Category: Sample Interpretations

SASSI-4 Profile of Adult Male Involved in a Custody Suit with ex-Spouse

A substance use evaluation administered on an individual involved in a custody suit can reliably be fraught with issues. This one presents a number of them.

This 39-year-old client was instructed to complete the FVA/FVOD questions for his whole lifetime.

A significant issue was his history of 4 DUI’s from 2020 – 2021 while in the process of separation and divorce. He denies his current use is anything like it was during that period.

The SASSI result indicated a Low Probability of a substance use disorder.

His RAP was 1 but not enough to flag the results and his Prescription Drug Scale was zero.

Looking at how his scores compare on the graph; we first see the average scores of his FVA and FVOD scales which may be suspect given his DUI history. His average SYM score suggests he does not acknowledge significant symptoms or consequences of his use despite 4 DUI’s. Face Valid Scales are easy to manipulate or minimize if the client chooses as they directly relate to substance use.

Moving on to the subtle scales starting with OAT, we see it is very low but within the norm. If it were any lower, it would indicate he has a hard time acknowledging personal limitations and shortcomings so there may be a hint of that going on. It is the next two subtle scales which contribute the most. The SAT scale is below the 15th percentile and when it is this low can indicate the client is hypersensitive to what others think of him, maybe experiences feelings of rejection so comes across as having a chip on his shoulder.

The extremely high-DEF score (above the 98th percentile) questions the Low Probability Result.  As suggested, If the DEF is 8 or more, that increases the possibility of the SASSI missing individuals with a substance use disorder. It does not invalidate the result. There are many reasons for a high DEF – it could be situational – and it is not unusual in custody disputes to see a high DEF. It could be the client was defensive around their substance use. It could be that he has a defensive personality in general. The administrator is tasked with determining the meaning of the DEF scale score. It also tells you how to clinically approach a client who has difficulty opening up, is hypersensitive to others and is defensive.

The SAM score, though low, is the only scale which does not have an individual clinical interpretation. It is used in the decision rules to increase the validity and accuracy of the other scales it is paired with. It is also used to ascertain if the client is defensive around their substance use if both the DEF and SAM are elevated.

The FAM and COR results are not clinically significant.

In this kind of a case, the question of what timeframe to use with the FVA and FVOD scales comes up. It depends on several factors. Lifetime does give you an overall baseline of substance use but if you want a more “focused” timeframe, the last twelve months should be considered. Sometimes there is the issue of missing someone who had a significant issue in the past but is not currently using it, so a high probability result becomes a risk statement. A reminder:  the SASSI cannot determine what a client is currently doing. This inventory is part of the information gathered by the administrator which is incorporated into the whole assessment.

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Elevated RAP/ High Probability Results on an Adult SASSl-4

This profile on a 21-year-old female with the FVA and FVOD, based on the last 12 months, is interesting primarily because it is so unusual.

As you look at the profile graph, all the scale scores are within the norm, i.e., between the 15th and 85th percentiles except for the SYM score which is above the 85th percentile. This tells you that she is acknowledging symptoms and consequences of her use and indicates she is associating with friends or family who are also heavy users. This is a bit of a contrast to her FVA and FVOD scores, both of which are above average but not above the 85th percentile.

The SAT score of 5 is within the norm which is a positive – no denial or lack of awareness or insight is indicated. However, with the OAT score within the norm, it is a possibility that she does not identify with other substance users and those characteristics we associate with substance users such as impatience, self-pity, resentment, or impulsivity. If marijuana is her primary drug, she may not see it as a problem so the high probability of a substance use disorder may be an unexpected result for the client.

Another positive is the DEF score, which is above average but not clinically significant since it is below the 85th percentile.

The client meets decision rules 5, 6 and 9 and 10 thus meeting the criteria for a high probability of a substance use disorder. As a reminder, more rules that are met does not mean a more severe problem. As we often mention on the clinical helpline, the diagnosis and severity of a substance use disorder is based on the criteria in the DSM-5.

Note the Prescription Drug Scale score of 2. It does not meet the cut-off criteria for prescription drug abuse, but it is worth a look at those items she endorsed.

The caller was puzzled by the RAP score of 2 and how it affected the result of the SASSI.

A RAP score of 2 or more always needs to be explored, preferably with the client. The two items which posed the problem were ‘I never have been picked on and I have never been sad’.
Cultural and language contexts need to be considered for possible reasons the client answered as she did. The possibility of her deliberately trying to ‘skew’ the questionnaire is low given the high probability result. More likely, the client answered accurately for her based on her life experience.

The clinician can now safely accept the overall result as valid.

As a reminder, the free clinical helpline, (800-726-0526) is available M-F, 12- 5 pm (EST) for any questions you may have. We also offer a free Q&A zoom meeting once a month for an hour as well. Please check the blog notice for dates and time to register. And finally, if you have additional inquiries, please contact the Clinical Director, Kristin Kimmell, LCSW, LCAC at kristin@sassi.com.

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Pre-employment Screening / A Profile Review on the Proper Use of the SASSI-4

A recent caller wanted help in interpreting a profile completed by a 33-year-old male. He was instructed to complete the FVA/FVOD side of the questionnaire for the last 12 months. The administrator revealed during the call that the assessment was a pre-employment screening for the Department of Transportation. The helpline does receive regular calls from counselors who administer the SASSI-4 for the Department of Transportation after a driver has failed a drug or alcohol test for substances, but not for pre-employment screening.

In review, the client comes up with a high probability of a substance use disorder based on Rules 2,5,6 and 9. The RAP is 0 and the Rx Prescription Drug Scale is 0.

The FVA is below average use, the FVOD is on the 50th percentile. The SYM scale of 7 is above the 85th percentile, considered elevated and thus Rule 2 meets the criteria of a High Probability of a Substance Use Disorder. The rest of the scale scores are within the norm (between 15-85th percentiles) so clinically are not significant but are significant in meeting the criteria of a Substance Use Disorder if accounting for the additional rules of # 5, 6 and 9. The SAT of 5, being in the norm indicates the client was not in denial about his usage.

Considerations

Although the results do not account for current or actual use, further assessment may include urine screens that would give a more accurate representation of current use of substances. He does come up with a high probability of a Substance Use Disorder, so deeper inquiry is necessary.

The administration of this SASSI was part of a pre-employment screening and our position on the proper use of the SASSI in this regard, is very explicit:

From our User’s Guide and Manual: *

“The purpose of the SASSI is to help identify people who are likely to have substance use disorders so that early intervention and treatment can be initiated when appropriate.”

“To use the SASSI to discriminate against individuals violates the intent of the authors and may even violate the law.”

“SASSI results should not be used to abridge the rights of individuals or to disqualify applicants for positions, such as jobs or benefits, such as public assistance programs.”

Thus, it is extremely important to use the results in the most therapeutic way possible with the best intentions of helping individuals with a substance use disorder.

If you have any questions, please contact the Clinical Director, Kristin S. Kimmell, LCSW, LCAC at kristin@sassi.com.

*SASSI -4 User Guide & Manual – Chapter 1 (overview), pg.7
SASSI-4 Online User Guide – Proper Use of the SASSI. pg. 8

SASSl-4 Profile Analysis – DOT Client

We frequently receive calls requesting clinical interpretation of profiles done on Department of Transportation (DOT) clients. These clients have failed their drug/alcohol screening and their license to drive has been suspended pending an evaluation. In this particular case, the client is a 68-year-old female whose alcohol level registered above the DOT threshold. Her SASSI result indicated a high probability of a substance use disorder based on Rule 9. As you see on the graph, most of the scale’s clinical results fall within the norm. DEF, at 11, is above the 98th percentile and FAM, at 12 is above the 85th percentile. The OAT score of 1 falls in the 15th percentile. The high-DEF score is not unusual in DOT evaluations. It is incumbent on the evaluator to determine what the defensiveness is about. The SAM scale is no help in this case because it is not elevated. An elevated DEF coupled with an elevated SAM indicates the defensiveness is related to substance use. The elevated FAM score indicates someone who is not comfortable looking at their own issues. And the low OAT score indicates someone who has difficulty acknowledging their personal limitations and shortcomings. The combination of these three scales provides information to the evaluator that most likely, this client is not going to be forthcoming in disclosing issues or problems. During the evaluation, another piece of information disclosed was the client’s admission of trying to manage or monitor her drinking to try to stay below DOT’s threshold of alcohol use. That certainly may be a red flag.

Since the SASSI is a screening inventory and does not diagnose, the evaluator needs to reference the DSM-5 to determine if, indeed, the client meets the criteria for a substance use disorder and if so, what level – mild, moderate, or severe. Based on that, the evaluator has a couple of options to consider. If possible, work individually or refer to an individual substance abuse counselor to establish rapport and work to get the defensiveness down. Motivational Interviewing is a good asset to pull out in this case. Another option is to refer her to an outpatient group setting with the goal of connecting her to other clients and also have access to individual counseling as well. Regardless, outpatient treatment seems to be the most likely intervention.

It would be helpful to acknowledge the financial impact on the client that suspension of driving privileges is having on her. That certainly could be triggering the extreme defensiveness we see in the results and the consequences for the client could be significant.

We hope these reviews are helpful and whether you are a new user or a very experienced one,

clinicians are here to help with any questions you might have. Clinicians are available M-F, 11-5 (EST). Call us at 800-726-0526 or 888-297-2774.

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Addressing the Ethical Issues of Mandated Client

This sample profile is about a 27-year-old, Sally, who is a single mother of two small children. Sally was ordered by the court to report for a substance abuse assessment following an arrest for illegal possession of a controlled substance. Sally is also being investigated by the county’s Child Protective Services Agency, who has placed her children into foster care pending the outcome of the case.

An initial review of Sally’s scores indicates that, although she apparently understood the SASSI items and most likely responded in a meaningful way (RAP=1), there is evidence of significant defensive responding (DEF=9). Despite her defensiveness, the results indicate that she has a high probability of having a substance use disorder (SUD) based on Decision Rule 8 and 9. To put it another way, there is a 93% chance that Sally will meet the DSM-5 diagnostic criteria for having a substance use disorder once a more comprehensive evaluation is completed.

For now, however, the SASSI has provided us with important information concerning Sally’s illegal act; her behavior is likely to be related to a serious addiction problem. In this light, we can now shift to looking for additional features on her profile that might help us to understand Sally better and develop a more empathic point of view. Learning more about her perspective and how she is dealing with this entire process, including the new information from the SASSI, certainly is one way to provide supportive and effective care to her during a mandated process of evaluation.

A prominent aspect of Sally’s SASSI results reflects her similarity to people with SUDs who were instructed to conceal and minimize any evidence of their substance use problems (DEF=9, SAM=12). In addition, an elevated DEF coupled with an elevated SAM indicates her defensiveness is related to her substance use.  One inference that can be drawn from this is that she is likely to have significant difficulty in disclosing personal information about her misuse of substances, as well as other problematic behaviors. Other SASSI scale scores may be reflecting this mind set. For example, she does acknowledge some misuse of alcohol and other drugs but no more so than the average person in the general population (FVA=5, FVOD=7). Her SYM score of 2 is also average, indicating no significant similarity to people with substance use disorders who do report experiencing many of the behaviors correlated with addictions. However, given that each of these scales is derived from face valid items that can be easily manipulated, it would be reasonable to suspect that Sally may be underreporting or misrepresenting problems in each of these areas.

It is easy to imagine that Sally may harbor some resentment towards the evaluation process and the practitioners involved. After all, she stands to lose not only her freedom but her two children as well. Underlying the overt anger and resistance may be an extreme sense of fear, apprehension and powerlessness in the face of feeling helpless to influence decisions that will undoubtedly affect the rest of Sally’s life. When viewed from her standpoint, it then becomes easy to see Sally’s defensiveness as a somewhat natural response to the threat she must be feeling. It’s no wonder that she is having difficulty acknowledging her substance use problems.

If further diagnostic evaluation for substance use disorder does indicate that Sally has an SUD, the following treatment approaches may prove useful based on insight gained from Sally’s SASSI scores. Despite Sally’s lack of ability and willingness to recognize the impact of her substance use on her life, it is our ethical responsibility as counselors to use our knowledge, skills and experience to lead her to an accurate understanding of the nature of her substance use disorder. This should be accomplished in a climate of respect and acknowledgement of the pressures that she is currently facing. An attitude of respect is particularly important when attempting to build a therapeutic alliance with clients like Sally that are mandated for assessment and treatment.

One way to engender open communication in a respectful way is to invite Sally to join you in a process of reviewing her responses on the SASSI face valid items. Acknowledging that it is important for you to understand her point of view, perhaps asking for further clarification or details as you actively listen is one way to cultivate trust and rapport. This communicates genuine concern and interest that may help Sally feel supported and empowered as she describes her experiences. Empathic responses that demonstrate a good understanding of the difficulties she is facing while helping her to gain insight regarding the nature of her substance use problems would be useful in making her an active partner in creating a treatment plan that she can accept.

Another effective way to increase Sally’s awareness of her substance use problems while maintaining a respectful relationship is to provide cognitively based educational programming. Didactic presentations of alcohol and drug information generally are viewed by clients as less threatening and often tend to elicit a more favorable response. Sally may particularly benefit from content that describes the impact of substance abuse on families and how, with proper treatment and aftercare, recovering individuals are often able to be reunited with their children and other family members.

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Reviewing an Adolescent SASSI-A3: Vaping Issue

This is an issue that may be turning up in your clinical practice. The caller wanted help with a profile interpretation on a 13-year-old male who had turned in a vaping pen. The school was mandated to do a substance use evaluation as a result. The online report indicated “inconsistencies” in the results so the counselor wanted more information. The client was instructed to complete the FVA/FVOD side for his whole lifetime.

The overall result, based on all the rules being ‘no’, came up with a Low Probability of a substance use disorder. The Prescription Drug Scale was zero. However, the Validity Check Scale was 6 so further evaluation was recommended. Elevated VAL and DEF scores coupled with a Low Probability result increases the possibility of the SASSI missing individuals with a substance use disorder.

Looking at the graph on the profile sheet helps to pull out additional information. Note the very low (below the 15th percentile) OAT and SAT scores. The low OAT can indicate someone who has a hard time acknowledging personal limitations or shortcomings. The low SAT can indicate someone who has a chip on their shoulder, feelings of rejection and hypersensitivity to others. Interestingly, the DEF score is within the norm and does not indicate the student was defensive completing the SASSI. The FRISK score is above average but within the norm and because it is a Face-valid scale, content analysis of those items may be useful. The other Face-valid scales, ATT and SYM with their scores of 1 can also be examined.

The student who turned in the vaping pen indicated it was not his. It was not clear from the caller what substances they suspected were being used. Clinically, the best thing to keep in mind is that the student has a hard time opening up and is probably very concerned about how he is viewed by teachers, counselors, etc. and very quick to feel rejected. Interacting with him in an accepting and affirming way is probably the best approach.

Substance use issues: The VAL of 6 is a red flag so further evaluation with this student is warranted. It could be on-going oversight within the school, i.e. school counselor or referral to a Substance Use counselor who could do a more formal and comprehensive assessment.

We hope this is useful for you.

As usual, don’t hesitate to call the Clinical Helpline at 800-726-0626 with any clinical questions. Live clinicians are available M-F, 11-5 pm (EST). Otherwise, feel free to leave a message and we will get back to you the next business day.

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Profile Configurations: When the OAT is higher than the SAT vs when the SAT is higher than the OAT     

One question we field often on the clinical helpline is what does it mean when either the OAT (Obvious Attributes) is higher than the SAT (Subtle Attributes) or when the SAT is higher than the OAT when both are elevated above the 85th percentile?

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A SASSI-4 Profile Analysis: Prescription Drug Abuse

A caller requested help interpreting the result of a SASSI-4 questionnaire on a male client who presented himself as having an opioid addiction.

‘Curtis’ is a 36-year-old married man. He and his wife have no children. He works as a landscaper which he describes as physically very demanding. His parents smoked marijuana while he was growing up and Curtis also smokes marijuana. His older brother died ten years ago, and Curtis is still grieving. His brother also had substance use issues. Curtis also may have a history of being molested as a child which he does not remember, but his brother relayed that they were both molested by a babysitter.

Curtis reports a four-year history of opioid addiction which started as a result of a herniated disc in his back. He was initially prescribed hydrocodone for pain. He tried to quit once three years ago. Currently, he is ordering “stuff off the internet” or getting oxycontin from friends. He has been taking 180 mg/day with a maximum of 240 mg per day. It takes 150 mg. for him not to get “sick.” Curtis continues to smoke marijuana on the weekends about one time per week. He has a legal history of possession of marijuana in 2004 and attended an outpatient treatment program doing “what I had to do.”

He has been slowly tapering off the opioids for the past five weeks and currently is down to 80 mg/day.  His goal is to completely get off the opioids but he is not interested in residential treatment at this time because it is his busiest time of year. Although he has attended NA, he does not like it. Curtis is more drawn to Smart Recovery.

The SASSI-4 was administered for lifetime use on the face valid side of the questionnaire.

What were his SASSI-4 results?  Curtis has a ‘High Probability of having a Substance Use Disorder’ and a ‘High Probability of Prescription Drug Abuse.’

This looks like a straightforward profile on the face of it. His score of 42 on the FVOD and 18 on the SYM indicate someone who is very open concerning his drug use, and because these are face valid scales, content analysis could provide useful information to further explore with the client.

The OAT score of 6 is right at the 85th percentile. The client may be able to identify with some of the characteristics of substance users such as impatience, resentment, self-pity and impulsiveness. However, the SAT score of 8 is higher than the OAT and may blunt the ability for Curtis to have insight into his behavior. When the SAT is higher than the OAT, the client may exhibit a lack of awareness or simply denial around the impact drugs are having on his life. In this case and not unusual, opioid users do not see themselves as “typical” addicts. That may account for the OAT score.

The DEF score of 2 can be a ‘red-flag’ as it is below the 15th percentile. A score this low can indicate someone with poor ego strength, feeling helpless and hopeless and may be exhibiting symptoms that look like depression. The clinician may want to do a mental health screening or refer the client for screening.

The FAM score of 5 is also very low, below the 15th percentile. This can indicate the client is focused on himself and not that concerned about others. This does not indicate a personality disorder but given the client’s circumstances, makes sense that he would be more internally focused.

The COR score of 8 is elevated above the 85th percentile. He has answered in a similar way to people who have had legal issues for any reason. We suggest screening for those behaviors or characteristics we often see in that population. These can range from poor social skills, low frustration tolerance, risk-taking behaviors, anger management issues or impulse control issues. These issues could be impacting on Curtis’s choice-making abilities.

Finally, looking at the Prescription Drug Scale. With the score of 14, it is quite clear that he is identifying behaviors associated with prescription drug abuse. Again, as a face valid scale, looking at these individual items will generate a lot of information for the clinician. The clinician will need to look at treatment readiness, discuss medication needs, possible referral and other reported clinical issues.

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A SASSI-4 Profile Analysis: Context Matters

If you have attended one of our trainings either in-person or online, you know the section on how to administer the SASSI to a client is one of the most important. A thoughtful approach can set the tone for the entire assessment by helping a client feel more at ease and engaged in the treatment process. We emphasize the importance of first establishing rapport with the client. The questionnaire is presented as an aid, not a test with right or wrong answers. We instruct to administer the true/false side first, then checking the appropriate time frame for the face valid side.  Letting the client know s/he will have a chance to discuss the results at a later time increases the client’s comfort level.

Our protocol is based on the recommended one-on-one consultation.  We realize that is not always possible. Administrators of the SASSI work in a variety of settings including schools, probation departments, EAP, treatment agencies, institutions and private practice. Since the SASSI does not require a professional to administer it, a variety of personnel can be trained, but both the context and the administrator can have a significant impact on the receptivity of the client.

This example of the context of a SASSI given to a client dramatically shows the difference the setting can make in the results. One of our clinicians fielded this call. The administrator did not know which results to use even though both profiles came up with a high probability of having a Substance Use Disorder.

The client is a 46-year-old male who was given the SASSI at the Courthouse in a packet of material he was instructed to complete. Two weeks later he was given another SASSI to complete. This time with a counselor assigned to evaluate him.

Here are the results of the first SASSI he completed at the Courthouse:

As you can see, he meets Decision Rule # 9.  Looking at the graph, some scales and numbers stand out.  On his face valid scales, including SYM, his numbers were within the norm, between the 15th and 85th percentile. His OAT score is extremely low which indicates he has a hard time acknowledging personal limitations or shortcomings and may have difficulty in groups. The other significant score is the DEF score of 8. In spite of the elevated DEF score, he did meet one rule. The SAM is almost at the 85th percentile so, in my mind, I might be more inclined to say he was defensive about his substance use and perhaps minimizing on the face valid scales. This hypothesis would depend on the rest of the assessment with any additional information. However, he was given the SASSI to complete within a packet of materials, and it is very unclear what instructions he was given, if any, on how to complete the SASSI.

Let’s look at the results of the 2nd administration given just two weeks later in the office of the counselor who was evaluating him after meeting and talking with the counselor.

In this profile, the client meets multiple decision rules including numbers 3, 4, 5, 6, 7 and 10. All it takes is one rule to meet high probability and more than one does not mean a more severe substance use disorder. Diagnosis and severity are based on the DSM-5 criteria.  It is evident his raw scores have changed to impact the decision rule results.

There is a significant change in his Face Valid Scales with an FVA of 11 and an FVOD of 14. His SYM score of 6 also shows elevation. OAT has changed from a 0 to a 9. He is now indicating a willingness to acknowledge shortcomings and limitations. In addition, he probably can identify with other substance abusers so a referral to a group treatment program can be considered.

The significant drop in the DEF score from an 8 to a 5 is nice to see.  The client met with the counselor who was able to establish rapport by making the client more comfortable and explaining what the SASSI is and how it will be used in the context of the assessment. The low FAM score reflects the client’s internal state of mind. He is probably very concerned about what is going on within himself and not so concerned about others.

The final interesting scale change is the COR score and probably more representative of the client’s self- assessment at this point. Perhaps he is more able to identify impulsive or anger management issues, risk-taking behaviors, low frustration issues, or poor social skills. It gives the counselor some insight on what to explore, regarding behaviors which are impacting the client’s choices.

The most important difference in these two profiles was how the SASSI was presented to the client. Context, and establishing rapport can produce a more useful SASSI by obtaining a depth of clinical information. As an aside, we were not informed on why the SASSI was administered twice within a two-week time frame. We do not usually recommend doing so. It may have been the counselor was unaware of the first SASSI administration until receiving the completed materials from probation.

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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SASSI Identifies Rx Abuse (with video)

 ‘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.