‘Reggie’ is a 37-year-old married man. He and his wife have two children. He works as a warehouse worker where he was recently injured in a shipping dock accident. He recently returned to work after being on worker’s comp for several months during which time he was prescribed opioids for his pain. He was sent to his employer’s EAP provider for evaluation after returning to work and struggling with coping with the continued pain and poor job performance.
Reggie T’s responses illustrate another profile often seen in people who acknowledge that they use drugs excessively and that it negatively impacts on their functioning and relationships.
Given Reggie’s high level of drug use and consequences, you might consider a more comprehensive evaluation to determine whether he may need supervised detoxification or other intensive intervention.
You may find Reggie ready to acknowledge that he uses drugs frequently and that he may also drink too much. However, he may not see that his behavior varies dramatically from others who don’t have a substance use disorder. Feedback on where his scores fall on the profile sheet may help him see that his behaviors are not typical. It may be useful to know that Reggie’s wife is currently in treatment for drug and alcohol abuse due to a DUI. Their mutual abuse of substances may help promote their beliefs that their substance use is normal. Examining the items that Reggie endorsed on the FVA, FVOD, SYM and Rx scales may provide useful insight into his motivations for using and help him see the consequences that result from his use.
In this first video watch Reggie’s initial EAP visit in which he was asked to take the SASSI.
This second video is the follow-up session where he discusses his SASSI results with the EAP provider.
We regularly get inquiries about the acceptability of reading the questionnaire to a client who may have difficulty with their reading skills. We discourage the evaluator from reading the questionnaire to the client for a variety of reasons, but the primary one concerns the validity of the results. No matter how careful the reader might be, the tone of voice or emphasis on a particular part of the question may lead the client in one direction or another. Or the client may interrupt with a question regarding the meaning of a word or intention of a particular question. This is why we offer a professionally read audio CD of the SASSI-4, Adolescent SASSI-A3 and Spanish SASSI paper and pencil versions for clients who have reading difficulties. We hope in the future to be able to offer this for the online platform as well. Please contact our customer service department for ordering information.
Another frequent question is related to the clinical interpretations of the “low” scores on the profiles. These mostly relate to the subtle scales which include the OAT, SAT, DEF and SAM scales. Most callers know what a low DEF indicates. And SAM has no clinical interpretation.
So what about those low OAT and SAT scales? What does “low’ mean? A low score is anything below the 15th percentile on the graph. In the example to the right, the caller indicated that she was doing an assessment on a health care professional who had been arrested for her one and only DWI the previous year, had completed her alcohol education class and needed this evaluation as a final step for probation. She was not in trouble in her job and in fact, highly regarded in her profession. Given the client was at the end of her requirements, the evaluator was somewhat concerned with the results and what it meant. The instructions were given to answer the FVA/FVOD side for the last twelve months. Her RAP is zero. Her Prescription Drug Scale is zero. She has ‘no’ on all the rules so came up with a Low Probability of having a Substance Use Disorder. However, her DEF of 9 is highly elevated. Elevated DEF scores increase the possibility of the SASSI missing individuals with a substance use disorder. Elevated DEF may also reflect situational factors. Note that the SAM is within the norm so it is probably more likely that her DEF is situational given the context. She also has an OAT score of ‘O’ and a SAT score of ‘2’. Both are below the 15th percentile. A low OAT indicates someone has difficulty acknowledging personal limitations or shortcomings. A low SAT indicates someone who might have a ‘chip’ on her shoulder, a hypersensitivity to others or feelings of rejection.
So even though this client is nearing the completion of her probation requirements, we still get a picture of someone who is highly guarded (DEF), has a hard time acknowledging shortcomings (OAT) and may continue to exhibit resentment (SAT) for the situation she is in. Perhaps this is due to her profession, or perhaps it is her personality. What the results give the evaluator is clinical direction on how to approach the client to help reduce her defensiveness and give her permission to open up. Affirming how demanding her job is and how on top of things she must be could be a pathway to discussing her feelings of shame related to the DWI and how it might be affecting her self-esteem. Could she be minimizing her use of alcohol and drugs? Perhaps, but as we strongly express, the SASSI is only one part of a clinician’s assessment. Hopefully, with the input of all the information you have, the clinician can evaluate the results which fit the context for this client.
The SASSI-4 I am reviewing is interesting for what it is not.
The client was instructed to complete the FVA/FVOD for the last 12 months. The client is a 34 year old male with a history of drug and alcohol use. He reports that two and a half years ago he successfully completed treatment. He stopped doing drugs but continues to consume alcohol. He was being evaluated by the order of the court for an “altercation with his ex-spouse”. He does meet multiple rules and comes up with a high probability of a substance use disorder. Remember the number of Rules met does not mean a more significant disorder. The diagnosis is based on the DSM-5 with the designation of mild, moderate or severe based on the number of symptoms met.
As seen on the profile sheet, he has a number of elevated scales including the FVA, SYM, OAT, SAT and COR. What is interesting, is that his DEF is not elevated and is below average staying within the norm. For domestic violence cases, this is fairly unusual. Often we see an elevated DEF above the 85th percentile. The FVA and SYM scores indicate an openness and acknowledgment of his use as well as symptoms and consequences. The elevated SYM also indicates he is either hanging out with or from a family of heavy users. In this case, he disclosed his family has a history of alcohol abuse.
The elevated OAT score indicates that he can probably identify with other substance users and those behaviors we often see with substance abusers i.e. impatience, resentment, self-pity and impulsiveness. On the other hand, his elevated SAT indicates a lack of awareness or insight or simple denial of the impact alcohol is having on him. He readily acknowledges his past drug issues but has put alcohol in a separate category. His final elevated scale is COR. Regardless of any past or present legal issues, we encourage evaluating for those behaviors that impact the ability to make good choices. These behaviors can range from poor social skills, low frustration tolerance, risk-taking behaviors to impulse control or anger management issues.
Utilizing the results: The evaluation started out as a domestic violence case but transitioned to also include substance use. The fact that the client was open about his alcohol use, not defensive and has a successful treatment history suggests he may be willing to take a look at his alcohol use and its impact on his behavior. His elevated OAT score does indicate treatment readiness and he is not going to feel out of place in a group setting. The emphasis will be to help him connect the dots between his alcohol use and any impulsive behaviors. This does not take the place of any recommended intervention for anger management issues he may have. The administrator has a good opportunity to facilitate the client to continue the work needed on his recovery and deal with all his issues.
We hope this is helpful for you in your work with your clients. As usual, the free clinical helpline is open for your questions M-F, 11-5, (EST). Don’t hesitate to call us whether you are new to the SASSI or an old hand.
The client, Carol, is a 43-year-old married female, a successful business woman and mother of two children. She recently was arrested and charged with her first DWI after leaving a business dinner with sales associates. This is the first significant consequence related to her drinking. She claims that she does not have a drinking problem; however, she characterizes her mother as an alcoholic.
As we take a look at her scores, first notice that Carol appears to have responded in a meaningful way to the items on the SASSI-4 (RAP=0). However, there is some evidence that she may have approached the assessment process in a defensive manner (DEF=8). Despite her apparent defensiveness, the SASSI results indicate that she has a high probability of having a moderate to severe substance use disorder (SAT=7 leading to a positive on decision rule 4).
Given the elevations on the SAT and DEF, we get the sense that Carol may have some difficulty recognizing (high SAT) and acknowledging (high DEF) the nature of her substance-related problems. Yes, it is true that she reports significant problematic use of alcohol (FVA=10). However, it will be important to review with her the content of her responses on the face valid alcohol scale in order to gain some understanding of how she views these consequences. Our experience with the SASSI and our knowledge of the nature of the addictive process suggest to us that individuals who have elevated SAT and DEF scores (especially when OAT is average or below, as is the case here) often have difficulty seeing the manner in which their drinking has pervaded other areas of functioning. Therefore, it is reasonable to expect that much of what she has reported on the FVA may be flavored with a theme of, “I’m so embarrassed about these things, but thank God I don’t have a problem.”
Carol’s FAM score is elevated (13), suggesting that her responses are similar to individuals who have a history of being in relationships with others who are substance dependent. This is often related to a tendency to focus on others and a need to try to control the external environment. Elevated scores on SAT, DEF, and FAM suggest that Carol is likely to have an exceptionally strong tendency to deflect attention away from any suggestion that it is important for her to make significant changes in her life. Carol’s lack of awareness and insight may not only be rooted in her own addictive disorder but may also be fostered by a long history of trying to cover up for her mother and feeling responsible for the family’s welfare.
Despite Carol’s inability to see her substance misuse as a serious problem in her life, the SASSI results clearly indicate that she is likely to meet the diagnostic criteria of a substance use disorder. Therefore, effective treatment planning will need to include some form of addictions therapy, most likely at the outpatient level of care. The therapeutic challenge for the treatment provider will be to establish a working relationship with Carol that is conducive to helping her explore the substance abuse issues in her life. This usually means starting where the client is and moving her in a direction of increased awareness and insight regarding the nature of her own substance use problems and the changes that can help her begin a process of healing and recovery.
Carol comes to the treatment setting with recognition of her mother’s alcoholism. She has a desire to disclose information about her life growing up with an alcoholic mom. This gives the treatment provider a naturally occurring place to begin. As Carol bonds with her therapist in the work of resolving the pain of her childhood, the therapist can help her examine the significance of her own alcohol usage. The therapy can be augmented by support groups in which Carol can learn from the experiences of others who come from similar home environments and from other people who have had to struggle with the reality of their own addiction problems. Ongoing assessment will be helpful during this process to monitor her progress and make adjustments in the treatment plan as necessary. For example, if she is unable to refrain from using, has additional alcohol-related social or legal consequences, or becomes non-compliant in the treatment process, it may be necessary to move to a more intensive level of care.
The emotional impact of growing up in an environment that is dominated by the pain and shame of addiction takes many forms and can exert its influence throughout a person’s life. Carol’s DWI can be a gift. With appropriate intervention, Carol can begin a process of self-examination and growth that will lead to a freer, richer life.
The Substance Abuse Subtle Screening Inventory (SASSI) has been used successfully in correctional screening in multiple settings since its release. These include outpatient evaluations of offenders as well as assessments of incarcerated individuals in federal, state, and local correctional centers.
Many clients served in behavioral health and substance abuse treatment programs have histories of involvement with the criminal justice system in addition to mental health and substance use disorders. Samples in the SASSI-4 validation study included assessments in community corrections, probation and parole and drug courts, as well as cases from DWI and DOT education and screening programs. SASSI-4 overall screening accuracy in criminal justice settings was 95%; in DWI and DOT education programs SUD screening accuracy was 91%, and these accuracy levels were found not to differ significantly from the overall accuracy rate for all settings (92%). In addition, many cases included routine information on clients’ number and types of arrests and blood alcohol levels. Analyses revealed that SASSI-4 screening accuracy was 92% for clients with a history of criminal offenses, and 90% for clients who had no such histories.[i]
Interestingly, of those who had been diagnosed with a substance use disorder, criminal offenders acknowledged significantly less illicit drug use and consequences as well as less alcohol use and consequences on the SASSI-4 face valid scales than did clients with diagnosed substance use disorders in settings other than criminal justice programs — suggesting offenders minimized reported use and substance-related problems. By contrast, offenders with substance use disorders showed no differences in their endorsements of subtle items on the SASSI-4 compared to individuals with substance use disorders in other types of assessment settings. Despite offenders’ attempts at minimization, SASSI-4 overall accuracy in the offender samples was 94%. Together these findings illustrate strengths of using SASSI-4 to screen criminal offenders as compared to entirely face valid screens such as the AUDIT, CAGE or DAST. That is, the inclusion of subtle items on the SASSI-4 as well as a scale to identify clients’ level of defensive responding strengthens the ability of the SASSI-4 to accurately identify clients with substance use disorders.
In addition to legal offenses and possible substance use disorders, offenders also often have other mental health problems, which can affect their responses on many types of assessments they are given. Research on the SASSI-4 has shown its screening sensitivity is 98% in dual diagnosis clients; specificity is 93% in persons diagnosed with nonsubstance-related psychological disorders only, for an overall accuracy rate of 97% in people suffering from other psychological disorders. Moreover, accuracy was shown to be unaffected by ethnic background, and other demographic variables such as age and education.
For information on integrating the SASSI-4 into correctional programs, contact us at 800.726.0526.
[i] For additional validation information please refer to: Lazowski, L.E. (2016). Estimates of the reliability and criterion validity of the Adult SASSI-4. Springville, IN: The SASSI Institute.
This SASSI-4 profile of a 37-year-old female was called in to our clinical support line. As we look at her results, it appears that she answered the items in a meaningful manner (RAP=0). She is likely to have a high probability of a substance use disorder (SYM=6, SAM=8) based on decision rule 8.
Notice that despite the relatively low DEF score and apparent lack of defensive responding, the SAM scale score, when combined with the elevated SYM score, leads to a test positive result. While it is true that the SAM scale score plays a vital role in the accuracy of the decision rules in this case, it is important to remember that the clinical meaning of this score is unclear. Therefore, it would be inappropriate to draw any clinical inference from the fact that the SAM score is elevated.
The client acknowledges significant problems related to her use of drugs other than alcohol. She is likely to have experienced some loss of control, negative consequences, and increased tolerance as a result of her substance misuse. However, her average OAT score (OAT=3) may be an indication of some limited ability or willingness to acknowledge behavioral problems commonly associated with individuals who have substance use disorders.
The moderately elevated SYM (SYM=6) is consistent with clients who often are not able to recognize the manner in which substance use is manifested in their lives. Her responses are similar to individuals who live in a social milieu where substance abuse and its related consequences are fairly routine and normalized. This experience may limit her ability to characterize her substance usage as problematic. Indeed, she may be somewhat surprised that the SASSI results could even indicate an addiction problem.
The client’s responses are similar to those of individuals who are experiencing emotional pain (DEF=3). Individuals who score in this range tend to be overly self-critical, may experience depressive symptoms and sometimes report a history of trauma. She may be quite limited in her ability to recognize personal strengths, focusing more on limitations, failures and feelings of low self-worth.
This client is likely to have a high probability of a substance use disorder and should be considered for relatively intensive addictions treatment. A comprehensive behavioral health evaluation may be necessary to rule out the need for additional psychiatric intervention. Although she demonstrates some ability to acknowledge relevant behavioral symptoms of her addiction, a viable treatment plan should include initial efforts to increase her self-awareness and insight into the full nature of her substance use problems. Education and other cognitively based interventions may be helpful.
Most likely, she will need help in recognizing that her misuse of alcohol and other drugs is similar to that of other substance dependent people. A content analysis of her responses on the FVOD and SYM items may be one way to help her realize that it is in her best interest and within her capacity to change.
Community-based self-help support groups could provide additional encouragement and support.
In addition, evaluation for depressive symptoms and its relationship to her substance us would be important to consider.