Author: David Helton, LMSW, LCDC

David is the Clinical Director for The SASSI Institute and has worked in the behavioral health field in Texas for over 35 years as a clinician, a manager, a division director, a trainer, an evaluator, a program developer, and a grant writer/reviewer.

Lowering Defensiveness in Clients

In our last blog we discussed a profile with defensive responding on the SASSI. In this blog, we would like to discuss strategies for handling clients who respond in this manner and the steps that might be taken to reduce defensiveness prior to administration of the SASSI.

The two factors most frequently related to defensive responding are 1) the purpose of the evaluation – i.e. to determine if there is a high probability of a substance use disorder and 2) the context or setting in which the evaluation is taking place – i.e. situational factors that may result in serious consequences for the individual such as jail time, loss of a job or loss of child custody. While there may be little that can be done to change the reason for a SASSI screening, there are a few things you can do to reduce the effect of the stigma and fear that many individuals feel in legal, EAP, or child welfare settings. Research suggests that professionals working with a client in any setting are more likely to have positive successful results with that person if they are able to develop a positive rapport with them. Specifically, you can help the client view your role as one of a helping professional who values them as an individual, recognizes and is empathetic to the difficulty they are currently facing and desires not to punish or demean them, but to assist in getting them any help they may need.

Building rapport with a client before presenting the SASSI to them can be as simple as meeting them in the lobby, smiling at them genuinely, asking about their well-being, and spending some time talking to them in a manner that you would use with anyone you were interested in getting to know better, rather than immediately “getting to the business” of the trouble that brought them there. Talking to the client in this friendly, engaging and empathetic way can be useful in helping the client to develop a higher level of trust in you, to lower their defensiveness, and to be more forthright and honest in their answers on the SASSI questionnaire. Using this procedure gives you a chance to put the client at ease and reduce any perceived threat by beginning to develop a trusting and empathic relationship. Letting clients know that you understand their pain and acknowledging how scary it must be to go through this process will also help to reduce the fear and apprehension that often leads to defensive responding.

Additionally, clinical experience has shown that clients tend to respond less defensively when told in advance that they will have a chance to talk over their answers to the questionnaire with you after they’ve finished. Letting the client know upfront that you will discuss their responses with them after they finish gives clients the message that you view them as important and value their input and perspective. One very common fear among mandated clients is that they will be mistakenly or unfairly judged by a system that doesn’t care much about their well-being. If clients know that you are someone who will not jump to conclusions and are willing to listen to their point of view, they will usually have less of a reason to feel threatened. Letting them know that the questionnaire is simply a way for you to get to know them better and to find out what problems, if any, you can help them with, as well as telling them that there are no right or wrong answers increases the likelihood that they will respond in a more open and forthright manner. It is also often useful to refer to the SASSI in terms that are not perceived as negative such as “questionnaire” rather than “test”; “survey” rather than “screening instrument.” Taking these steps will help to ensure that clients will be more open to hearing your feedback and comments when it is time to review the SASSI results.

In short, the two most effective ways to reduce the likelihood of defensive responding on the SASSI are to 1) spend some time building a positive trusting rapport with the client before ever introducing the SASSI or talking about why the client is seeing you, and 2) administer the SASSI in the context of an empathic and trusting relationship and let the clients know that they will have a chance to review the results with you.

If you would like to discuss any of your clients screening results, feel free to call the free clinical helpline at 800-726-0526, option 2.

Young Parent in Custody Evaluation: Low Probability with High DEF

The profile being discussed is for Julia, a 21-year-old single parent female, who is participating in mandated counseling following an allegation that she has been neglecting her child. The child was removed from her care and placed with family members temporarily. This counseling will play a major role in her being allowed to resume custody of her child.

There is probably no circumstance more likely to evoke feelings of defensiveness in a person than revealing the details of personal, family life, and private attitudes for others to scrutinize, particularly when other people are given the power to determine an individual’s parenting abilities and possibly remove one’s child from custody. It is no surprise then that Julia’s DEF score is elevated, given the difficult situation she is in. In reviewing Julia’s SASSI scores, she does not meet the criteria for classification as High Probability of having a substance use disorder (SUD). While elevated DEF scores, when coupled with a Low Probability result, can potentially imply an increased possibility of the SASSI missing an individual with an SUD (a false negative), an elevated DEF may also reflect serious and difficult situational factors facing Julia with custody of her child at risk.

The most striking and important feature of her profile is that most of her individual scale scores are rather “flat”, not really deviating very far from the mean (T Score of 50), which is where most average people would score. Besides the DEF scale score, only the COR score is significantly elevated. This suggests that overall she responded in a generally “average” way (answering similarly to people not in treatment for SUD). The two exceptions are DEF and COR.

Her high DEF score indicates a possible tendency to endorse only things that make her look good to others, to have her guard up so as to not reveal anything about herself that may be viewed as negative. Again, when one is being accused of child neglect and one’s child could be removed from the parent, it is quite normal for that parent to have their defenses, their guard way up and not want to show any weakness or negative traits, even though all humans have weaknesses with which they struggle. Therefore, this high level of defensiveness could be seen as entirely situational or perhaps even a personality trait. In addition, it is noted that while Julia’s DEF scale score is very high, her SAM scale score is not at all high. Prior case studies reveal to us that often when a person has a high DEF scale score and also has a high SAM score, this could be an indicator that the person’s defensiveness may be related to substance abuse. That is not the case here though. It is therefore most likely that her defensiveness is more general and situational rather than being specifically related to substance misuse.

Julia also had a very high score on the COR scale. While this score has nothing to do with the SASSI decision rules leading to a result of high or low probability of a substance use disorder, our experience with high COR scores indicates that a person with high COR scores is answering the questions on that scale very similarly to the way a person with a long history of criminal justice involvement would answer. Therefore, a person with a high COR scale score could be at greater risk of engaging in behavior that may get them arrested. Sometimes certain personality traits of the individual can be found in clients with high COR scores that may contribute to their risk of acting out and being arrested. Therefore, it is often recommended that the therapist explore for signs of low frustration tolerance, anger management problems, poor social skills, poor impulse control or being one who enjoys engaging in high risk behaviors and add these to the treatment plan to try to lower risk.

In summary: While Julia is alleged to have engaged in child neglect, there can be many reasons why a parent may engage in this behavior, with substance abuse being only one of them. As the SASSI is not designed to be a measure of a wide variety of pathologies, but is limited to the role of determining the likelihood of a substance use disorder, the results indicate that substance use disorder is not likely.

It is important to acknowledge the reality of the fear and pain underlying defensive responding on the SASSI. In order to do so, it is valuable to have a good understanding of the nature of your client’s defensiveness. There is no clear evidence in this case that defensiveness is an ongoing characterological feature or personality characteristic of Julia. Her defensiveness therefore is likely to stem from situational factors. Having said that, her high COR score indicates potential risk of engaging in behaviors that could cause her to get in trouble which may be fueled by difficulty controlling her anger and frustration and may cause her therefore to display poor judgement and act impulsively. These potential issues could indeed put her child at risk as well as herself and so should be explored carefully.

Be sure to read our next blog which will discuss tips for reducing defensiveness.

As always, feel free to call our free clinical helpline M-F 1-5 pm ET for assistance in administering, scoring, and/or interpretation of profile results at 800-726-0526 Option 1.

What is The SASSI Institute’s Clinical Help Line?

The SASSI Institute’s Clinical Help Line is a free resource designed to support clinicians and professionals using the Substance Abuse Subtle Screening Inventory (SASSI). It provides assistance with clinical interpretation of scores on each of the SASSI scales; helps individuals understand typical trends seen in SASSI profiles and how to use that information in educating clients, making referrals for clients, or developing treatment plans; provides assistance in manual scoring issues; and addresses any other specific SASSI-related questions.

Typical Clinical Help Line services include:

· Clarifying how to interpret complex or ambiguous results.

· Answering questions about the SASSI tools’ methodology or scoring.

· Providing recommendations for follow-up based on screening results.

· Offering advice on integrating SASSI assessments into broader treatment planning.

This service helps clinicians maximize the effectiveness of the SASSI tools in identifying and addressing substance use issues in diverse client populations. The Clinical Help Line is staffed by experienced, licensed/certified professionals with many years of experience and expertise in the SASSI instruments, substance use disorders and screening and assessment. They are available to answer your questions Monday thru Friday from 1:00pm to 5:00pm EST. This is a totally free service so give our friendly clinicians a call and allow us to help you make your experience with the SASSI even better for you and your clients!

An Adolescent SASSI-A3 Profile: Low-Probability with Possible Clinical Issues

Alyssa (revised) is a 14-year-old female adolescent sent for evaluation by her teachers after noticing significant changes in her emotions and behavior. Her demeanor has gradually changed from a smiling, mostly compliant teen to that of a more rebellious and sullen one. She’s been caught skipping school a few times and was found to be in the company of some older adolescents who are consistently in trouble and suspected of using alcohol and drugs. The SASSI-A3 classified Alyssa with a LOW PROBABILITY of having a substance use disorder (SUD). Neither the VAL or DEF scale scores met the criteria for the possibility of a false negative. While the scale scores do not meet the criteria for classifying her as high probability of having an SUD, there are some other scale scores which could indicate some other clinical issues that may need to be addressed. 

In going beyond the decision rules and looking at the individual raw scale scores, it is possible to develop a more general hypothesis regarding her level of adjustment and functioning. The fact that she scored above a zero (0) on the FVA, FVOD and SYM scales tells us that, while her scores are not high enough to indicate the probability of an SUD and are in fact very close to the mean, at 14 years old she has used both alcohol and drugs and experienced some negative consequences and/or problems as a result of that use. Based on her elevated FRISK score of 3, her slightly elevated ATT score of 3 and her elevated COR score of 6 (along with the observations made by her teachers), we can further hypothesize that Alyssa is likely to be surrounded by a close social system who are abusing substances and, as a result of this, her attitudes toward substance use lean more toward endorsing and promoting such use as a good thing. Assuming that this social system likely consists of her peers, namely the older teens mentioned earlier, this may explain her elevated COR scale score. In other words, she may have similar thinking patterns, beliefs, values and attitudes as those who are more likely to engage in rule-breaking, unlawful behaviors and/or disdain for authority. Her OAT score seems to indicate that Alyssa does not at all identify with any of the typical attributes that we would normally associate with an active substance abuser and that she firmly believes that she does not have a substance use problem. One of the most concerning scale scores on this profile is the DEF score of 2. SASSI research tells us that very low DEF scores such as this, often indicate a young woman who is experiencing a great deal of emotional pain and many of the typical symptoms associated with a syndrome of clinical depression. She may tend to engage in negative self-statements, identifying herself as a loser or misfit. She may be experiencing a sense of hopelessness, inability to enjoy positive experiences, lethargy, general bad feelings, impaired functioning in vital areas such as sleeping and eating, and sometimes even suicidal ideation.

While a low DEF score is not a clinical diagnosis in itself, this profile raises some questions that a counselor may wish to pursue in an interview or further ongoing assessment. For example, what is causing the significant change in emotion and behavior that was noticed by the teachers? Is it simply the normal emotional volatility of a growing and changing adolescent? Is there something happening in this teenager’s family which has caused this sudden shift in emotion and acting out? In any case, hopelessness, suicidal ideation, depressive symptoms or other psychiatric problems are important concerns to be investigated. It would also be valuable to explore the extent and context of her drinking and drug use to determine if it is just normal adolescent experimentation, a reaction to peer pressure, or an attempt to deal with emotions too overwhelming to control on her own. While the SASSI does not indicate a high probability of having an SUD currently, without some sort of intervention regarding these sudden changes in emotions and behaviors, a future SUD problem is not out of the question. It is difficult to suggest appropriate interventions without further information. However, appears that she could benefit from seeing a safe, trustworthy and empathetic counselor who could further explore the issues and immediately address her emotional pain and help her develop coping skills other than alcohol and/or drugs. Using the raw scale score interpretations described previously, in an open two-way conversation the therapist and Alyssa could use these scores to begin to collaboratively develop a plan of action that could help her confront and overcome the difficulties she is facing.

We hope you find this useful information regarding clinical issues.  As always, the Clinical Helpline at 888-297-2774 is open to serve you Monday through Friday, 1 pm to 5 pm (EST).

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A SASSI-4 Profile Analysis: Drug Offender with SAT As Highest Score

The following profile result is of a 35-year-old male referred for screening and possible assessment after a drug-related arrest. He completed the FVA/FVOD side of the questionnaire based on his entire life timeframe. His RAP score was 0, indicating no random responding and that the result should be valid. His Prescription Drug Scale score (Rx) was 1, so he did not meet the cutoff for High Probability of Prescription Drug Abuse.

Looking at this profile, we see that he was classified as high probability of a substance use disorder based on the following Decision Rules:

  • Decision Rule 1 with a FVOD score of 32.
  • Decision Rule 3 with an OAT score of 9.
  • Decision Rule 4 with a SAT score of 14.
  • Decision Rule 5 with a SYM score of 6 (5 or more) and a SAT score of 14 (4 or more).
  • Decision Rule 7 with an OAT score of 9 (7 or more) and a SAT score of 14 (6 or more).

Looking at the graph on the SASSI Adult Male Profile sheet, we see an extremely high elevation on the FVOD scale score which is significantly above the 98th percentile. Individuals who score this high on the FVOD are able to acknowledge currently having or having had numerous negative consequences and problems as a result of their use of drugs. This can include loss of control of the drug use as well as using a coping mechanism.  It is important to note that, since he was asked to use the “entire life” timeframe for the FVA and FVOD scales, his admission of having these consequences and problems with drugs may be related to some time in his past and not necessarily currently. For example, the client’s score on the SYM scale (which is similar to the FVA/FVOD in what it is measuring), is not nearly as elevated as his score on the FVOD even though the questions are not that dissimilar from the FVOD questions.

This suggests that he is not showing as much acknowledgement on the SYM scale of the symptoms of substance misuse that he admitted to on the FVOD scale. This could be related to the fact that the SYM scale (like all scales on the True/False side of the questionnaire) has no specific timeframe associated with it and therefore the client may have the belief that, while he has had significant problems with drugs in the past, he may not believe his current drug use is as much of a problem currently. It is highly recommended that clinicians do a content analysis of the client’s answers to the FVOD and SYM scale questions as this will provide more insight into the client’s acknowledged problems with drugs.   

This client’s elevated OAT scale score, like the elevated FVOD scale score, suggests a capacity to acknowledge and identify with many of the typical negative attributes (general personality and behavioral characteristics) and personal limitations that are often common among those with substance use disorders – e.g. impatience, resentment, self-pity, impulsiveness).  While the client can often see these “character defects”, they may not always feel motivated to change them or feel capable of changing. Given that the OAT score in this case is above the 98th percentile, it is highly probable that this individual may be able to closely identify with individuals in recovery from substance use disorder, such as those found at recovery support groups, and therefore may be more willing to trust these recovering individuals and follow their recovery advice.

The client’s highly elevated SAT score (the highest score on this profile), which is higher on the graph than the OAT score, suggests that despite the client’s capacity to acknowledge the more obvious problems and negative consequences associated with his use of drugs, there are subtle aspects of his behavior, personality, and addiction that are extremely hard for him to acknowledge. In other words, he may not be able recognize the pervasiveness of his addiction, how it negatively affects and rules every aspect of his life with deeply held negative thinking patterns, beliefs and negative coping patterns driving his addictive behaviors.

Clients with a pattern of scores like this client who tend to be able to acknowledge heavy usage, negative consequences and problem behaviors, may still be convinced, sincerely deluded into thinking that they are not truly addicted. They will often present as more “superficial” saying things like “well, I go to work every day and do my job so I couldn’t be addicted”. Clients with elevated SAT scores (especially higher on the graph than their OAT score) tend to be more initially resistant to the need for treatment and are more likely to relapse. These clients tend to be detached from their feelings and have relatively little insight into the basis and causes of their problems (namely substance addiction). These clients typically need a more intensive level of treatment where they can receive constant support for their recovery efforts and can get the kind of group processing therapy needed to help them connect with their feelings and learn how to cope with them without drugs.

In providing treatment to this type of client it is important to recognize that underneath the many excuses (other than substance addiction) for their problems, there is an individual with a substance use disorder who is likely in pain and scared. Individuals with high SAT scores may not be in touch with the pain and fear, largely because they immediately numb any negative feelings with substances as soon as they appear, but the pain and fear. In this case, intensive treatment and group work has to be accompanied by sensitive and skillful clinical intervention that lets the individual know that somebody is aware of their fear deep within and that it will be a relief to let it out to begin healing.

We hope you find this useful information regarding clinical issues.  As always, the Clinical Helpline at 888-297-2774 is open to serve you Monday through Friday, 9 am to 5 pm (EST).

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Hope Remains: Attacking some of the Veiled COVID-19 Challenges

This has been an interesting year hasn’t it? I’ve worked in the behavioral health field, primarily substance use disorder, since 1989. During those 31 years I’ve never come across the types of challenges I’ve seen this year, for those struggling with substance addiction and for those healthcare providers trying to help them.

“Social isolation” is the new mantra in the culture and yet it is the very thing that is anathema to behavioral health counselors trying to help individuals coping with addiction. Resources are going out of business and events which once brought enjoyment, support, solidarity and an alternative to substances for having fun are being cancelled one after another. Fear is paramount, and it’s drastically shaping the face of addiction and recovery. We are seeing more initiation of substance abuse, more cycles of relapse and overdose, and more barriers to successful recovery in order to cope with a world in chaos. While outpatient treatment programs have successfully used technology to transition to online counseling groups, this has presented a barrier for those without the resources to purchase the technology needed to participate. For the last 10 years, I’ve worked for a local non-profit treatment center for women and adolescent girls here in Dallas, Texas called Nexus Recovery Center. Recently, the Executive Director, Heather Ormand, wrote the following in a blog post:

“COVID-19 has stripped so many sober women of our community. Twelve-step meetings are no longer being held in churches.  Churches are closed or access is limited and people are afraid to sit shoulder to shoulder right now. For those with long-term sobriety and a strong support system, we can probably get by with Zoom twelve-step meetings, reading literature and connecting with other sober women via text or calls. But what about the woman struggling in her disease? The woman isolated in an unsafe home without the resources to leave and get treatment? The woman without a place for her children to go while she tries to piece together continuous days of sobriety and start rebuilding their lives?”

But there is hope. Treatment staff have proven that they are indeed essential, and programs like those at Nexus Recovery Center are showing that recovery staff are willing to risk getting sick themselves in order to help another human being break the cycle of addiction. They are showing that empathy and compassion and hope can still be conveyed through a mask or through a live, online group or individual counseling session. We can still find innovative ways to connect and share our experience, strength and hope with those who are struggling to find someone who cares.

I’ve also been associated with The SASSI Institute as a trainer for the past 25+ years and have found them to be an organization that strives hard to give agencies effective and easy to use resources for helping identify individuals struggling with a substance use disorder and guiding them to the most appropriate path for their recovery journey. I’m also proud to have been allowed to help people on The SASSI Institute’s Clinical Helpline for the past few years. One consistent thing I hear from callers is how much they appreciate the fact that they can reach out in frustration or puzzlement over a client they are working with, and how those on the Clinical Helpline are always there to help them work through a SASSI screening result, craft how to phrase the results to the client or in a report, and guide them in helping clients discover things about themselves, in order to initiate their recovery process. The SASSI Institute, though at a “social distance,” is there for me like a warm blanket on a cold night and for many other behavioral health workers in the US and in other countries who sometimes just need a willing ear to process some of their cases and SASSI results. Working together we can get through 2020 and beyond, despite any obstacles.