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Centre for Ethnic Minority Mental Health
Part 1: (Please answer ALL
questions) |
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To be entered in
to the prize draw, please enter you email address:
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1. Your Age at last birthday:
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2. Your Gender:
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3. Your Marital status:
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4. How would you define yourself, ethnically?
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Black
or Black British:
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5. What is the highest level of academic qualification
you have attained?
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6. What is your accessible annual income?
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7. Below is a copy of the ‘von Luschan Skin Tone Chart’. This series does not represent
all possible skin tones. Can you please indicate which skin tone most
represents your own on an unexposed part of your body?
19 20 21 22
23 24
25 26
27 28
29 30
31 32
33 34
35 36
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Part 2:
Instructions: This questionnaire assesses concerns about physical appearance.
Please read each question carefully and check the answer that best describes
your experience. Also write in answers where indicated.
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1. Do other people appear concerned
about the appearance of some part of your body, which they consider
especially unattractive??
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2. What do think these
concerns are? What specifically bothers them about the appearance of these
body parts?
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3. If, they are at least somewhat concerned, do these
concerns preoccupy you? That is, you think about them a lot and they’re
hard to stop thinking about? (Check the best answer )
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4. What effect has their preoccupation with your physical
appearance had on your life? Please describe):
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5. Does their behaviour towards you often caused you a lot of distress, torment or pain? How much?
(Please check the best answer)
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6. Has other people’s apparent concern with your
physical appearance significantly interfered with your relationships at home,
school, college, work, or your ability tio function
in your role or other important areas of your life? And if so how much?
(Please check the best answer)
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7. Do you ever avoid thing because of other
people’s apparent concern with your physical appearance? And if so how
much? (Please check the best answer).
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Part 3:
Instructions: This part of the questionnaire looks at how
you represent relationships within your own mind. Please read each statement
carefully, and highlight the answer that best describes your
experience.
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1) When I close my eyes and think
about my past experiences, most of the images that come to mind are of
me with:
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a) )
People who make racist comments about other black people, but it’s not
serious, and it doesn’t involve me.
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b) People who make insulting remarks about other black
people, but they always make a point of excluding me:
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c) People who never mention the colour of my skin, my hair
texture, or the thickness of my lips, but I know they have a significant
effect on how they respond to me:
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d) People like to socialise
with me, but they wouldn’t want other people like me to have a personal
relationship with any member of their families:
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2) When I
close my eyes and think about my past experiences, most of the images
that come to mind of me with:
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a) People who make racist remarks about some aspect of my
black body.
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b) People who tell me how much they don't like the
darkness of my skin colour, my lips or texture of texture:
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c) People who make racist jokes, and usually direct them
at me.
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d) People who say insulting things about my skin colour,
shape of my nose, or the thickness of my lips, and don’t seem to care
if it makes me feel unwanted and unhappy.
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3) When I
close my eyes and think about my past experiences, most of the images that
come to mind show me with:
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a) People who rarely, if ever, socialise with anyone who
is not from the same racial background.
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b) People who often make more positive remarks about the
colour of my skin, the shape of my nose, texture of my hair, or thickness of
my lips, than they do people from other racial backgrounds
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c) People who made me feel valued as black person, more
so than they do about people from other racial backgrounds
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d) People who prefer to be with other people from the
same racial background; to the exclusion of people from other racial
backgrounds.
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4) When I
close my eyes and think about my past experiences, most of the images
that come to mind show me with:
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a) People who value their own individual racial identity,
as much as they do, others.
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b) People who often make positive statements about the
physical bodies of people from different racial backgrounds.
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c) People who accept racial difference, and encourage socialising
between different racial backgrounds
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d) People who accept both the positive and negative
aspects of their own physical bodies.
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Part
4:
This
questionnaire consists of 15 statements about experiences that you may have
in your daily life. We are interested in the strength of your agreement with these
statements; when you are not under the influence of alcohol or drugs. (Using
the drop-down menu, indicate to what extent you agree or disgree
with the statement)
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1. There are things I prefer
not to think about:
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2. Sometimes, I wonder why I
have the thoughts I do.
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3. I have thoughts that I can
not stop.
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4. There are images that come to mind that I can not
erase.
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5. My thoughts frequently return to one idea.
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6. I wish I could stop
thinking of certain things..
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7. Sometimes my mind races so fast I wish I could
stop it.
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8. I always try to put
problems out of mind.
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9. There are thoughts that
keep jumping into my head.
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10. Sometimes, I stay busy
just to keep thoughts from intruding on my mind.
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11. There are things that I
try not to think about.
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12. Sometimes, I stay bust
just to keep thoughts from intruding on my mind.
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13. I often do things to distract
myself from my thoughts.
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14. I often have thoughts that I try to avoid.
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15. There are many thoughts that I have that I
don’t tell anyone.
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Part 5:
Please choose the degree to which you
agree or disagree with each statement from the drop-down menu.
Please respond to ALL statements.
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1. I feel
that I am a person of worth, at least on an equal basis with others.
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2. At
times I think I am no good at all
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3. I feel
that I have a number of good qualities.
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4. All in
all, I am inclined to feel that I am a failure.
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5. I am able
to do things as well as most other people.
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6. I feel
I do not have much to be proud of
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7. I take
a positive attitude toward myself
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8. On the
whole, I am satisfied with myself.
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9. I wish
I could have more respect for myself.
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10. I certainly
feel useless at times.
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