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.
Bob is a 43-year old male who was referred by his attorney for a substance evaluation following a traffic fatality in which he was driving under the influence. Bob seems to have understood the items and responded in a meaningful way (RAP = 0). There is no significant evidence that Bob was defensive (DEF = 7).
The most salient feature of the profile is the significantly elevated SAT score, which is a key feature in both decision rules that lead to a test positive on the SASSI (Decision Rules 4, 5, 6, and 7). His responses were highly similar to substance dependent individuals regardless of their ability or willingness to report symptoms relevant to substance misuse. Given the lack of evidence of defensive responding, it’s likely that Bob falls in the category of those who are unaware of the full impact of substance use problems in their lives.
Individuals with this configuration of scores are often willing to acknowledge some behavioral problems related to their substance use. Bob demonstrates this by acknowledging significant current and/or past alcohol (FVA=14) and drug (FVOD=12) use. His pattern of responding also indicates some awareness of behavioral problems that are commonly associated with individuals with substance use disorders: low frustration tolerance, self-centeredness, grandiosity, etc. (OAT=7). However, given the elevated SAT, he will most likely not be able to make any connection between his acknowledged use and behavioral problems and their impact on other areas of his life.
He also responds in a fashion similar to individuals who live in an environment dominated by substance abuse (SYM=6). Although the SYM is not extremely elevated, it does tend to support the notion that Mr. B. may view his substance use as normal. Further content analysis may reveal additional factors about his life circumstances that might be important to consider in treatment planning.
Bob may be relatively well presented. He may also appear to be emotionally detached while maintaining a sense of pragmatism regarding his situation. Relatively poor insight and self-awareness are commonly present in these types of profiles. It’s not that Bob refuses to understand or is intentionally resistant; he literally doesn’t grasp that his substance use may be a problem that requires further exploration. In his mind, external factors or stressors may be to blame for his current predicament. The possibility that this tragic incident may be directly related to a substance use problem would be quite difficult for Bob to understand at this time.
Through the years, we have had the opportunity to share inspirational stories with our colleagues about their experience using the SASSI. One such story came recently from a psychologist who uses the SASSI in his practice. This was a gratifying story for us to hear and we are pleased that he has allowed us to share it with you.
The mother of a 22-year-old woman called me because she felt very strongly that her daughter Aimee (not client’s actual name) had an alcohol problem. But Aimee was adamant, no question about it, “I don’t have a problem.”
After some persuasion, Aimee agreed to come into my office, and I invited her mother to stay in the office during the interview, with Aimee’s permission. I really think Aimee was very certain that there wasn’t a problem, and that having Mom there during the process would convince her mother of this, too. I said, “You know, Mom can be a bit of a reality check here, but I’m listening to what YOU are saying.” Aimee’s mother agreed to just listen, since she had had her say when making the referral.
We talked about it, and Aimee restated that she didn’t have a problem. She was just not aware of any bad consequences coming from drinking. Aimee really seemed to believe what she was saying, “My friends and I, we don’t have any consequences; we just enjoy drinking.” I told her that was fine and asked, “Would you like to find out if you, in fact, do have a problem, or would you rather not know?” Of course, this is right in front of Mom. And she thought about it, seeing herself as being free to say “no.” But she did say, “Yeah, I think I would want to know.” When asked about each of the DSM diagnostic criteria for substance use disorders, Aimee answered no to all symptom questions.
Then, I brought out the SASSI-4, and told her a little bit about how it would compare her responses to two known groups of people: those who have a problem and know it, own it, and the other group that is just as aware that they do not have a problem, and own that. And we will see how your responses go. She agreed that that sounded good. She took the SASSI-4, and her responses showed a high probability of having a substance use disorder. This was very surprising to her. Then I went back and showed Aimee her scores on the FVA and the SYM.
When she looked at those scores, she could see by the profile that the consequences she was getting were way out of line compared to ordinary people who drink. She runs with folks whose norm is to drink a lot, and there is a history in her family of substance use issues. She just said, “It’s almost like thinking about it and realizing that you are surrounded, and your best bet is to give up!” She surrendered to the idea that, “Yes, I’ve got a problem.” From there on she was willing to do something about it. Aimee made an appointment to see me again, and we went on from there.
Let’s say that the SASSI did not exist, and I would have had only the DSM criteria and her history. I would have had her mother’s reflections and thoughts and observations, and—I don’t feel certain, but I’m guessing—she would have walked away with the understanding that she did not have a problem. She would have gone on as she had been—because I would not have been able to make a case that she did have a problem, because there would have been no data to base that on. She may well have been one of those who left the interview, and for the rest of her life said, “No, I don’t have a problem, so get off my back.” In a sense, I really believe that the SASSI saved this young woman’s life, or at least spared her significant pain. I have always been impressed by the accuracy of the SASSI. It picks up on people who really are “sincerely deluded.” It’s interesting that her score on the Defensiveness (DEF) scale was not particularly elevated, so it was not that she was being defensive, she was just unaware of how her drinking and symptoms associated with it were beyond the norm. Her elevated SAT score – at the 98th percentile – supports the interpretation that Aimee has little insight into what may be motivating her to drink with her friends, or the negative consequences that follow from spending time that way. I am very grateful for the SASSI, and I wouldn’t do an assessment or a screening without it. I literally would refuse, because just the verbal reports can be so misleading, although not intentionally misleading, necessarily. Clients will compare themselves with the people they know who are much further along in the addiction process, and not really understand that their own behavior is a problem, just because their own behavior is not yet as severe as what they see in others. The SASSI can put a client’s use into a broader, and often more realistic context.
Original depiction, written by Nancy Winningham, M.A. based on an actual experience a clinician had using the SASSI with a client. Adapted to reflect SASSI-4 information.
We had the opportunity
to consult with a treatment provider who had called in SASSI-4 scores for a
Native American couple residing in Canada. Since both profiles nicely
illustrate important clinical features of each client, we decided to present
the interpretations in this sample. We are grateful to the treatment agency in
Northern Canada that granted us permission to use the information included in this
sample. To facilitate the presentation of the profiles in a confidential
manner, we have created fictitious names for each of the clients.
Mary, a 25-year-old
Native American female, and her husband John, a 28-year-old Native American
male, were referred to the agency for a substance use evaluation. They live in a
very small community where the base rate of substance misuse is extremely high.
Their children were recently removed from the home as child protective services
suspected alcohol abuse to be a serious problem for both parents. Mary lost her
mother, father and siblings in a tragic accident that occurred just a few
months prior to the evaluation.
Upon first glance at
Mary’s profile, she appears to have responded in a meaningful manner (RAP=0),
and there is no evidence of defensive responding (DEF=1). Given this low DEF
score, she is likely to be in considerable emotional pain. She acknowledges
significant problematic use of alcohol over her lifetime (FVA=13) and reports
behaviors and experiences that are highly correlated with substance abuse SYM=8).
In fact, her SYM score is the sole basis for classifying her as test positive
on the SASSI-4 (Decision Rule 2).
A quick look at John’s
SASSI results reveals a similar profile but with some noteworthy differences.
Although he too shows no evidence of defensive responding (DEF=4), his RAP
score of 2 raises immediate concerns of random or non-meaningful responding.
Fortunately, the treatment provider had investigated this potential problem and
was satisfied that John fully understood the items and that he responded in a
meaningful manner. The counselor attributed the elevated RAP to cultural
differences and circumstances surrounding the nature of the evaluation.
John also acknowledges
significant alcohol problems (FVA=18, decision rules 1, 2, 6, 10). Like Mary,
his responses are highly similar to individuals with substance use disorders
who report life circumstances and experiences commonly associated with substance
abuse (SYM=9). This score likewise results in a test positive on the SASSI-4 (Decision
that Mary and John both have a high probability of a substance use disorder, we
can now proceed to examine the salient clinical aspects of the SASSI results,
hopefully illuminating more specific treatment needs for each client. Notice
that Mary’s and John’s SYM scores are highly consistent with the milieu in
which they are reported to have lived. The treatment provider made specific reference
to the high rate of alcoholism in their community. Individuals who have substance
use disorders with high SYM scores frequently live in environments where the abuse
of alcohol and/or other drugs and the associated consequences are common and
normal experiences. In fact, it can be such an accepted way of living in the
community that most of its inhabitants would be flabbergasted to have their drinking
behavior characterized as unhealthy or problematic. Consequently, it is
perfectly understandable that Mary and John may have difficulty recognizing the
precarious nature of their alcohol misuse, especially as it relates to their
current difficulties with the child protective agency.
Despite the similarity
of the two profiles, one important difference is Mary’s significantly low DEF
score. This score would certainly seem to fit in with the recent trauma she
experienced. Unresolved loss and grief issues may be strong contributing
factors to Mary’s emotional pain. Moreover, the thought of now losing her
children because of her substance use may be adding significantly to her
distress. The risk of depressive symptoms possibly related to a mood disorder
may indicate the need for a comprehensive mental health evaluation, especially
to rule out clinical depression or suicidal ideation.
Individuals with this
high a level of emotional distress are often overly self-critical and can
become immobilized with feelings of helplessness and hopelessness. However,
it’s also possible that Mary’s pain may act as a catalyst in helping her
recognize the need to do something about her drinking. Indeed, the treatment
provider confirmed this to be the case and described Mary as a willing
candidate for substance use disorder treatment.
On the other hand,
John’s focus may be less internally directed with a tendency to see people,
places or things outside himself as the major cause for his problems.
Individuals with low SAT scores often present as victims of circumstances,
powerless to change their behavior because of a perceived lack of influence and
control over their immediate environment. In John’s case, the treatment
provider reported that John perceived his wife as the major cause of his
problems. He was content to focus on Mary’s drinking, grief issues, and
possible infidelity as the sole source of difficulties in the family. Despite
his acknowledgment of significant symptoms related to his drinking (FVA=18
& SYM =9), he remained unwilling and unable to accept this as an important
A viable treatment
plan for this couple will have to take into consideration a number of issues.
Mary seems primed for substance use treatment but may need additional
behavioral health services. A comprehensive mental health evaluation would be
helpful in identifying the nature and extent of any concurrent problems.
Interventions directed at processing loss and grief and those that provide
support would undoubtedly be important actions to consider. Efforts should be
made to provide bonding opportunities with a treatment provider and other
sources of encouragement and affirmation. In this regard, community self-help
support groups would be a valuable adjunct to relatively intensive substance
use disorder treatment. Pending the results of the mental health evaluation,
additional behavioral health care services may be added as required.
Although John is also
in need of substance use disorder treatment, he does not appear to be a willing
candidate at this time. Efforts should be made to increase awareness and
understanding of his alcoholism and how it contributes to his relationship and
family problems. The SASSI-4 results could be used as a graphic illustration of
the serious nature of his drinking problems. Using the high SYM score, the
treatment provider may be able to convey some understanding of how John may
have difficulty seeing the unhealthiness of his drinking. A content analysis of
the FVA and SYM scales may help him to see specific ways in which his alcohol
misuse has affected his life. It would be important to keep John focused on his
own needs by helping him to accept responsibility for his life and to make
choices that are in his own best interest. Attendance at self-help support
group meetings could help to reinforce this notion. Conjoint or family therapy
may need to be deferred in order to reinforce self-focus and to discourage John
from externalizing blame to Mary.
This case emphasizes
the importance of recognizing and assessing the impact of environmental factors
when developing effective treatment planning. It is true that substance
dependent individuals often live in an environment where the abuse of alcohol
and other drugs is commonly practiced and accepted as a normal way of life. In
these situations, individuals frequently engage in heavy substance usage as a
means of maintaining acceptance and approval in the community. It’s no wonder, then,
that clients living in this type of environment are amazed when we begin to
identify their misuse of alcohol or other drugs as problematic. Given their
life experience, it would never have occurred to these clients that anyone
would view their drinking or drugging as a sign of serious problems.
As we were able to see from the above discussion, the SYM scale on the SASSI-4 can often help you to recognize this phenomenon as a potential issue to explore further. In cases where the SYM is significantly elevated, clients may express puzzlement and surprise at your suggestion that their substance use is contributing significantly to their problems. However, the knowledge that this reaction most likely stems from the normalization of substance abuse in a client’s milieu provides an opportunity for you to communicate empathetic understanding and develop further rapport with the client. Once an appropriate bond is established, efforts should be directed at helping the client achieve some awareness of and insight into the full nature of his/her substance misuse and its relationship to other presenting problems.