Informed Consent Form

You are invited to participate in a study entitled: Study of Self Harm Behavior:
Exploring the role of Distress Tolerance, Perceived Social Support, Self
Esteem and Coping style. Please read this form carefully and feel free to ask
any questions you might have.

Researchers:

Neelkanth Bankar, Assistant Professor, Dept. of Applied Psychology, C.D.

Deshmukh Bhavan, Vidyanagari, University of Mumbai, Santacruz (East),
myname_12@hotmail.com, Mobile Number: 09833851202, Office Phone: -
022-26543067

Nilesh Shinde, Project Fellow, Dept. of Applied Psychology, C.D. Deshmukh

Bhavan, Vidyanagari, University of Mumbai, Santacruz (East),
nileshmshinde23@rediffmail.com, Mobile Number: 09594774325, Office
Phone: - 022-26543067

Purpose and Procedure:

The purpose of the study is to understand the self-harm behavior in relation

to distress tolerance, perceived social support, self-esteem and coping style.
The study will involve filling out a series of questionnaires/ scales related to
theses factors. These questionnaires/ scales will be collected and analyzed by
the researchers.

Confidentiality:

It is anticipated that the data from this study will be published and presented
at scholarly conferences; however, your individual identity will be kept
confidential. Results will be expressed in terms of the overall groups making
your identity unknown. In the database your identity will be represented as a
number, and no attachment will be associated with you name. Only the
researcher will review and analyze the data collected. Names or other
identifying particulars will not be discussed or made public outside of the
research team.

Storage of Data:

All research material will be securely stored by researchers of this study for a
minimum of one year following the completion of the research study.

Right to Withdraw:

You have the ability to withdraw from the study for any reason, at any time,
without penalty of any sort, including current or future participation in this or
any other study. Should you decide to withdraw from the project, your
information in terms of consent forms and questionnaires will be deleted
(erased) from the study and destroyed.

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Sometimes participation in research projects, particularly a study that asks
about sensitive information, can be distressing for participants. If your
participation in this study has identified concerns about safety, caused you
anxiety, or otherwise distressed you, please be aware that you may contact
the researchers of this study for assistance. However, research investigators
will not incur the financial costs of resources indicated by them.

Questions:

If you have any questions concerning the study, please feel free to ask at any
point, you are also free to contact the researchers at the contact numbers
provided above if you have questions at a later time. You may contact the
researchers to find out the information interpreted by them in your context.

Consent to Participate:

I have read and understood the description provided above. I have been
provided with an opportunity to ask questions and my questions have been
answered satisfactorily. I consent to participate in the study described above
and understand that I may withdraw this consent at any time.

____________________ ____________________

Respondent’s Name Date

____________________ ____________________

Researcher’s Name Date

___________________ ____________________

Researcher’s Name Date

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 Demographic Information
Respondent’s ID Code (to be filled up by researchers): -___________________

Gender (Male or Female): - ___________________

Date of Birth: - __________________

Nationality: -__________________

Religion: -___________________ Caste: -____________________

Marital Status (Married for the first time/ never married/ Separated/
Remarried): -

___________________

Mention number of children, if any:-_______________

Education: -_______________

Employment Status (List the name of your job or the title of your post and the
company/organization where you work): -

________________________________________________________________________

________________________________________________________________________

Your per month income: - ____________________

Total per month family income (including your own income):

-_____________________

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 [Please make sure that you will respond to all the scales in one
seating only.]

Scale-I

Instructions: We are interested in how you feel about the following

statements. Read each statement carefully. Indicate how you feel about each
statement by putting Y at appropriate places.

Response
Very Strongly Mildly Neutral Mildly Strongly Very
Scale Items Strongly Disagree Disagree Agree Agree Strongly
Disagree Agree

1. There is a special
person who is around
when I am in need.

2. There is a special
person with whom I
can share my joys and
sorrows.

3. My family really
tries to help me.

4. I get the emotional

help and support I
need from my family.

5. I have a special
person who is a real
source of comfort to
me.

6. My friends really try

to help me.

7. I can count on my
friends when things go
wrong.

8. I can talk about my

problems with my

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family.

9. I have friends with

whom I can share my
joys and sorrows.

10. There is a special

person in my life who
cares about my
feelings.

11. My family is willing

to help me make
decisions.

12. I can talk about my

problems with my
friends.

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 Scale-II

Directions: Think of times that you feel distressed or upset. Select the
response to items from the menu that best describes your beliefs about
feeling distressed or upset. Indicate your response by putting Y at
appropriate places.

Response
Scale Item
Strongly Mildly Agree & Mildly Strongly
Agree Agree Disagree Disagree Disagree
Equally
1. Feeling distressed or
upset is unbearable to
me.
2. When I feel distressed
or upset, all I can think
about is how bad I feel.
3. I can’t handle feeling
distressed or upset.
4. My feelings of distress
are so intense that they
completely take over.
5. There’s nothing worse
than feeling distressed or
upset.
6. I can tolerate being
distressed or upset as well
as most people.
7. My feelings of distress
or being upset are not
acceptable.

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8. I’ll do anything to avoid
feeling distressed or
upset.
9. Other people seem to
be able to tolerate feeling
distressed or upset better
than I can.
10. Being distressed or
upset is always a major
ordeal for me.
11. I am ashamed of
myself when I feel
distressed or upset.
12. My feelings of distress
or being upset scare me.
13. I’ll do anything to stop
feeling distressed or
upset.
14. When I feel distressed
or upset, I must do
something about it
immediately.
15. When I feel distressed
or upset, I cannot help but
concentrate on how bad
the distress actually feels.
Scale-III

Instructions: A series of statements are given below. Read each statement

carefully. Indicate how much agree or disagree with each statement by
putting Y at appropriate places.

There are no “right” or “wrong” answers. So please answer truthfully,

according to what you feel. Do not omit any item.

Scale Items Response

Strongly Disagree Agree Strongly
Disagree Agree
1. On the whole I am satisfied with myself.
2. At times I think I am no good at all.
3. I feel that I have number of good qualities.
4. I am able to do things as well as most other people.
5. I feel I do not have much to be proud of.
6. I certainly feel useless at times.
7. I feel that I am a person of worth, at least on an

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equal plane with others.
8. I wish I could have more respect for myself.
9. All in all, I am inclined to feel that I am a failure.
10. I take a positive attitude towards myself.

Scale-IV

Instructions: Although people may react in different ways to different situations, we all
tend to have a characteristic way of dealing with things which upset us. How would you
describe the way you typically react to stress?

Indicate your response by putting Y at appropriate places for Always, Often, Sometimes,
or Never to each item below:

Responses
Always Often Sometimes Never
Scale Items
1. Feel overpowered and at the
mercy of the situation.
2. Work out a plan for dealing
with what has happened.
3. See the situation for what it
actually is and nothing more.
4. See the problem as something
separate from myself so I can
deal with it.
5. Become miserable or
depressed.
6. Feel that no-one understands.
7. Stop doing hobbies or interests.
8. Do not see the problem or

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situation as a threat.
9. Try to find the positive side of
the problem.
10. Become lonely or isolated.
11. Daydream about times in the
past when things were better.
12. Take action to change things.
13. Have presence of mind when
dealing with the problem or
circumstances.
14. Avoid family or friends in
general.
15. Feel helpless-there’s nothing
you can do about it.
16. Try to find out more
information to help make a
decision about things.
17. Keep things to myself and not
let others know how bad things
are for me.
Scale Items Responses
Always Often Sometimes Never
18. Think about how someone I
respect would handle the situaion
and try to do the same.
19. Feel independent of the
circumstances.
20. Sit tight and hope it all goes
away.
21. Take my frustrations out on
the people closest to me.
22. ‘Distance’ myself so I don’t
have to make any decision about
the situation.
23. Resolve the issue by not
becoming identified with it.
24. Assess myself or the problem
without getting emotional.
25. Cry, or feel like crying.

26. Try to see things from the

other person’s point of view.
27. Respond neutrally to the
problem.
28. Pretend there’s nothing the

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matter, even if people ask what’s
bothering me.
29. Get things into proportion-
nothing is really that important.
30. Keep reminding myself about
the good things about myself.
31. Feel that time will sort things
out.
32. Feel completely clear-headed
about the whole thing.
33. Try to keep a sense of
humour-laugh at myself or the
situation.
34. Keep thinking it over in the
hope that it will go away.
35. Believe that I can cope with
most things with the minimum of
fuss.
36. Try not to let my heart rule
my head.
Scale Items Responses
Always Often Sometimes Never
37. Eat more ( or less) than usual.
38. Daydream about things
getting better in future.
39. Try to find a logical way of
explaining the problem.
40. Decide it’s useless to get
upset and just get on with things.
41. Feel worthless and
unimportant.
42. Trust in fate-that things have a
way of working out for the best.
43. Use my past ecperience to try
deal with the situation.
44. Try to forget the whole thing.
45. Just take nothing personally.
46. Become irritable or angry.
47. Just give the situation my full
attention.
48. Just take one step at a time.
49. Criticise or blame myself.
50. Simply and quickly disregard
all irrelavant information.
51. Pray that things will just

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change.
52. Think or talk about the
problem as if it did not belong to
me.
53. Talk about it as little as
possible.
54. Prepare myself for the worst
possible outcome.
55. Feel completely calm in the
face of any adversity.
56. Look for sympathy and
understanding from people.
57. See the thing as a challenge
that must be met.
58. Be realistic in my approach to
the situation.
59. Try to think about or do
something else.
60. Do something that will make
me feel better.
Scale- V

A lot of people do things which are dangerous and might get them hurt.
There are many reasons why people take these risks. Often people take risks
without thinking about the fact that they might get hurt. Sometimes,
however, people hurt themselves on purpose. We are interested in learning
more about the ways in which you may have intentionally or unintentionally
hurt yourself. We are also interested in trying to understand why people your
age may do some of these dangerous things. It si important for you to
understand that if you tell us about things you’ve done which may have been
unsafe or make it possible that you may not be able to keep yourself safe, we
will encourage you to discuss this with a counsellor or other confident I order
to keep you safe in the future.

Please highlight by selecting blue colour YES or NO (for example if

your response is YES then, highlight in this manner, YES NO ) in
response to each question and answer the follow-up questions. For questions
where you are asked who you told something to do not give specific names.
We only want to know if it was someone like a parent, teacher, doctor, etc.

Things you may have actually done to yourself on purpose.

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 Question No. 1.

Have you ever hurt yourself on purpose? (E.g. scratched yourself with finger
nails or sharp object.) YES NO

If no, go on to Question No. 2

If yes, what did you do?

______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

a. Approximately how many times did you do this? ______________

b. Approximately when did you first do this to yourself? (write you age)
__________
c. When was the last time you did this to yourself? (write your age)
__________
d. Have you ever told any one that you had done these things? YES NO
If yes, who did you tell? ____________________________

e. Have you ever needed to see a doctor after doing these things? YES
NO

Times you hurt yourself badly on purpose or tried to kill yourself.

Question No. 2.

Have you ever attempted suicide? YES NO

If no, go on to Question No. 4

If yes, how?
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________

(Note: if you took pills, what kind? ________________;

how many?_____________; over how long a period of time did you take
them?__________________)

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a. How many times have you attempted suicide? ____________________
b. When was the most recent attempt? (write you age)__________________
c. Did you tell anyone about the attempt? YES NO
Who? ____________________________

d. Did you require medical attention after the attempt? YES NO

If yes, were you hospitalized over night or longer? YES NO

How long were you hospitalized? _________________________

e. Did you talk to a counsellor or some other person like that after your
attempt?
YES NO Who? ___________________________

Question No. 3.

If you attempted suicide, please answer the following:

a. What other things were going on in your life around the time that you
tried to kill yourself?

___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________

b. Did you actually want to die? YES NO

c. Were you hoping for a specific reaction to your attempt? YES NO

If yes, what was the reaction you were looking for?

___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________

d. Did you get the reaction you wanted? YES NO

If you didn’t, what type of reaction was there to your attempt?
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________

e. Who knew about your attempt? ______________________________________

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Times you threatened to hurt yourself badly or try to kill yourself.

Question No. 4.

Have you ever threatened to commit suicide? YES NO

If no, go on to Question Number. 5.

If yes, what did you threaten to do/

___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________

a. Approximately how many times did you do this?______________________

b. Approximately when did you first do this? ( write your
age)__________________
c. When was the last time you did this? (write you
age)______________________
d. Who did you make the threats to? (e.g. mom, dad)
______________________
e. What other things were going on in your life during the time that you
were threatening to kill yourself?
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________

f. Did you actually want to die? YES NO

g. Were you hoping for a specific reaction to your threat? YES NO

If yes, what was the reaction you were looking for?

___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________

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 h. Did you get the reaction you wanted? YES NO
i. If you didn’t what type of reaction was there to your attempt?
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________

Question No. 5.

Have you ever talked or thought about:

- wanting to die YES NO

- committing suicide YES NO
a. What did you talk about doing?
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

b. With whom did you discuss this? _______________________________________

c. What made you feel like doing that?

______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

d. Did you have a specific plan for how you would try to kill yourself? YES
NO

If yes, what plan did you have?

______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

e. In looking back, how did you imagine people would react to your attempt?
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

f. Did you think about how people would react if you did succeed in killing
yourself?

YES NO

If yes, how did you think they would react?

______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

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 f. Did you ever take steps to prepare for this plan? YES NO
If yes, what did you do to prepare?
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

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