Tag: High Probability of a SUD

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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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: 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.

A Review of a SASSI-4

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.

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The “Unaware” Client

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.

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Interpreting the Spanish SASSI

Carlos C. is a 36-year-old Mexican-American male who’s Spanish SASSI results indicate that he has a high probability of having a substance use disorder based on “yes” answers to Rules 1, 2, 3, 4 and 6 and because his FPOS score is 5 or less (FPOS=2). Validation studies indicate that 86% of the people who have substance use disorders are correctly classified by the Spanish SASSI based on the Decision Rule (High Probability) and the False Positive Check (5 or less).

In addition, Carlos has an SCS score of 8 or more (SCS=9) indicating that he is more likely to have a substance dependence disorder than substance abuse. In validation studies, the majority of people (77%) who are test positive on the Spanish SASSI and have SCS scores of 8 or more have a substance dependence disorder rather than substance abuse or no disorder.

The Administration and Scoring Instructions and Development and Validation of the Spanish SASSI provide detailed information on interpreting the Decision Rule results, the False Positive and False Negative Check (FPOS and FNEG) and the Supplementary Classification Scale (SCS).

Three of the Spanish SASSI scales, FVA, FVOD and SYM, are composed of “face valid” items that address substance misuse in an apparent or obvious manner. Some questions address inability to control usage. For example, on one of the FVA items, Carlos acknowledged that on several occasions he has had more to drink than he intended to. Other items on these scales reflect usage in order to better cope with negative feelings or other problems. Carlos, for example, reported on one of the SYM items that when he is anxious, he feels the need to drink. The face valid scales also include items that address negative consequences of substance misuse, such as physical, emotional and relationship problems. Carlos indicated on an FVA item that on several occasions his drinking has led to problems with friends and family members, and on a SYM item he acknowledged that he has had a drink first thing in the morning to steady his nerves or get rid of a hangover.

As you can see, by reading clients’ answers to specific questions on the FVA, FVOD, and SYM scales, it is possible to gain greater understanding of the types of problems they may be having with alcohol and other drug usage. Also, providing feedback to clients on the types of problems they have identified on the face valid items of the Spanish SASSI may be useful in the process of establishing treatment goals.

The remaining scales, OAT, SAT, DEF and SAM are subtle scales — i.e., the items that comprise these scales do not address substance misuse in an obvious or apparent manner. Therefore, Carlos’ responses to questions on those scales cannot be readily interpreted. The SASSI Institute provides guidelines for interpreting four similar scales as they appear on the English versions of the SASSI. However, the subtle scales on the Spanish SASSI are not identical to the English scales, and there is not enough information available to formulate guidelines for interpreting them for clinical purposes. The SASSI Institute, therefore, does not recommend interpreting scores on the subtle scales for clinical purposes. We will however, be delighted to help you with scoring or administering the questionnaire.

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Interpreting the Results of an Adolescent SASSI-A3 with a High OAT Score

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.

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