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.

Beyond the Screening Rules: How Collateral Data Clarifies Complex SASSI Profiles

This very unusual profile was called in to our Clinical Helpline Staff and provides us the opportunity to discuss several key issues with regard to clinical interpretation of individual SASSI scale raw scores:

  1. It is critical to gather additional information beyond the SASSI from reliable sources and then integrate this information with the basic foundational scale interpretations provided by our case study research;
  2. When highly unusual scale scores occur, seemingly contradicting one another, resist the temptation to over-interpret and;
  3. Notice when scale score interpretations suggest potential problem areas beyond just the substance use disorder issues and make a plan to address these.   

This client profile is a clear example of the need for additional clarifying information about the client. The only information we were given was the client’s biological sex (female) and their age (25 years old). What makes this profile confusing is that the individual scale scores sharply deviate from “normal” scoring patterns in a few places, which leads to scale interpretations that seem to contradict one another. For example, the client has clearly acknowledged that she has had or is having significant negative consequences, problems or trouble as a result of her use of both alcohol and other drugs (FVA=23 and FVOD=30) and therefore may have lost control of her use and may be using as a coping mechanism. These scores are extremely high compared to the general population and typically leave no doubt that this person has most certainly crossed the line into substance addiction and is quite willing and able to recognize and admit the severe consequences her substance mis-use has caused in her life.  This is further confirmed by an extremely high OAT scale score of 8 which would generally be interpreted to mean that this person greatly identifies with many of the usual negative attributes or personal limitations/weaknesses that are common among those with active substance use disorders (e.g. impatience, resentment, self-pity, impulsiveness, restlessness) and usually, if asked, would readily admit to sharing many similarities with those who have substance problems. Lastly, her SAT scale score is also extremely high, once again strongly indicating a person with a significant substance problem.

But there are other scale scores which seem to contradict some of these basic interpretations. For example, the client has a DEF score of 11 which is far above the 98th percentile and suggests that the client is answering the questions in such a way on this scale that would indicate someone who would tend to not share anything about herself that would put them in a bad light or show weakness or vulnerability. DEF scores like this usually tend to suggest a client who wants to appear as if they have it altogether as they are endorsing only positives about themselves. How can this be true though if their FVA/FVOD and OAT scale scores are so high that they strongly indicate a person who is able to admit and acknowledge numerous negative consequences from substance mis-use and is able to strongly identify with many of the same negative attributes or weaknesses that are often found in those with active substance disorders? In addition to that, how can this client have such extremely high scores on FVA and FVOD and yet have a relatively normal score of 4 on the SYM scale? The SYM scale, like the FVA/FVOD scales, is also a very obvious, face valid set of questions about problems with substance use and yet her score on the SYM seems to indicate relatively none of the typical symptoms we would associate with one struggling with a SUD. One possible reason for the discrepancy between the scores on the FVA/FVOD scales and those on the SYM scale would be because of the timeframe that the client was asked to use in answering the FVA/FVOD scale questions. Unfortunately, we were not given this information about this client profile, but if the client was asked to answer the FVA/FVOD questions based on their entire life, then the scores could be quite high but be representative of a time in the distant past. Since the T/F questions have no specific timeframe associated with them, the client may have answered the SYM questions based on a more recent timeframe in which they had achieved some level of sobriety.

Even the extremely high SAT score seems a bit contradictory with other scale scores since usually a high SAT score would indicate someone who is not able to admit or acknowledge that they have a substance problem. However, since the SAT score was positioned higher on the graph then the OAT scale score, our research suggests that individuals with that type of scoring pattern are sometimes able to admit to the very obvious consequences of their substance misuse (when OAT and Face Valid scale scores are high like this client) and may even be able at times to self-identify to a certain extent with certain obvious behavior patterns that often lead to substance misuse. However, people with very high SAT scores, and especially ones that are higher on the graph then the OAT score, are often not able to see the deeper, underlying, less conscious issues that are constantly plaguing them and significantly influencing their substance misuse behaviors in a much more covert way. They often simply cannot see the pervasive nature of the disease acting in their everyday life. They often are emotionally avoidant and superficially may believe that their substance problems are just a set of bad habits that they can stop on their own. They see the physical manifestations of the problem, but are unable or unwilling to see the emotional and spiritual aspects of the problem. They often will actively avoid treatment that involves examining their negative thought patterns, deeply held negative beliefs, fears, and other deeply rooted issues that have a stranglehold on their life and behaviors. Some of these clients will incorrectly assume that their substance problems only reside with their use of the “hard” drugs and if they just quit using those, then they can continue to drink and smoke marijuana and all will be well.

This explanation actually helps us to better interpret the client’s very high DEF score as well. While the client is able to admit and acknowledge having a lot of problems and trouble as a result of her use of alcohol and other drugs as seen in her very high FVA, FVOD, and OAT scores, her very high SAT and DEF scores show that her admission and acknowledgement is only at a very surface level. In other words, she admits all the things that are pretty much already part of the public record and everyone knows about, but the problem is much deeper than that and she is oblivious to how deep and pervasive it really is. This is what we would call a sincere delusion. She admits what she is aware of and what she feels she has control over. But there is much more beneath the surface that she can’t see. Her defensiveness is potentially a way for her to demonstrate that she’s in control, that there’s nothing to see here and everyone should move on. Like her very high SAT score implies, she may be unable to identify or get in touch with her real emotions and pain and she may have situational reasons or life experiences which have taught her to not let people see her flaws or weaknesses, the real her. She will tend to focus away from internal processes and look instead at tasks and factors outside of herself. This increases the likelihood that she may put herself at risk without awareness of her own vulnerability.  She will be more likely to find excuses not to engage in treatment and recovery activities, especially if she is able to achieve short spurts of sobriety. Once the challenge of proving she can abstain from alcohol or drugs for a short time loses its luster or crises arise that she cannot cope with on the basis of her more superficial focus, she will be more likely to relapse.

The risk of relapse is particularly increased given her similarity to others who violate cultural norms sufficiently to have repeated involvement with the criminal justice system, as evidenced by her elevated COR scale score (COR=12). In addition, the elevated COR score suggests increased risk for future criminal behavior independent of the client’s substance use or mis-use. A comprehensive assessment of underlying risk factors in the client such as poor social skills, anger management issues, poor impulse control or low frustration tolerance would be a valuable exercise so that, if any of these issues are uncovered, an effective treatment plan that specifically addresses these issues could be developed to potentially decrease the risk of repeated involvement with the criminal justice system.

In summary, this young woman’s profile indicates three problem areas that need to be the focus of potential treatment: her substance use disorder (if diagnosed), her defensiveness, and her risk for legal problems. This client meets SASSI Decision Rules indicating a high probability of a substance use disorder. While the SASSI does not specifically provide a prediction of the level of the disorder (i.e. mild, moderate or severe), typically clients with FVA/FVOD, OAT and SAT scores as high as this client’s often have moderate to severe disorders if the disorder is active. The scores also suggest a pattern of addictive behaviors that have a pervasive influence on her life, which she is not likely able to fully recognize or accept. She most likely has little or no self-awareness with regard to her underlying emotional pain and may tend to shift responsibility or blame to her life situation and/or other people.

In light of this, she will most likely resist many conventional forms of treatment and prefer to “fix it” herself. There is a high risk of premature self-labeling as “cured” after one or two successful short attempts at sobriety, ultimately resulting in full blown relapse.  The risk of future criminal behavior is high, suggesting that compliance with other rules may also be problematic. Further assessment and/or building in a specific treatment focus on this risk through cognitive-behavioral interventions would be reasonable options to consider.

In trying to interpret the individual scale scores for this client, one can see that, while the foundational interpretations that normally apply to certain scoring patterns certainly can lead us in the right direction, without more data from other reliable sources, one can only speculate as to why some of the standard scale score interpretations initially seem to be in contradiction with one another. With more information from collateral sources (family, teacher, employer, coach, friends, etc.), naturally occurring records (e.g. arrests, ER visits, prior treatments, etc.) or behavioral records (work behavior, school behavior), we could more easily narrow down, shape and confirm or deny our initial interpretations.

Getting additional information from other sources also can help us to resist over-interpreting. In the absence of clear information, one is more likely to speculate. While no SASSI interpretations are ever meant to be considered absolute, we can nevertheless trust that the foundational interpretations which came from our case study research have proven to be quite reliable and accurate in most cases. But when individual scale score interpretations seem to clash, we have to resist making up information and therefore over-interpreting or mis-interpreting and instead gather actual data that could more correctly resolve the perceived conflicts.

And finally, spend time learning and practicing how to utilize the SASSI foundational scale score interpretations in combination with other reliable sources to identify and address any other non-substance-specific challenges facing the client. These could range from defensiveness and high risk of involvement in the criminal justice system like this client to possible depression, suicidal ideation, or typical symptoms associated with co-dependency. While the SASSI’s primary function is not that of a depression, suicide risk or co-dependency screening, basic scale score interpretation can provide clinicians with a “heads up” on the possibility of these and other issues, prompting the clinician to do further evaluation in these areas and develop treatment plans, educational resources and/or referral plans to address them.

To become more familiar with clinical interpretation, we invite you to attend one of our training sessions taught by a SASSI-certified trainer ( https://sassi.com/sassi-training/) and/or to utilize our free Clinical Helpline at 1-888-297-2774 which is available Monday – Friday from 1:00pm – 5:00pm EST to assist clinicians in learning how to interpret their client’s results better.   

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Complimentary SASSI Clinical Interpretation Assistance for Professionals

SASSI Institute is proud to continue to offer its customers a free Clinical Help Line to assist professionals in the use and interpretation of Substance Use Subtle Screening Inventory (SASSI) screenings performed on their clients. The Help Line is available Monday through Friday (except holidays) from 1:00 PM to 5:00 PM (EST) at 800-697-2774 (Option 2). This dedicated service provides direct access to experienced SASSI-trained clinicians who can assist with questionnaire administration, scoring, and interpreting basic or complex client profiles.

Accurately identifying and addressing substance use disorders (SUD) is both critical and challenging. The SASSI screening tool can be an important part of that diagnostic process. Especially when working with clients who are highly resistant or in denial, clinical interpretation of screening results can often leave clinicians with uncertainty and questions. That is exactly where our free Clinical Help Line comes into play. Our experienced licensed clinicians can provide insights into how the individual SASSI scale scores could be interpreted and how this information could potentially be used to best benefit the client.

Our Clinical Help Line is a free confidential resource designed specifically to support professionals who use the SASSI tool with their clients. Utilizing this resource allows you to potentially learn more about your client and build an even stronger rapport with them by increasing their awareness and understanding of how their substance use may be impacting their life. Discussing the potential meanings underlying their individual raw scores on each of the SASSI scales can help clients better comprehend the significance of their behaviors and provide the professional and client the opportunity to collaboratively identify goals to address these issues.

The next time you review a SASSI profile and need a second opinion or clarification prior to discussing the results with your client, don’t guess—consult with the experts. Call 800-697-2774 (Option 2) Monday thru Friday from 1:00pm – 5:00pm EST to keep your clinical screenings accurate, informed, and highly effective. And remember, it is free of charge and there is no limit to the number of times per day or week that you can call to discuss your clients’ SASSI results! Give it a try!

Have You Been SASSI Trained?!

In my conversations with SASSI users on our free Clinical Helpline, I often run into people who have never participated in an official training led by a SASSI-certified trainer. Some of them have never been trained by anyone and are just trying to figure it out on their own or using the SASSI User Guide & Manual. Others have had a co-worker show them what they know about the instrument, sometimes inadvertently receiving misinformation or information lacking in important details. Thankfully, the SASSI was originally designed to be a simple and easy to use screening instrument that doesn’t necessarily require one to have a specific credential or college degree in order to successfully administer and score the instrument. So, anyone can easily learn to use the SASSI effectively and accurately with proper training.

I remember several years ago I was doing a training on the SASSI for a probation department and one of the attendees, who had been using the SASSI for over 10 years and who wasn’t sure why he had to be at the training, came up to me at the break and told me he had already learned several things in the first 1 ½ hours that he hadn’t known for the past ten years! He had never been to an official SASSI training done by a SASSI certified trainer until that day. For him, he was now glad he had been required to go to the training that day!

While the basics of administering and scoring the instruments are quite simple, the SASSI also has additional utility in the form of Clinical Interpretation of the Sub-Scales that can be used to help us in treatment planning, educating the client, making referrals for clients and just understanding our clients better. Like most things involving humans though, clinical interpretation can be rather complex and not as straight forward as the basics of administration and scoring. Getting good training by a SASSI-certified trainer is a first step to learning to master the interpretation of individual sub-scales on the instruments. The second step after training is to regularly utilize the free Clinical Helpline service offered by the SASSI Institute weekly M-F from 1:00pm-5:00pm EST. Through this service, callers are able to essentially extend their training on the SASSI for free and practice their clinical interpretation with SASSI clinical experts as often as they want or need each week.

So, if you’ve never been to an official SASSI-certified training or it’s been many years ago and you need to go to training again to get a “refresher,” let me encourage you to take that step in improving your knowledge base to get more out of this amazing screening instrument to better assist your clients. You can go to the Training section of the SASSI website by going here: https://sassi.com/sassi-training/. From there, you can click on United States or Canada to see if there are any trainings scheduled by state, province or region by our certified trainers; or you can click “Online” to view and register for any of our upcoming live public webinar trainings which are separated by those that are specifically for the Online/Web-based version of the SASSI and those for the traditional paper/pencil version of the SASSI. On this page you can also register for “On-Demand” recorded SASSI trainings if you don’t want to wait for a live training. The live trainings offer you the advantage of being able to interact in real time with the trainer and other participants and ask any questions you might have on the spot. The “on-demand” recordings offer the convenience of immediate viewing. Choose what works best for you but please consider getting training in an official SASSI-certified session. Who knows? You might find out some things about the SASSI you never knew that can help you use the instruments more effectively.

High Probability by Subtle Scales Only

Many people know that the SASSI is possibly the best substance use disorder screening tool that exists in the behavioral health field today. The instrument can be easily administered in 15 minutes or less and manually scored in less than two minutes (or scored automatically in the online web-based version), resulting in an objective empirically-based statement of the likelihood of the client having a substance use disorder with an overall accuracy of 92% for adults and 89% for adolescents. And it achieves this kind of accuracy even in clients who are unwilling or unable to acknowledge their substance misuse or the symptoms associated with it!

Through extensive case study research, the SASSI has been found to be able to provide even more utility to clinicians in the form of clinical interpretations that go beyond just the high or low probability of a substance use disorder result. In addition to interpretations of individual scale raw scores that fall outside the boundaries of the research-based established normal distribution, we also have discovered some trends or characteristics in the specific situation in which the client scores as high probability of a substance use disorder based on SASSI decision rules that involve only subtle scales rather than face valid scales. That is the subject of our blog today.

The SASSI is made up of both face-valid scales and subtle scales. Face-valid scales such as FVA, FVOD and SYM are scales that are very obvious about what they are measuring, while subtle scales such as OAT, SAT and DEF are made up of items that do not seem to have anything at all to do with substance use. Our case study analysis showed that certain behaviors, characteristics or patterns emerge in individuals who score as high probability based only on subtle scales. Let’s take a look at an example. Byron is a 31-year-old male who was asked to be evaluated because of a child custody battle in which the mother alleges that Byron misuses drugs. Byron has not yet had a comprehensive assessment done, but has so far only admitted to some occasional use of marijuana. A SASSI was administered and the results showed that Byron met the criteria for Decision Rules 3, 4 and 7. Each of these decision rules involve only subtle scales and no face-valid scales. So, what characteristics do we tend to find in individuals with this type of scoring pattern?

One key feature of this type of scoring pattern is the fact that these individuals often have very little insight into the pervasive nature of the addictive disorder in their lives. Most of the time, this type of client actually has a very sincere delusion regarding their substance misuse. In other words, they are not trying to trick you into thinking they do not have a problem with substances; they simply do not see it. Often, every single activity this person is engaged in and every decision they make somehow involves substance use. Often, the substance misuse has become an unhealthy way to cope with emotions that are too overwhelming and so individuals with this type of scoring pattern are very emotionally avoidant. Many times, this individual has difficulty admitting their weaknesses or the personal limitations with which they struggle and instead choose to focus on very superficial things, ignoring the depth of the substance problem in their life. We can see these types of traits and behavior patterns manifested in this client’s individual face-valid scale scores such as lower than average (T-score of 50 is the mean) FVA and FVOD scores and only an average SYM score. These all indicate a client who does not acknowledge or admit to having any significant problems or negative consequences as a result of substance use. The client’s extremely high DEF score indicates a very high level of guardedness and the desire to be seen as having no weaknesses or faults. It’s even possible that the FVA, FVOD and/or SYM scale scores could be artificially low because of minimization of symptoms in the client’s answering patterns on these scales fueled by this defensiveness. However, as mentioned previously, it’s possible and even probable that this client really has very little insight into his problem with substance misuse and so he may be unable to even recognize the obvious negative consequences he is experiencing. This is especially typical of clients with high SAT scale scores as this client has. While this client does also have an equally high OAT score, which often indicates some ability to recognize negative attributes that are common in individuals with substance problems such as impulsiveness, self-pity, resentment, and impatience, it is more likely in this case that the client does not see these issues as having any relationship to his misuse of substances.

At this point, a comprehensive assessment needs to be done along with a formal diagnosis and possible treatment plan formulated. Since the SASSI does not provide an actual diagnosis and does not, by itself, indicate a need for treatment or the level of treatment, it is important to gather more information such as self-reports of the client’s current usage patterns, collateral reports, naturally occurring records, behavioral records, etc. to determine a diagnosis and course of action. Typically, clients with this scoring pattern do have a significant substance use disorder and many of them, if they need treatment, will often need a relatively intensive level of treatment which includes individual and group therapy sessions; more than just cognitive/educational programming. However, individuals with this type of scoring pattern will often be initially resistant to any treatment as they honestly do not see a problem that needs to be treated. The high level of defensiveness will require lots of time spent in developing a therapeutic alliance and positive rapport, affirming and supporting him throughout the process. Clients like this are often a high relapse risk and so it is important to provide wraparound supports and a level of intensity in the treatment regimen which allows for quicker and stronger intervention in the event the client attempts to relapse. Individuals who score as high probability of a SUD based only on subtle scales are often some of the most challenging clients, but with information gained from the client’s scoring patterns on the SASSI combined with additional information from other sources, you are in a better position to know what to address to increase the possibility of success with this client.

Don’t forget that full training on administering/scoring the SASSI and clinical interpretation of the sub-scales is available. Check out https://sassi.com/sassi-training/ to register for an upcoming training. Also, our free Clinical Helpline is available M-F from 1:00pm to 5:00pm EST to answer any questions you have about the SASSI.

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A Common Element in Domestic Violence: Substance Misuse

The following profile is for a 38-year-old male, “Blair,” who has been mandated to counseling following an instance of spousal abuse. First, note that the scale scores do not meet the criteria for classifying Blair as High Probability of having a substance use disorder (SUD).  However, the Face-Valid Alcohol (FVA-12) and Face-Valid Other Drugs (FVOD-13) scores are moderately elevated above the mean (50th percentile) since they are more than one standard deviation from the mean and above the 85th percentile. It is important to recognize that FVA and FVOD are not just measures of frequency and quantity of consumption. Rather, they are mostly measures indicating acknowledgement of significant negative consequences as a result of substance misuse, as well as possible loss of control and using as a coping mechanism. Thus, even moderately elevated scores that do not in and of themselves lead to classifying the person as high probability of having a SUD are often indicative of some level of substance misuse. It is important to investigate this further. We not only want to establish whether substance misuse is a current or past pattern of use, but (in the context of this client’s reason for referral) further investigation is also needed to determine more about the relationship between physical abuse and substance misuse in this client’s life.

Note that the Obvious Attributes (OAT-1) score is low, i.e. it is below T40 where less than 15% of the normative sample typically scores. This type of OAT score suggests that Blair does not acknowledge the typical negative attributes or behaviors commonly associated with substance misusers such as impulse control problems, low frustration tolerance, impatience, a tendency to hold grudges, etc. An OAT score this low suggests it is not simply that he does not perceive himself as engaging in such behaviors, but that he actively (consciously or unconsciously) distances himself from any hint that he has such tendencies. In other words, he finds it difficult to acknowledge common weaknesses, personal limitations or human foibles and certainly does not see himself as being in any way similar to those who have substance problems. Often, people who come from homes that were dominated by abuse, substance misuse, or other problems are motivated to see themselves as not being like the primary abuser in their family of origin. His very elevated FAM score (FAM-14) and to some extent his somewhat elevated SYM (SYM-5) score suggest that he may have lived in an environment affected by substance misuse.

The Subtle Attributes (SAT-2) score is also significantly below average, and this can often indicate a person who may exhibit strong feelings of hypersensitivity to what others think of him stemming from his perception that others frequently reject him and unfairly judge and criticize him. This score suggests that Blair may be highly attuned to others’ opinions and may perceive slights or criticism, even when none are intended. 

The Defensiveness score (DEF-11) is very significantly elevated. This often indicates someone who has their guard up and answers the questions by endorsing only things that may make them look more positive. This is not particularly abnormal in cases like Blair’s where there are situational factors putting him at risk of losing something important to him. Since Blair is being evaluated following an accusation that he beat his spouse, he is naturally on guard. The defensiveness could also reflect a more general tendency to avoid seeing and acknowledging any personal limitations or weaknesses and is somewhat confirmed by his very low OAT score as discussed earlier. Regardless of the cause, it is important to recognize that Blair probably approached the screening process in a defensive manner and because of this there is also a higher-than-normal possibility of a false negative and potentially a possibility that Blair minimized some of his symptoms of misuse on the more face valid scales such as the FVA, FVOD and SYM.

As mentioned earlier, Blair’s score on the Family vs. Controls (FAM-14) scale is significantly elevated. The FAM scale is composed of items that tend to identify individuals who may have been involved in a family of origin in which there was significant substance misuse. People who have high FAM scores often may obsessively focus on the needs and feelings of others. It is therefore interesting to contemplate how a high FAM score might fit as a characteristic of a perpetrator of domestic violence since spousal abusers are not generally thought of as “caretakers.” The crucial element may be the tendency of individuals who score high on the FAM scale to base their happiness and their sense of well-being on the behavior of others, leading to a need to control. Violence can be an extreme expression of a profound need to control.

Based on his SASSI scores, the Decision Rules result indicates a low probability of Blair being diagnosed as having a SUD. However, the significantly elevated DEF score cautions that there is an increased possibility of a false negative result (i.e. test-miss). His FVA and FVOD scores, while not high enough by themselves to provide a “high probability of a SUD” result, were clear indicators of acknowledged negative consequences from misuse of substances. Given the fact that many people with DEF scores as high as Blair’s often minimize some or a lot on the face valid scales to make themselves look better, there is still a possibility that Blair may suffer from a substance use disorder. Substance misuse is a common ingredient in domestic violence.

Domestic abusers often do not assume responsibility for their behavior, claiming that the victim “made me do it.” Blair’s SASSI profile corroborates and expands on this. The low SAT score suggests that Blair may have this victim mentality, and the low OAT score suggests that he is indisposed to see in himself the very tendencies that are likely to lead to spousal abuse such as low frustration tolerance, poor impulse control, anger management problems, a tendency to hold grudges, etc. The high-DEF score suggests a broader proclivity not to acknowledge personal limitations and to only endorse positives; and an extreme focus on others, as suggested by the high FAM score, could lead to an inability to deal effectively with interpersonal conflict. Ongoing comprehensive assessment should be directed toward determining more precisely the role of substance misuse in Blair’s spousal abuse. Treatment should also be directed toward helping Blair perceive and act in accord with appropriate personal boundaries. He is likely to need help in learning to accept and deal with interpersonal conflict and to assume greater responsibility for his behavior. As it stands, his extreme need to control others may lead to poor social judgment that allows him to construe violent acts as mature behavior and provides him with a rationale for excusing the inexcusable.

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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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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