S.L. Rizvi (2009) - 1 -
Shame is a negative and painful feeling in which the entire self is viewed as bad and/orworthless. It may be accompanied by urges to withdraw or conceal some behavior oraspect of yourself. Shame is different from just generally being upset or distressed,because it relates to how you feel about
. Some people experience shame on aregular basis; others hardly experience shame at all.The questions below are about
shame feelings that you may experience.1.
Circle the number which indicates
you typically experience shame.Never Seldom OccasionallyOften Always0 1 2 3 42.
Circle the number which indicates the
intensity or severity
of shame that you typicallyexperience.None Slight ModerateConsiderableExtreme0 1 2 3 43.
To what extent does shame negatively affect the quality of your life?No Effect Slight EffectModerateEffectConsiderableEffectExtremeEffect0 1 2 3 4
This is a list of situations and behaviors that may be related to the experience of shamefor you. Please write a number (between 0-4) beside each statement which indicates theintensity of your
about that event. If the statement does not apply to you, write an“X” beside the statement.Didn’t Happen/DoesNot Apply to MeNoShameSlightShameModerateShameConsiderableShameExtremeShameX 0 1 2 3 4Rate0-4 A time when I . ._____ 1.
Was laughed at in front of others_____ 2.
Was criticized in front of others_____ 3.
Cried in front of others_____ 4.
Made a scene in public_____ 5.
Lost something important_____ 6.
Had sex with someone when I didn’t want to_____ 7.
Forced/coerced someone to have sex with me_____ 8.
Had an affair/was unfaithful/was sexually promiscuous