©DiFrancesco & Simeone, Dialog International Press, LLC, 1-15-12

Name:_____________________________________________ OR Research Code #:_____________________Date:______________

INSTRUCTIONS:  

Please consider each statement as it applies to you, your partner, or your marriage or relationship NOW (meaning generally within the last  month).  Make a determination based on your “gut” feelings about how each statement would describe your relationship as you, and not others or your partner, experience how you are together.  Pick the appropriate number from the rating scale which best describes this.  If you feel your relationship was considerably different at a different point in time, such as at the beginning of the marriage, please make a column in the margin entitled: THEN (specify the approximate time frame), and mark how it was “then” as opposed to NOW.  

If an item has more than one aspect to it, in order for it to be a “6”, all aspects have to so describe your relationship.  If only one aspect describes it and the other does not fit at all or as much, then rate it according to the quality that least fits it.  

Rating Scale:  

1 = Completely untrue                                               4 = Moderately true  

2 = Mostly untrue                                                        5 = Mostly true  

3 = Slightly more true than untrue                        6 = Describes perfectly 

            EXAMPLE: 

Then (onset    

of relationship)                                                                                                                                         

5        A. ___2__ We talk through everything regarding how we run our lives. 

(You would rate this by creating a special column if when you met it was “Mostly true”, but NOW it is “Mostly untrue”.) 

           B.___2__ We empathize with each other and practice good listening.

(If you feel you empathize on a “Mostly true” level, but the listening is “Mostly untrue”, then rate it according to the listening.)  

1.______ We know how to de-escalate our clashes to avoid them becoming terrible memories.

2. ______When my partner becomes angry, I generally don’t withdraw and close off.
3. ______ When I am withdrawn or closed off, my partner knows how to tenderly reach out to me and get me to open up.
4. ______ When my partner is loud, annoyed or angry, I am able to go beyond how “off-putting” their behavior is, and comfort the hurting and vulnerable little person within.
5. ______ After our clashes we regularly talk about our regrettable incidents in a way that helps us both try to understand each other and take responsibility for what we can do differently next time.
6. ______ We take regular weekly time to connect with each other about how we are doing together and what our needs are.
7. ______ More often than not, during a clash we give each other the benefit of the doubt with a positive interpretation of each other.
8. ______ We are best friends.
9. ______ We may not always like what the other does, but we do like each other.
10. ______I believe we were meant to be together.
11. ______ I feel devoted to my partner because he or she has been good to me in ways no one else has ever been.
12. ______ Given a choice, I would re-choose my partner.
13. ______ I am glad we are together.
14. ______ I go to my partner for soothing and de-stressing first, above all others.
15. ______ I regularly seek out soothing and de-stressing from life’s pressures  in  a healthy adult manner with my partner.
16. ______ My partner regularly comes to me for soothing and de-stressing.

17._______I go to my Vulnerable or Healthy Adult side (mode) of myself to best  to connect with my partner.

18._______We celebrate and make good memories together.

19. ______ We practice non-sexual ways of soothing and de-stressing together
20. ______ I see our home as a refuge for becoming soothed, refreshed and built up again.

21._______We are deliberately and habitually enthusiastic with each other.

22. ______ I feel my partners’ devotion and loyalty to me.
23. ______When my partner is triggered (upset) about something, she or he is generally able to self-calm after a time-out and become receptive to my needs and feelings as well as their own.
24. ______I regularly offer my partner forgiveness because I know I mess up and need that myself.
25. ______ Even though we may forgive each other, we always take the time to talk about regrettable incidents.
26. ______ When I hurt my partner, I always try to understand what my own underlying attitudes and modes are that need  changing; I make an attempt at understanding myself better so I can handle things in a healthier and less negative mode when I get triggered in the future.
27. ______ When we have a conflict, I generally don’t let myself put it out of mind without reflecting on what we each need to do differently.
28. ______ I generally don’t battle back and become attacking of my partner in (circle which or both) verbal and/or physical ways.
29. ______ I generally don’t feel my partner battles back at me and becomes attacking (circle which or both) verbally or physically.
30. ______ I generally don’t avoid bringing up issues between us because of feeling emotionally unsafe or  because I will feel hurt, upset and not validated if I bring them up.
31. ______ I generally don’t feel that I just pacify my partner or avoid an immediate argument by saying “yes”, but then just forget about it, don’t do it, or ignore it.       
32. ______ I don’t feel like I am being frequently corrected or criticized.
33. ______ I don’t feel like I am being frequently yelled at.
34. ______ I do not feel disrespected or treated like an object in our sex life together.
35. ______ My partner’s sexual attitudes and behaviors do not make me feel that I am not enough or good enough.
36. ______ I feel we really emotionally connect when we have sex.
37. ______ I never use porn to soothe myself when I am lonely.
38. ______ I know how to let my partner know that I am lonely;
39. ______ I generally don’t feel “set-up” by my partner to look bad, fail, or behave poorly.
40. ______ I generally don’t feel I have to protect myself emotionally from my partner.
41. ______ I generally don’t feel my partner “out-talks” me when we have an issue.
42. ______ If I let my guard down, my partner will not hurt or disappoint me.
43. ______ I would like to be really close and connected to my partner.

44.______ My partner and I are really close and connected.

45. ______ I feel in love with my partner.
46. ______ I feel special to my partner.
47. ______ We do not have gridlocked issues where I cannot see future resolution happening.
48. ______I feel my partner is able to give me emotionally precisely what my parent(s) did not.

49. ______ I have strong hope that I can have my needs met with my partner and be happy together.

50.______ If my partner reaches out to be soothed or soothe me, I never act independent and not let myself need my partner.

51.______My partner goes to their Vulnerable or Healthy Adult side (mode) frequently with me.

52.______ I feel that we physically touch each other a lot in caring ways throughout the day.

53. ______ I feel understood and listened to by my partner.
54. ______ I feel that we are warm and affectionate with each other.
55. ______ We pray together in our own tradition (individually or separately), for our relationship.
56. ______ I have shared my childhood hurts with my partner, ways in which others were not necessarily there for me, or not consistently, or may have negatively affected me. These affect what I feel and need today.
57. ______ My partner acts understanding when I have shared this, and finds it easier to know what I need and come through in a caring and empathic way.
58. ______ I never feel that even though my partner acts understanding and listens, in actual fact, he or she does not connect what happened to me in the past,  with how I need to be treated now to offset it
59. ______ My partner can understand the hurts or disappointments I received from peers and relationships growing up and dating.
60. ______ My partner is ordinarily conscious of painful experiences of mine, and tries to offset them and provide the opposite out of their caring love for me.
61. ______ My partner tries hard to provide what my parent(s) or others in my life, did not provide enough of, such as affirmation, warmth, caring, constancy, sharing, limit setting with empathy, etc.
62. ______ We are able to empathically confront the unhealthy patterns of the other person in a soft way. This is done with sensitivity to how life experiences have shaped their behavior, without making him or her feel blamed or rejected.
63. ______ We know each other’s main schemas.
64. ______ I have been practicing empathic confrontation and found it works.
65. ______ Next to God or a higher power, connecting with each other is the most important thing in the world for me.
66. ______ When we have a clash, we are in the habit of reflecting about our modes, our schemas, our unmet needs, and each other’s core memories. This helps us reach each other and also reach out for what we each need.
67. ______ I am hopeful that even when things really hurt between us, we can work it out.
68. ______ Learning to connect and trust my therapist has helped me trust and connect with my partner.
69. ______ I believe that the rough edges of our personalities can indeed change.
70. ______ Our therapist and I talk about the therapy relationship and use it to help my partner and me overcome our clashes.
71. ______ When we are physically intimate, I feel it is an act of love.
72. ______ Our children (or our common goals) make our relationship stronger.
73. ______ I can be vulnerable with my partner, know how to identify my needs, and actually do make the effort to express them in a vulnerable or healthy adult mode.
74. ______ I have healthy ways of getting my relationship needs met with my partner.
75. ______ I understand and care about filling my partner’s core needs.

76._______When we talk about regrettable incidents, I feel my partner really empathizes with what I was feeling.

77._______With my partner forgiveness is for the asking.

78._______Though it may not be easy, my partner regularly expresses his or her inner self  (feelings, thought, needs, desires) in words, versus expecting me to just “know” them or bottling them up inside.

79._______I hear my partner say or act that home is a safe harbor and a place to be refreshed.

80._______ I do not fear my partner will be too busy, will think I am weak, or will be non-receptive, if I should say I feel lonely.

A) Please indicate approximately how many sessions of schema therapy you have had, including both individual and joint sessions on the date of this administration:__________
B) Therapist, please note what stage the client is in therapy: (mark any applicable)
—1) initial evaluation
–2) crisis management and skills building
–3) schema assessment and education;
–4)mode identification and dialogues; creation of individual mode maps
–5) identification of mode cycles & clashes; creation of couples’ mode cycle flashcards
–6) working on individual schema healing
–7) learning how to identify and de-escalate schema and mode cycle clashes
–8) re-parenting of each other and healing specific bad memories
–9) continuing with processing more regrettable incidents and bringing them to resolution,
–10) putting gridlocked problems and patterns into schema conceptualizations
–11) applying dialog tools and special techniques to enhance the re-parenting
–12) taking new clashes and providing opportunity for resolution within the office while therapist observes and helps only when couple goes off course, then identifies and strengthens what is needed
–13) teaching specialized bonding exercises for the couple to continue to build the friendship system
–13) looking to the future and identifying future schema clashes
–14) re-assessment of initial presenting feelings and resolution of any matters left hanging
–15) end of the active stage of therapy
–16) Check-ups and readjustments:
— 1x/month
–every 3rd. month
–every 6 months
–once per year
–one year after therapy
–two years after therapy
–three years after therapy
–more years after therapy (write in)_________

**This scale is for research purposes only, and has not been validated or replicated. Any interpretations made from it have not been established for clinical use. The authors or publishing company take no clinical or other responsibility for its use or misuse.
Scoring tabulation:
Page 1 total:____
Page 2 total:____
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Page 5 total:____
Grand
Total: ______

Therapist’s Evaluation of Category Scoring: (choose one verbal description connected to the score ranges which seems to represent where your clients are at)_________________________