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?
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.
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).
‘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.
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.
Happy New Year everyone!
I received my first Adolescent A-3 call on the helpline and was so excited and when I heard the numbers, I knew exactly why the clinician was calling.
As you look at the profile, you can see most of the numbers are within the norm. He meets Rule 6 so comes up with a High Probability of a Substance Use Disorder and no Prescription Drug Abuse. So, what clinical information can the scale scores give you with so few scales outside the norm?
Although the FVOD is within the norm, it is above average and as recommended, you can do content analysis of his Face Valid scales. Another scale to pay attention to is the OAT score of 7 which is elevated. This suggests the client can acknowledge personal limitations and shortcomings and identify with other substance abusers. However, he may not want to or think he can change. The other significant score is SAT with a score of 1 which is below the 15th percentile. This suggests he may be hypersensitive to others and comes across as having a chip on his shoulder. This gives you good information on how to approach this client, especially when giving him feedback as you process the results with him because he is not giving you a whole lot of direct information regarding his use.
A word about the VAL of 6. If the numbers had resulted in a Low Probability of a Substance Use Disorder, you would question the results and do further investigation. Because he met Rule 6, there is no need to address the VAL. That said, with the VAL being so high, was this individual trying to manipulate the questionnaire and didn’t succeed?
Finally, users of the older version will notice that the SCS has been eliminated. This will require your use of the DSM-5 to determine the diagnosis and level of severity from your assessment.
Hope this information is instructive and assists you in your practice. And remember, as usual, we are here to help, so give the clinical line a call at 800-726-0526, press 2.