful.

123 Sometimes I get so angry I feel like I could kill someone.

124 I have a good sense of who I am and what I need to make myself happy.

© 2014 Young, J., Amtz, A., Atkinson, T., Lobbestael, J., Weishaar, M. van Vreeswijk, M and Klokman J.
Unauthorized reproduction or translation without written consent of the author or strictly prohibited. The small watermark is your assurance
that you are an authorized version of this inventory. Postal Code: In Schema Therapy Institute, 561 10th Ave., Ste. 43D, New York, NY 10036. E-
mail: [email protected] / in Brazil– Grupo de Avaliação e Atendimento em Psicoterapias Cognitivas e Comportamentais, coordenado
pela pesquisadora Dra. Margareth da Silva Oliveira - Av. Ipiranga, 6681, prédio 11, sala 941, Partenon, 90619-900 - Porto Alegre - RS. E-mail:
[email protected]
The english version is equivalente to the Dutch SMI 1.0. For the Dutch version,write: J. Lobbestael, Clinical Psychological Science, PO Box 616, 6200
MD, Maastricht, the Netherlands. Email: [email protected]