Self-Injury (SI) Survey

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The purpose of this questionnaire on self-injury or self-mutilation is to collect information from persons of all ages and backgrounds that currently si or have si’d in order to educate professionals and others to better assist those seeking their assistance in any form for professional reasons to include medical, therapeutic, etc. and/or personal reasons to include parental, friendship, etc.

There are many forms of self injury to include the use of drugs and alcohol.  For the purpose of this survey we would like to limit self injury to the following definition:  Taking an object and purposefully inflicting pain on oneself.

Please take care of yourself: Anytime you are involved in addressing issues regarding self-injury it is possible that you will become triggered.  Please make sure you have some healthy coping skills at your side as you fill out this survey just in case you become triggered.  If it becomes overwhelming please discontinue this survey and use healthy coping skills or ask for help immediately.  It is not our intention or our wish to make this survey unpleasant.  Please take care of you!  

Self-injury is an extremely personal and often shameful issue.  I have the greatest respect for your privacy as I have struggled with si for over two decades.  You have a right to confidentiality and I will not violate that in any way.  For integrity purposes I ask that the only information you withhold is your real name if you choose.  You may enter an alias for your first name as the last name is optional.  If you choose to use your real name it will not be given to anyone.  Everyone completing this questionnaire will be assigned a unique number for identification.  Please be honest with all of the other answers in this survey so that I am able to maintain the integrity of data collected. 

Before you begin...This survey is lengthy and has over 175 questions!  We want to be thorough and collect a lot of data.  Please allow time for this!

SECTION 1

First Name
Last Name optional
Age
Date of Birth  (mmddyy)
Sex Male Female
Ethnicity Hispanic Caucasian Asian African American      Native American other
Marital Status married single divorced
Religious preference Christian Catholic Muslim Protestant Baptist Non-Denominational Atheist Other 
Education (completed) GED 12 14 (AA) 16 graduate work
Education (current)   college student High school student                     middle school student elementary school student
Alcohol Use none rare moderate heavy
Drug Use (illegal) none rare moderate heavy
Pain Killers none rare moderate heavy
Psychiatric Meds yes no
Currently in therapy? yes no

Past or current...

Sexual abuse 
Physical abuse 
Emotional abuse 
Significant loss 
Significant trauma 
Suicide attempt 

Do you suffer from...
depression
anxiety
schizophrenia
bipolar disorder
Post Traumatic Stress Disorder
Dissociative Identity Disorder
major medical problem
Do you have other addictions...
alcohol
illegal drugs
prescription drugs
food

Do you have a family history of...
depression
addictions
suicide
physical abuse
sexual abuse
hereditary diseases

SECTION 2    

    Background

1.Do you have self-worth? yes no
2.Do you believe you can stop SI'ing? yes no
3.Do you have self-confidence? yes no
4.Do you engage in self injury? yes no I used to
5.How long have you been SI'ing? 1yr 1-5yrs 5-10yrs 10-15yrs 15-20yrs >20yrs
6.How often do you SI? once a month 1-5x a month 6-10x a months 11-15x a month over 15x a month daily
7.What do you use when you SI? (ck all that apply) sharp object burn object blunt object
8.What are the results of your SI? (ck all that apply) cuts/scratches burns    broken bones
9.Why do you SI? (ck all that apply) to feel to numb to punish to relieve stress other
10.What is your primary feeling state when you SI? anger sadness frustration anxiety other
11.How long after does it take for you feel the affects of SI? immediate within an hour never
12.Do you feel any pain while SI'ing? yes no sometimes
13.Do you feel pain after you SI? yes no sometimes
14.While you SI do you feel like you are out of your body watching the process? yes no sometimes
15.Do you black out when you SI? yes no sometimes
16.Do you believe that SI solves your problems? yes no sometimes
17.Would you agree that SI is a temporary "fix"? yes no
18.Is your SI destroying your relationship with others? yes no
19.What is the severity of your SI? mild moderate severe
20.Have you ever severed an artery by mistake? yes no
21.Have you ever caused nerve damage by mistake? yes no
22.Have you ever caused irreversible functional damage? yes no
23.How many scars do you have from SI? 1-10 11-20 21-40 >40
24.Where are your SI scars located? (ck all that apply) arms upper torso legs hands thighs head/face/neck
25.Do you like the fact that you SI? yes no sometimes
26.Do you SI for attention? yes no sometimes
27.Do you think SI is addictive? yes no
28.Do you use SI to cope? yes no
29.What time of day do you typically SI? 6am-12 12-6pm 6pm-midnight midnight-6am varies
30.Do you constantly think about SI'ing? yes no
31.Are you under the influence of drugs or alcohol when you SI? yes no sometimes
32.Are you completely alone when you SI? yes no sometimes
33.Do you hide SI from family and friends? yes no
34.Have you ever been confronted about your SI? yes no
35.Have you ever lied about SI? yes no
36.Do you lie about your injuries or scars? yes no sometimes
37.Do you believe that to SI is a sin? yes no don't know       don't care
38.What typically triggers you to SI? (ck all that apply) image thought event smell touch other
39.Do you ever start "deal making" to refrain from SI? yes no 
40.Do you consciously think about SI? yes no sometimes
41.Do you dissociate when you SI? yes no sometimes
42.What is the strongest feeling you experience right before you SI? frustration anger anticipation joy happiness anxiety
43.Rate your anxiety level prior to SI... 1 2 3 4 5 6 7 8 9 10
44.What are you feeling when you SI? (ck all that apply) anger frustration joy anticipation sadness nothing
45.What is the strongest feeling you experience right after you SI? (ck all that apply) exhilaration relief guilt remorse happiness numbness
46.Rate your anxiety level after you SI... 1 2 3 4 5 6 7 8 9 10
47.What do you do right after you SI? sleep exercise tell someone continue with your day
48.What do you typically feel 24 hours after you SI? (ck all that apply) shame embarrassment happiness remorse joy guilt relief
49.Do you need to see blood to successfully SI? yes no sometimes
50.Do you need to break the skin to successfully SI? yes no sometimes
51.Do you enjoy being in the moment of a SI episode? yes no sometimes
52.Do you want help but are afraid to tell anyone? yes no n/a
53.Have you told someone but lie about how often you do it? yes no n/a
54.Do your parents know you SI? yes no n/a
55.Are you afraid to tell your parents? yes no n/a
56.If you are afraid to tell your parents. Why? (check all that apply)
they will over-react           they will judge me             they will blame my friends   they won't understand            I'll get in a lot of trouble       n/a
57.Which parent (mom or dad) would you be more comfortable telling that you SI? mom dad n/a
58.Do you feel like your parents don't listen to you? yes no n/a
59.Do you feel like your parents don't understand the pressures you deal with? yes no n/a
60.Do you have a self-esteem problem? yes no 
61.Who would you be comfortable asking for help from regarding SI? (ck all that apply) school counselor therapistpastor friend parent friend's parent teacher other
62.Would you be willing to see a therapist if you knew it would be confidential? yes no n/a
63.What triggered the first SI incident?  movie person memory event other
64.Was there a delay from what triggered the first SI incident to actually SI'ing for the first time? yes no
65.What influenced you to first use SI as a coping skill? movie person news source other I'm not sure
66.Do you think people who care about you have a right to be concerned that you SI? yes no n/a
67.Do you think your parents care about you? yes no n/a
68.Do you think anyone cares about you? yes no sometimes
69.Does SI interfere with school or work? yes no sometimes
70.Do you wear specific clothing to cover scars? yes no sometimes
71.Have you ever attempted suicide? yes no
72.Do you think about wanting to complete suicide? yes no sometimes
73.Has your SI ever been mistaken for a suicide attempt? yes no
74.Do you carry SI instruments with you? always never sometimes
75.Do you have a special place that you store SI instruments? yes no
76.Do you ever plan out a SI episode? yes no sometimes
77.Are your episodes of SI spontaneous? yes no sometimes
78.Do you take your time during a SI episode? yes no sometimes
79.Do you make a conscious decision on just how far you will go during a SI episode? yes no sometimes
80.Do you think about the consequences of SI? yes no sometimes
81.Do the thoughts of consequences ever stop you from SI? yes no sometimes
82.Rate the importance of educating yourself about why you SI... 1 2 3 4 5 6 7 8 9 10
83.Rate the importance of educating professionals about SI... 1 2 3 4 5 6 7 8 9 10
84.How important is it to you to replace your SI with healthy coping skills? not important somewhat important very important
85.Do you have tattoos? yes no
86.Have you ever been tattooed for the pain only? yes no sometimes n/a
87.Do you have piercings? yes no
88.Have you ever had piercings for the pain only? yes no sometimes n/a

   SECTION 3

    Experience with Medical Professionals...

1.Have you ever needed medical attention but didn't go? yes no
2.Do you medically treat your self inflicted injuries? yes no sometimes
3.Do you purchase bandages to treat your injuries? yes no sometimes
4.Do you purchase antiseptic to sanitize your injuries? yes no sometimes
5.Do you purchase antibiotic ointment? yes no sometimes
6.Do you purchase suture materials? yes no sometimes
7.Have you ever received medical treatment due to SI? yes no
8.What do you think med professionals think of those who SI? (ck all that apply) sick deranged depressed angry crazy suicidal other
9.If you have sought medical treatment, who did you see? regular doctor        new doctor n/a
10.What was his/her first reaction to the knowledge that you SI'd? positive negative neutral n/a
11.Would you prefer to seek treatment with the same sex or opposite sex doctor than yourself? same sex opposite sex it doesn't matter to me
12.Would you prefer an older or younger doctor regarding treatment for SI? younger older         it doesn't matter
13.When seeking treatment were you honest?. yes no n/a
14.How were you treated by the med professionals? (ck all that apply) respect compassion indifference disrespect  other n/a
15.Were they discreet regarding the situation while treating you? yes no sometimes n/a
16.Did they use numbing agents prior to treating you? yes no sometimes n/a
Do you think medical professionals...
17.have a right to ask about your SI behavior? yes no
18.have a right to ask if it was a suicide attempt? yes no
19.have a right to ask if you are in therapy for this problem? yes no
20.have a right to contact your therapist? yes no
21.have a right to contact parents of underage persons seeking treatment for SI? yes no
22.Would you be more likely to seek medical treatment for your injuries if doctor's only required to know the following: 1) was it a suicide attempt 2) are you currently seeing a therapist 3) have you or will you notify your therapist regarding this incident of SI yes no maybe

    SECTION 4

    Experience with Therapeutic Professionals...

1.Are you currently in therapy? yes no
*If you haven't any experience with therapists regarding SI then please skip down to question 24.
2.How long have you been in therapy? 1-2yrs 3-5yrs 6-9yrs >10yrs n/a
3.Does your therapist know you SI? yes no                 I don't know n/a
4.Do you tell your therapist when you feel like SI'ing? yes no n/a
5.Do you tell your therapist after you SI? yes no sometimes n/a
6.Does your therapist give you ultimatums regarding SI? yes no sometimes n/a
7.Do you have to sign a "no self-harm contract" with your therapist? yes no n/a
8.Does therapy help you combat thoughts of SI? yes no sometimes n/a
9.How does your therapist handle your SI behavior? (ck all that apply) w/compassion w/understanding w/respect w/disappointment w/ultimatums   other n/a
10.Is your therapist compassionate in dealing with your SI? yes no n/a
11.Does your therapist seemed to be disappointed when you SI? yes no sometimes n/a
12.Do you have a good relationship with your therapist? yes no n/a
13.Do you feel you can talk to him/her about anything? yes no n/a
14.Do you worry about the response you will get once you inform your therapist that you SI'd? yes no n/a
15.How would you like your therapist to respond? (ck all that apply) compassionately indifferent respectfully directlyother n/a
16.Have you ever been told that if you SI then he/she will no longer see you? yes no n/a
17.Does your therapist have consequences for you if you SI? yes no n/a
18.Are his/her consequences appropriate? yes no n/a
19.Are his/her consequences effective? yes no sometimes n/a
20.Do you believe consequences are helpful? yes no sometimes n/a
21.Does your therapist help you to come up with healthy coping skills to replace SI? yes no sometimes n/a
22.Do you prefer the same sex or opposite sex therapist? same opposite n/a
23.How many therapist have you interviewed that won't see you because you SI? 1-2 3-5 >5 none n/a 
24.Do you believe there is enough education on SI for therapists to help you? yes no
25.Do you believe SI is a healthy coping skill? yes no sometimes
26.Do you believe SI is your only coping skill that works? yes no sometimes
27.Do you believe you are the only one who SI's? yes no sometimes
28.Have you ever attended groups with others that SI? yes no 
29.If so, did you find those groups helpful? yes no sometimes
30.Do you find groups on SI to be triggering? yes no sometimes
31.What is the primary feeling you have about yourself regarding your SI behavior? anger disappointment frustration guilt embarrassment shame
32.Do you believe in consequences in therapy for SI'ing?  yes no 
33.Do healthy coping skills work for you? yes no sometimes
34.Do you want to stop SI'ing? yes no sometimes
35.Do you believe there is hope for you to stop SI? yes no sometimes
36.Do you believe there is hope for others to stop SI? yes no 
37.Do you search the internet to get help for your SI behavior? yes no sometimes
38.Are most SI web sites helpful? yes no 
39.Do you find most SI web sites triggering? yes no sometimes

    SECTION 5

    Experience with Others Regarding your SI History...

1.Have you ever told a friend or relative that you SI? yes no 
2.What was your experience those friends? (ck all that apply) judgmental shock non-judgmental concerned other n/a
3.Have you lost friends over this problem? yes no 
4.What was your experience with those relatives you told? (ck all that apply) judgmental shock non-judgmental         concern n/a
5.Does your SI behavior hurt others? yes no
6.Do you think you have a problem? yes no
7.Would you ever confide in a school counselor for help? yes no n/a 
8.Would you ever confide in a pastor for help? yes no 
9.Do you know others who SI? yes no 
10.What is the age group of others you know who SI? under 12 12-14 15-18 19-25 26-30 over 31
11.Have you ever SI'd with another person? yes no 
12.Have you ever had another person purposefully injure you? yes no 

    SECTION 6

    Experience with this Survey...

1.Did you find this survey triggering? yes no 
2.Do you think the results of this survey could help educate others? yes no 
3.Do you think taking this survey has helped you in any way? yes no 
4.How did you find out about this survey? friend therapist doctor                  surfing the internet  other
5.Will you encourage others that SI to take this survey? yes no 
6.May we contact you if we need further research data? yes no 

If so, my email address is..

    If something wasn't covered that you feel needs to be said please email me!! 

    Thank you for your time and honesty in filling out this survey! :)

Please address all questions and comments regarding this survey to the web administrator        at: webmaster@sisupport.org

 

Author: webmaster@sisupport.org
Copyright © 2006 [SI Support]. All rights reserved.
Revised: April 28, 2006