The Two- Track Bereavement Questionnaire

Transcription

1 TTBQ Eng VA 3b 11/2/ The Two- Track Bereavement Questionnaire Please complete the following questionnaire, which addresses a variety of questions concerning your life after the loss of a person important to you. The purpose of this questionnaire is to learn about people s reactions to the death of a person important to them. Please read the questions and mark the answer that seems most appropriate to you. At the end of the questionnaire is a section where you may add your comments. Thank you for your willingness to participate. The Research Group Questionnaire number: Details about the deceased First Name of the Deceased Today s date: / / Your Sex: (please circle) Male / Female Date of death: / / Age at death: Your Country of birth: Years in this country: Your age: Your religion: (please specify): Degree of religious observance (please circle) 1. Very religious 2. Religious 3. Moderate 4. Not very religious 5. Not at all religious 6. Other (please explain): Circumstances of the death: Your Relation to the deceased: (please circle) 1. My parent 2. My spouse 3. My sibling 4. My child 5. Other relation (please specify): 6. Good friend 7. Work colleague 8. Other (please specify):

2 TTBQ Eng VA 3b 11/2/ Part I. All questions refer to the past unless stated otherwise. 1. My health is: 1- very good 2- good 3- so so 4- not so good 2. My mood is: 1- very depressed 3. I feel: 2- depressed 3- so so 1- very anxious 2- anxious 3- so so 4- not so depressed 4- not so anxious 5- not good at all 5- not at all depressed 5- not anxious at all 4. Since the loss, life seems to me: 2- noticeably 4- not so 5- not different 1- very different 3- so so different different at all Please explain briefly and give an example: 5. Since the loss, the meaning of my life and the world around me has: 1- changed 4- not much 5- not changed 2- changed 3- so so greatly changed at all 6. The direction of the changes in the meaning of my life has been: 1- for worse only 2- mostly for worse, some for better 3- some for worse, some for better 7. Thoughts and feelings flood and confuse me: 4- mostly for better, some for worse 8. I am involved and participate in various activities and tasks: 5- for better only 1- not at all 2- a little 3- moderately 4- quite a lot 5- a great deal 9. I function at work: 1- very well 2- well 3- so so 4- not so well 5- not well at all 10. Following the loss, how I think of myself (my self-perception) has: 1-changed 3- changed 4- not changed 2-changed much greatly moderately much 6- does not apply, Please explain 5- not changed at all 11. My self-perception this has been: 2- mostly 1- only negative 3- so so negative 4- mostly positive 5- only positive

3 TTBQ Eng VA 3b 11/2/ I find it difficult to function socially: 2- mostly not 1- not 3- partly 4- mostly My connections with close family are: 1- very good 2- good 3- so so 4- not so good 5- not good 6- Does not apply, please explain why 14. My relationships with close family are a significant source of support for me: 6- Does not apply, 2- mostly not 4-mostly 1- not 3-partly 5- please explain why 15. Connections with others outside the family are a significant source of support for me: 2- mostly not 1- not 3- partly 4- mostly My functioning as a spouse is: 1- very good 2- good 3- so so 4-not so good 5- not good 17. My functioning as a parent is: 6- Does not apply; please explain 1- very good 2- good 3- so so 4- not so good 5- not good 6- Does not apply; please explain 18. My values and beliefs are a significant source of support for me: 1- not 2- mostly not 3- partly 4-mostly I believe and trust in my abilities to cope on my own with the tasks of life: 20. Following the loss, it is fair to describe my current situation as: 1-In great need 3- need some 4- don t really 5- don t need 2- need help of help help need help any help at all II Please read the instructions for the next section and proceed. In the following questions, wherever a line appears, please answer as if the name of the deceased was written there. The questions refer to the past, unless stated otherwise. 1. I find it hard to recollect memories of even when I try to: 1- not 2- mostly not 3- partly 4- mostly 5-

4 TTBQ Eng VA 3b 11/2/ Our relationship was such that when I think about, I usually remember our disagreements: 1- not 2- mostly not 3- partly 4- mostly 5-3. Because of virtues and unique qualities, it s very hard to have negative thoughts about him/her: 4. Occasionally, I behave or act emotionally, as if I don t believe that is gone. This happens to me:. I notice things that remind me of. For example, people that look like him/her, voices, or a feeling that he/she s around. This happens to me: 6. I think of all the time: 7. I ve reached a degree of acceptance of the loss of : 8. When I think of, I feel strong guilt and regret that I didn t do things differently: 9. Thoughts about bring up positive feelings in me: 10. I remember : 11. I avoid things that remind me of : 12. Thinking of and remembering significantly calms me: 13. Life without is too hard to bear:

5 TTBQ Eng VA 3b 11/2/ Since the loss, I ve discovered some negative things about that I didn t know before. Those things changed what I thought of him/her for the worse: 15. I yearn strongly for and miss him/her deeply: 16. I feel pain whenever I recall : 17. Now I understand people who think about putting an end to their own life after losing a close person: 18. I do things to keep alive and maintain the memory of : 1-2- mostly 3- partly 4- mostly not 5- not (please give 3 examples of keeping alive or maintaining the memory of ) 1) 2) 3) 19. Since the loss I ve discovered some positive things about that I didn t know before. Those things changed what I thought of him/her for the better: 20. It s possible to define my situation today, following the loss, as: 1- suffering 3- suffering 4- not suffering 2- suffering greatly somewhat much III. Please read the instructions for this section and proceed. The following questions relate to the last 2 years of the relationship between you and during his/her life. 1. My relationship with was: 1- very close 2- close 3- close and not close at the same time 4- not close 5- not suffering at all 5- not close at all 2. During his/her life, was a major source of emotional support for me:

6 TTBQ Eng VA 3b 11/2/ I was emotionally dependent on : 4. My relationship with had many and strong ups and downs: 4- mostly not 1-2- mostly 3- partly 5- not 5. My relationship with had much avoidance and distance: 6. was emotionally dependent on me: 7. My relationship with was characterized by sharp changes between being close to being angry and/or the wish to be distant: 8. was the person: 1- closest to 2- one of those 4- not so close to 5- not close to 3- close to me me closest to me me me at all 9. Overall, my relationship with was based on a sense of mutual trust: 10. The relationship between and I was based on mutual understanding, freedom, and a sense of comfort or flow : IV. Please proceed. The next questions regard your thoughts and feelings today. 1. The loss was traumatic for me: 2. The loss happened suddenly and unexpectedly: 3. The loss took place under circumstances of violence or horror (such as accident, terror, or self-harm) or other difficult circumstances: 4- mostly not 1-2- mostly 3- partly 5- not Please explain:

7 TTBQ Eng VA 3b 11/2/ I am angry because of the loss: Who are you angry at and why? A) B) 5. I witnessed the death of : 6. My life was in danger when died: 7. I keep on experiencing the loss as a shocking and traumatic event in my life: Please explain why: 8. Loss of the kind I encountered is usually experienced as a most difficult event: 9. The circumstances that caused the loss I experienced are usually considered as extremely difficult: 10. I see images or pictures from the death scene that enter my thoughts: 11. I see images or pictures of in my head: 12. I find myself actively avoiding thoughts of : 13. I am tense and not relaxed: 14. I am flooded by thoughts and feelings about the death of :

8 TTBQ Eng VA 3b 11/2/ People who are not family are aware of how great my loss is: 16. In facing life's difficulties, I usually trust only myself: 17. Before the loss, difficult events affected me for a short while only: 18. I am able to talk and share my feelings with other people and to receive their help and support: 19. I have managed to overcome difficult events in my life: 20. I believe that I m capable of handling my feelings and reactions to the loss without the support and help of others: If you wish to add information about how you have coped with your loss or to make additional comments, please add them here. Thank you.