| RPT |
.| .| The Acceptance and Action Questionnaire -Substance Abuse| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
be weak-willed.| <*Answer_7264*>| 14. People would be scared of me if they knew about my substance abuse history.| <*Answer_7265*>| 15. If someone were to find out about my history of
substance use, they would doubt my character.| <*Answer_7267*>| 16. People will think I have little talent or skill if they know about my substance history.| <*Answer_7266*>| 17. People think
the bad things that have happened to me are my fault.| <*Answer_7268*>| | Section 3:| | 18. I would choose to avoid someone who seemed interested in my friendship if I knew they had never used
substances.| <*Answer_7269*>| 19. I do things that are good for me, even if I feel like I don't deserve it.| <*Answer_7270*>| 20. If something is important to me, I keep doing it, even if I
feel incompetent.| <*Answer_7271*>| 21. When I feel incompetent at something I want to do, I stop trying.| <*Answer_7272*>| 22. I'm willing to be in situations where I might feel different
from others.| <*Answer_7273*>| 23. I am getting on with the business of living, no matter how guilty I feel.| <*Answer_7274*>| 24. I am open about my substance use history with most people.|
<*Answer_7275*>| 25. I put a lot of effort into hiding my substance use history.| <*Answer_7276*>| 26. I avoid doing things where I would be blamed if it didn't work out.| <*Answer_7277*>|
27. I wouldn't try to fill roles that required a person of character.| <*Answer_7278*>| 28. Shame gets in the way of how I want to live my life.| <*Answer_7279*>| 29. I pursue important goals
in life, even when I fear I might not follow through.| <*Answer_7280*>| 30. I can set a direction for my life even if I feel hopeless.| <*Answer_7281*>| 31. Even if I knew the employer didn't
like to hire people in recovery, I would still apply for a job if it interested me.| <*Answer_7282*>| 32. I would lie to people in my life about my substance use if I were sure they would never
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | AAQ-SA| Self devaluation: <-Self devaluation->| Fear of enacted stigma: <-Fear of enacted
find out.| <*Answer_7283*>| 33. I avoid situations where another person might have to depend on me.| <*Answer_7284*>| 34. I avoid situations that make me feel different.| <*Answer_7285*>|
35. I can't stand feeling like the bad things that happen to me are my fault.| <*Answer_7286*>| 36. I would willingly sacrifice important things in my life to feel like I fit in.|
<*Answer_7287*>| 37. Blaming myself for my substance abuse history gets in the way of my success.| <*Answer_7288*>| 38. I can set a course in my life and stick to it, even when I feel like I'm a
bad person.| <*Answer_7289*>| 39. If I didn't have a job, I would still look for one, even if it felt hopeless.| <*Answer_7290*>| 40. I would willingly sacrifice important life goals if that
meant I could feel better about myself.| <*Answer_7291*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.
Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
stigma->| Stigma avoidance: <-Stigma avoidance->| Values disengagement: <-Values disengagement->| | Questions and Answers| | Section 1:| | 1. I have the thought that a major reason for my
problems with substances is my own poor character.| <*Answer_7252*>| 2. I have the thought that I should be ashamed of myself.| <*Answer_7253*>| 3. I have the thought that I deserve the bad
things that have happened to me.| <*Answer_7254*>| 4. I have the thought that I can't be trusted.| <*Answer_7255*>| 5. I feel inferior to people who have never had a problem with substances.|
<*Answer_7256*>| 6. I feel out of place in the world because of my problems with substances.| <*Answer_7257*>| 7. I have the thought that I've permanently screwed up my life by using drugs.|
<*Answer_7258*>| 8. I feel ashamed of myself.| <*Answer_7259*>| | Section 2:| | 9. People think I'm worthless if they know about my substance use history.| <*Answer_7260*>| 10. People
around me will always suspect I have returned to using substances.| <*Answer_7261*>| 11. People without a substance use history could never really understand me.| <*Answer_7262*>| 12. A job
interviewer wouldn't hire me if I mentioned my substance history in a job interview.| <*Answer_7263*>| 13. If someone were to find out about my history of substance use, they would expect me to
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