Tag: High SAT

Beyond the Screening Rules: How Collateral Data Clarifies Complex SASSI Profiles

This very unusual profile was called in to our Clinical Helpline Staff and provides us the opportunity to discuss several key issues with regard to clinical interpretation of individual SASSI scale raw scores:

  1. It is critical to gather additional information beyond the SASSI from reliable sources and then integrate this information with the basic foundational scale interpretations provided by our case study research;
  2. When highly unusual scale scores occur, seemingly contradicting one another, resist the temptation to over-interpret and;
  3. Notice when scale score interpretations suggest potential problem areas beyond just the substance use disorder issues and make a plan to address these.   

This client profile is a clear example of the need for additional clarifying information about the client. The only information we were given was the client’s biological sex (female) and their age (25 years old). What makes this profile confusing is that the individual scale scores sharply deviate from “normal” scoring patterns in a few places, which leads to scale interpretations that seem to contradict one another. For example, the client has clearly acknowledged that she has had or is having significant negative consequences, problems or trouble as a result of her use of both alcohol and other drugs (FVA=23 and FVOD=30) and therefore may have lost control of her use and may be using as a coping mechanism. These scores are extremely high compared to the general population and typically leave no doubt that this person has most certainly crossed the line into substance addiction and is quite willing and able to recognize and admit the severe consequences her substance mis-use has caused in her life.  This is further confirmed by an extremely high OAT scale score of 8 which would generally be interpreted to mean that this person greatly identifies with many of the usual negative attributes or personal limitations/weaknesses that are common among those with active substance use disorders (e.g. impatience, resentment, self-pity, impulsiveness, restlessness) and usually, if asked, would readily admit to sharing many similarities with those who have substance problems. Lastly, her SAT scale score is also extremely high, once again strongly indicating a person with a significant substance problem.

But there are other scale scores which seem to contradict some of these basic interpretations. For example, the client has a DEF score of 11 which is far above the 98th percentile and suggests that the client is answering the questions in such a way on this scale that would indicate someone who would tend to not share anything about herself that would put them in a bad light or show weakness or vulnerability. DEF scores like this usually tend to suggest a client who wants to appear as if they have it altogether as they are endorsing only positives about themselves. How can this be true though if their FVA/FVOD and OAT scale scores are so high that they strongly indicate a person who is able to admit and acknowledge numerous negative consequences from substance mis-use and is able to strongly identify with many of the same negative attributes or weaknesses that are often found in those with active substance disorders? In addition to that, how can this client have such extremely high scores on FVA and FVOD and yet have a relatively normal score of 4 on the SYM scale? The SYM scale, like the FVA/FVOD scales, is also a very obvious, face valid set of questions about problems with substance use and yet her score on the SYM seems to indicate relatively none of the typical symptoms we would associate with one struggling with a SUD. One possible reason for the discrepancy between the scores on the FVA/FVOD scales and those on the SYM scale would be because of the timeframe that the client was asked to use in answering the FVA/FVOD scale questions. Unfortunately, we were not given this information about this client profile, but if the client was asked to answer the FVA/FVOD questions based on their entire life, then the scores could be quite high but be representative of a time in the distant past. Since the T/F questions have no specific timeframe associated with them, the client may have answered the SYM questions based on a more recent timeframe in which they had achieved some level of sobriety.

Even the extremely high SAT score seems a bit contradictory with other scale scores since usually a high SAT score would indicate someone who is not able to admit or acknowledge that they have a substance problem. However, since the SAT score was positioned higher on the graph then the OAT scale score, our research suggests that individuals with that type of scoring pattern are sometimes able to admit to the very obvious consequences of their substance misuse (when OAT and Face Valid scale scores are high like this client) and may even be able at times to self-identify to a certain extent with certain obvious behavior patterns that often lead to substance misuse. However, people with very high SAT scores, and especially ones that are higher on the graph then the OAT score, are often not able to see the deeper, underlying, less conscious issues that are constantly plaguing them and significantly influencing their substance misuse behaviors in a much more covert way. They often simply cannot see the pervasive nature of the disease acting in their everyday life. They often are emotionally avoidant and superficially may believe that their substance problems are just a set of bad habits that they can stop on their own. They see the physical manifestations of the problem, but are unable or unwilling to see the emotional and spiritual aspects of the problem. They often will actively avoid treatment that involves examining their negative thought patterns, deeply held negative beliefs, fears, and other deeply rooted issues that have a stranglehold on their life and behaviors. Some of these clients will incorrectly assume that their substance problems only reside with their use of the “hard” drugs and if they just quit using those, then they can continue to drink and smoke marijuana and all will be well.

This explanation actually helps us to better interpret the client’s very high DEF score as well. While the client is able to admit and acknowledge having a lot of problems and trouble as a result of her use of alcohol and other drugs as seen in her very high FVA, FVOD, and OAT scores, her very high SAT and DEF scores show that her admission and acknowledgement is only at a very surface level. In other words, she admits all the things that are pretty much already part of the public record and everyone knows about, but the problem is much deeper than that and she is oblivious to how deep and pervasive it really is. This is what we would call a sincere delusion. She admits what she is aware of and what she feels she has control over. But there is much more beneath the surface that she can’t see. Her defensiveness is potentially a way for her to demonstrate that she’s in control, that there’s nothing to see here and everyone should move on. Like her very high SAT score implies, she may be unable to identify or get in touch with her real emotions and pain and she may have situational reasons or life experiences which have taught her to not let people see her flaws or weaknesses, the real her. She will tend to focus away from internal processes and look instead at tasks and factors outside of herself. This increases the likelihood that she may put herself at risk without awareness of her own vulnerability.  She will be more likely to find excuses not to engage in treatment and recovery activities, especially if she is able to achieve short spurts of sobriety. Once the challenge of proving she can abstain from alcohol or drugs for a short time loses its luster or crises arise that she cannot cope with on the basis of her more superficial focus, she will be more likely to relapse.

The risk of relapse is particularly increased given her similarity to others who violate cultural norms sufficiently to have repeated involvement with the criminal justice system, as evidenced by her elevated COR scale score (COR=12). In addition, the elevated COR score suggests increased risk for future criminal behavior independent of the client’s substance use or mis-use. A comprehensive assessment of underlying risk factors in the client such as poor social skills, anger management issues, poor impulse control or low frustration tolerance would be a valuable exercise so that, if any of these issues are uncovered, an effective treatment plan that specifically addresses these issues could be developed to potentially decrease the risk of repeated involvement with the criminal justice system.

In summary, this young woman’s profile indicates three problem areas that need to be the focus of potential treatment: her substance use disorder (if diagnosed), her defensiveness, and her risk for legal problems. This client meets SASSI Decision Rules indicating a high probability of a substance use disorder. While the SASSI does not specifically provide a prediction of the level of the disorder (i.e. mild, moderate or severe), typically clients with FVA/FVOD, OAT and SAT scores as high as this client’s often have moderate to severe disorders if the disorder is active. The scores also suggest a pattern of addictive behaviors that have a pervasive influence on her life, which she is not likely able to fully recognize or accept. She most likely has little or no self-awareness with regard to her underlying emotional pain and may tend to shift responsibility or blame to her life situation and/or other people.

In light of this, she will most likely resist many conventional forms of treatment and prefer to “fix it” herself. There is a high risk of premature self-labeling as “cured” after one or two successful short attempts at sobriety, ultimately resulting in full blown relapse.  The risk of future criminal behavior is high, suggesting that compliance with other rules may also be problematic. Further assessment and/or building in a specific treatment focus on this risk through cognitive-behavioral interventions would be reasonable options to consider.

In trying to interpret the individual scale scores for this client, one can see that, while the foundational interpretations that normally apply to certain scoring patterns certainly can lead us in the right direction, without more data from other reliable sources, one can only speculate as to why some of the standard scale score interpretations initially seem to be in contradiction with one another. With more information from collateral sources (family, teacher, employer, coach, friends, etc.), naturally occurring records (e.g. arrests, ER visits, prior treatments, etc.) or behavioral records (work behavior, school behavior), we could more easily narrow down, shape and confirm or deny our initial interpretations.

Getting additional information from other sources also can help us to resist over-interpreting. In the absence of clear information, one is more likely to speculate. While no SASSI interpretations are ever meant to be considered absolute, we can nevertheless trust that the foundational interpretations which came from our case study research have proven to be quite reliable and accurate in most cases. But when individual scale score interpretations seem to clash, we have to resist making up information and therefore over-interpreting or mis-interpreting and instead gather actual data that could more correctly resolve the perceived conflicts.

And finally, spend time learning and practicing how to utilize the SASSI foundational scale score interpretations in combination with other reliable sources to identify and address any other non-substance-specific challenges facing the client. These could range from defensiveness and high risk of involvement in the criminal justice system like this client to possible depression, suicidal ideation, or typical symptoms associated with co-dependency. While the SASSI’s primary function is not that of a depression, suicide risk or co-dependency screening, basic scale score interpretation can provide clinicians with a “heads up” on the possibility of these and other issues, prompting the clinician to do further evaluation in these areas and develop treatment plans, educational resources and/or referral plans to address them.

To become more familiar with clinical interpretation, we invite you to attend one of our training sessions taught by a SASSI-certified trainer ( https://sassi.com/sassi-training/) and/or to utilize our free Clinical Helpline at 1-888-297-2774 which is available Monday – Friday from 1:00pm – 5:00pm EST to assist clinicians in learning how to interpret their client’s results better.   

PDF Version Available for Download

High Probability by Subtle Scales Only

Many people know that the SASSI is possibly the best substance use disorder screening tool that exists in the behavioral health field today. The instrument can be easily administered in 15 minutes or less and manually scored in less than two minutes (or scored automatically in the online web-based version), resulting in an objective empirically-based statement of the likelihood of the client having a substance use disorder with an overall accuracy of 92% for adults and 89% for adolescents. And it achieves this kind of accuracy even in clients who are unwilling or unable to acknowledge their substance misuse or the symptoms associated with it!

Through extensive case study research, the SASSI has been found to be able to provide even more utility to clinicians in the form of clinical interpretations that go beyond just the high or low probability of a substance use disorder result. In addition to interpretations of individual scale raw scores that fall outside the boundaries of the research-based established normal distribution, we also have discovered some trends or characteristics in the specific situation in which the client scores as high probability of a substance use disorder based on SASSI decision rules that involve only subtle scales rather than face valid scales. That is the subject of our blog today.

The SASSI is made up of both face-valid scales and subtle scales. Face-valid scales such as FVA, FVOD and SYM are scales that are very obvious about what they are measuring, while subtle scales such as OAT, SAT and DEF are made up of items that do not seem to have anything at all to do with substance use. Our case study analysis showed that certain behaviors, characteristics or patterns emerge in individuals who score as high probability based only on subtle scales. Let’s take a look at an example. Byron is a 31-year-old male who was asked to be evaluated because of a child custody battle in which the mother alleges that Byron misuses drugs. Byron has not yet had a comprehensive assessment done, but has so far only admitted to some occasional use of marijuana. A SASSI was administered and the results showed that Byron met the criteria for Decision Rules 3, 4 and 7. Each of these decision rules involve only subtle scales and no face-valid scales. So, what characteristics do we tend to find in individuals with this type of scoring pattern?

One key feature of this type of scoring pattern is the fact that these individuals often have very little insight into the pervasive nature of the addictive disorder in their lives. Most of the time, this type of client actually has a very sincere delusion regarding their substance misuse. In other words, they are not trying to trick you into thinking they do not have a problem with substances; they simply do not see it. Often, every single activity this person is engaged in and every decision they make somehow involves substance use. Often, the substance misuse has become an unhealthy way to cope with emotions that are too overwhelming and so individuals with this type of scoring pattern are very emotionally avoidant. Many times, this individual has difficulty admitting their weaknesses or the personal limitations with which they struggle and instead choose to focus on very superficial things, ignoring the depth of the substance problem in their life. We can see these types of traits and behavior patterns manifested in this client’s individual face-valid scale scores such as lower than average (T-score of 50 is the mean) FVA and FVOD scores and only an average SYM score. These all indicate a client who does not acknowledge or admit to having any significant problems or negative consequences as a result of substance use. The client’s extremely high DEF score indicates a very high level of guardedness and the desire to be seen as having no weaknesses or faults. It’s even possible that the FVA, FVOD and/or SYM scale scores could be artificially low because of minimization of symptoms in the client’s answering patterns on these scales fueled by this defensiveness. However, as mentioned previously, it’s possible and even probable that this client really has very little insight into his problem with substance misuse and so he may be unable to even recognize the obvious negative consequences he is experiencing. This is especially typical of clients with high SAT scale scores as this client has. While this client does also have an equally high OAT score, which often indicates some ability to recognize negative attributes that are common in individuals with substance problems such as impulsiveness, self-pity, resentment, and impatience, it is more likely in this case that the client does not see these issues as having any relationship to his misuse of substances.

At this point, a comprehensive assessment needs to be done along with a formal diagnosis and possible treatment plan formulated. Since the SASSI does not provide an actual diagnosis and does not, by itself, indicate a need for treatment or the level of treatment, it is important to gather more information such as self-reports of the client’s current usage patterns, collateral reports, naturally occurring records, behavioral records, etc. to determine a diagnosis and course of action. Typically, clients with this scoring pattern do have a significant substance use disorder and many of them, if they need treatment, will often need a relatively intensive level of treatment which includes individual and group therapy sessions; more than just cognitive/educational programming. However, individuals with this type of scoring pattern will often be initially resistant to any treatment as they honestly do not see a problem that needs to be treated. The high level of defensiveness will require lots of time spent in developing a therapeutic alliance and positive rapport, affirming and supporting him throughout the process. Clients like this are often a high relapse risk and so it is important to provide wraparound supports and a level of intensity in the treatment regimen which allows for quicker and stronger intervention in the event the client attempts to relapse. Individuals who score as high probability of a SUD based only on subtle scales are often some of the most challenging clients, but with information gained from the client’s scoring patterns on the SASSI combined with additional information from other sources, you are in a better position to know what to address to increase the possibility of success with this client.

Don’t forget that full training on administering/scoring the SASSI and clinical interpretation of the sub-scales is available. Check out https://sassi.com/sassi-training/ to register for an upcoming training. Also, our free Clinical Helpline is available M-F from 1:00pm to 5:00pm EST to answer any questions you have about the SASSI.

PDF Version Available for Download

A SASSI-4 Profile Analysis: Drug Offender with SAT As Highest Score

The following profile result is of a 35-year-old male referred for screening and possible assessment after a drug-related arrest. He completed the FVA/FVOD side of the questionnaire based on his entire life timeframe. His RAP score was 0, indicating no random responding and that the result should be valid. His Prescription Drug Scale score (Rx) was 1, so he did not meet the cutoff for High Probability of Prescription Drug Abuse.

Looking at this profile, we see that he was classified as high probability of a substance use disorder based on the following Decision Rules:

  • Decision Rule 1 with a FVOD score of 32.
  • Decision Rule 3 with an OAT score of 9.
  • Decision Rule 4 with a SAT score of 14.
  • Decision Rule 5 with a SYM score of 6 (5 or more) and a SAT score of 14 (4 or more).
  • Decision Rule 7 with an OAT score of 9 (7 or more) and a SAT score of 14 (6 or more).

Looking at the graph on the SASSI Adult Male Profile sheet, we see an extremely high elevation on the FVOD scale score which is significantly above the 98th percentile. Individuals who score this high on the FVOD are able to acknowledge currently having or having had numerous negative consequences and problems as a result of their use of drugs. This can include loss of control of the drug use as well as using a coping mechanism.  It is important to note that, since he was asked to use the “entire life” timeframe for the FVA and FVOD scales, his admission of having these consequences and problems with drugs may be related to some time in his past and not necessarily currently. For example, the client’s score on the SYM scale (which is similar to the FVA/FVOD in what it is measuring), is not nearly as elevated as his score on the FVOD even though the questions are not that dissimilar from the FVOD questions.

This suggests that he is not showing as much acknowledgement on the SYM scale of the symptoms of substance misuse that he admitted to on the FVOD scale. This could be related to the fact that the SYM scale (like all scales on the True/False side of the questionnaire) has no specific timeframe associated with it and therefore the client may have the belief that, while he has had significant problems with drugs in the past, he may not believe his current drug use is as much of a problem currently. It is highly recommended that clinicians do a content analysis of the client’s answers to the FVOD and SYM scale questions as this will provide more insight into the client’s acknowledged problems with drugs.   

This client’s elevated OAT scale score, like the elevated FVOD scale score, suggests a capacity to acknowledge and identify with many of the typical negative attributes (general personality and behavioral characteristics) and personal limitations that are often common among those with substance use disorders – e.g. impatience, resentment, self-pity, impulsiveness).  While the client can often see these “character defects”, they may not always feel motivated to change them or feel capable of changing. Given that the OAT score in this case is above the 98th percentile, it is highly probable that this individual may be able to closely identify with individuals in recovery from substance use disorder, such as those found at recovery support groups, and therefore may be more willing to trust these recovering individuals and follow their recovery advice.

The client’s highly elevated SAT score (the highest score on this profile), which is higher on the graph than the OAT score, suggests that despite the client’s capacity to acknowledge the more obvious problems and negative consequences associated with his use of drugs, there are subtle aspects of his behavior, personality, and addiction that are extremely hard for him to acknowledge. In other words, he may not be able recognize the pervasiveness of his addiction, how it negatively affects and rules every aspect of his life with deeply held negative thinking patterns, beliefs and negative coping patterns driving his addictive behaviors.

Clients with a pattern of scores like this client who tend to be able to acknowledge heavy usage, negative consequences and problem behaviors, may still be convinced, sincerely deluded into thinking that they are not truly addicted. They will often present as more “superficial” saying things like “well, I go to work every day and do my job so I couldn’t be addicted”. Clients with elevated SAT scores (especially higher on the graph than their OAT score) tend to be more initially resistant to the need for treatment and are more likely to relapse. These clients tend to be detached from their feelings and have relatively little insight into the basis and causes of their problems (namely substance addiction). These clients typically need a more intensive level of treatment where they can receive constant support for their recovery efforts and can get the kind of group processing therapy needed to help them connect with their feelings and learn how to cope with them without drugs.

In providing treatment to this type of client it is important to recognize that underneath the many excuses (other than substance addiction) for their problems, there is an individual with a substance use disorder who is likely in pain and scared. Individuals with high SAT scores may not be in touch with the pain and fear, largely because they immediately numb any negative feelings with substances as soon as they appear, but the pain and fear. In this case, intensive treatment and group work has to be accompanied by sensitive and skillful clinical intervention that lets the individual know that somebody is aware of their fear deep within and that it will be a relief to let it out to begin healing.

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).

PDF Version Available for Download

Adolescent A3 – Emphasis on COR Scale

This profile is a good example of needing to be careful with assumptions.

Overview of CORRECTIONAL (COR) SCALE

The COR scale provides information pertaining to the possibility that the client may have a relatively high risk of experiencing legal problems. It is composed of items that differentiated between people who had a history of involvement in the juvenile justice system and those who did not.

It is very important not to over-interpret elevated COR scores. Teens who have elevated COR scores are responding similarly to individuals who have violated the law. This does not mean that all clients with elevated COR scores have broken laws. Also, there is no empirical evidence that these clients are at risk for future offenses.

If a client has an elevated COR score, it is worth exploring those behaviors which may be leading the client to make poor choices, especially after using substances and magnifying the tendency to exhibit those behaviors. These include anger management issues, impulsivity, risk taking behaviors, low frustration tolerance or poor social skills. The task of the clinician is to help the client see the relationship of their behavior to the consequences they have experienced and introduce alternatives to regulate their emotions and behavior.

The SASSI A3 was administered on a 15-year-old male and the time frame for the FVA/FVOD was for the past 6 months. The caller explained this time frame was used as the client identified that his substance use became problematic during this time. He indicated he had initially started smoking marijuana but in the last 6 months started abusing Percocet.

There is a lot to look at in this profile below.

He meets Rules 1, 3, 4, 5, 6 and 8 so met the criteria of a High Probability of having a Substance Use Disorder. A reminder that more “yeses” does not necessarily mean a more severe problem or meets the DSM-5 criteria for severity.

His Rx scale score was 1.

The FVA (2) is below average and within the norm.

The FVOD (18) is highly elevated and close to the 98th percentile so he is very open about his use and under what circumstances he is using.

As seen on the profile graph, both the FRISK (2) and ATT (3) are within the norm though above average.  These scores indicate he is not necessarily using due to peer pressure nor does he have a strong belief or value system that endorses substance use.

The SYM (9) is off the chart. He is endorsing negative consequences and symptoms of his use as well as loss of control.

It is worth taking the time to look at how he has answered his face valid scales and do content analysis of his answers because these will generate a lot of information for clinical insight and discussion on how and why he is using substances. As a reminder, the face valid scales are the FVA, FVOD, FRISK, ATT, SYM and Rx scales. You cannot do content analysis on the subtle scales.

Both the OAT (8) and SAT (7) are above the 85th percentile. Although the OAT indicates he can acknowledge personal limitations, the higher SAT score indicates a level of denial or lack of awareness or detachment from feelings and may present himself functioning well.

The DEF (4) score is very significant as it is below the 15th percentile. This indicates severe emotional pain, and he may be exhibiting depressive symptoms so it is suggested a mental status exam should be conducted.

As usual, there is no individual clinical interpretation to SAM (4).

The last scale, COR (10) is highly elevated above the 98th percentile. He is identifying with those issues that are normally seen in juveniles with legal issues.

This is where one must be careful with assumptions because this client has had no legal issues for any reason. It is more productive to explore those issues he is identifying with and affecting his choice making.

It is also curious that one can be very open (based on the FVOD and SYM) yet have an elevated SAT score as well. This may be due to the DEF score and the emotional pain he is in. Hypothetically, he may believe that if he was not “depressed” he would not be abusing drugs.

Another aspect of the profile is to explore his Rx result. According to the client’s report, he is primarily abusing Percocet. His score may reflect he is getting it illicitly and not through a doctor.

Finally, regarding treatment considerations, the caller reported he has tried to quit using the Percocet for a week but relapsed. A treatment plan including inpatient should be considered considering his reported relapse.

We hope this is helpful to you.

The clinical helpline line is open for your inquiries, M-F, 12- 5 (EST) at 888-297-2774 and you will be directed to a clinical consultant. If we are not available, please leave a message and we will return your call.

And as always, Thank you for your interest in the SASSI.

PDF Version Available for Download

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?

Read more

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.

PDF Version Available for Download

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).

PDF Version Available for Download

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.

PDF Version Available for Download

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.

PDF Version Available for Download

Client’s High SAT Score Indicates Lack of Awareness

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.

PDF Version Available for Download