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.
Through the years, we have had the opportunity to share inspirational stories with our colleagues about their experience using the SASSI. One such story came recently from a psychologist who uses the SASSI in his practice. This was a gratifying story for us to hear and we are pleased that he has allowed us to share it with you.
The mother of a 22-year-old woman called me because she felt very strongly that her daughter Aimee (not client’s actual name) had an alcohol problem. But Aimee was adamant, no question about it, “I don’t have a problem.”
After some persuasion, Aimee agreed to come into my office, and I invited her mother to stay in the office during the interview, with Aimee’s permission. I really think Aimee was very certain that there wasn’t a problem, and that having Mom there during the process would convince her mother of this, too. I said, “You know, Mom can be a bit of a reality check here, but I’m listening to what YOU are saying.” Aimee’s mother agreed to just listen, since she had had her say when making the referral.
We talked about it, and Aimee restated that she didn’t have a problem. She was just not aware of any bad consequences coming from drinking. Aimee really seemed to believe what she was saying, “My friends and I, we don’t have any consequences; we just enjoy drinking.” I told her that was fine and asked, “Would you like to find out if you, in fact, do have a problem, or would you rather not know?” Of course, this is right in front of Mom. And she thought about it, seeing herself as being free to say “no.” But she did say, “Yeah, I think I would want to know.” When asked about each of the DSM diagnostic criteria for substance use disorders, Aimee answered no to all symptom questions.
Then, I brought out the SASSI-4, and told her a little bit about how it would compare her responses to two known groups of people: those who have a problem and know it, own it, and the other group that is just as aware that they do not have a problem, and own that. And we will see how your responses go. She agreed that that sounded good. She took the SASSI-4, and her responses showed a high probability of having a substance use disorder. This was very surprising to her. Then I went back and showed Aimee her scores on the FVA and the SYM.
When she looked at those scores, she could see by the profile that the consequences she was getting were way out of line compared to ordinary people who drink. She runs with folks whose norm is to drink a lot, and there is a history in her family of substance use issues. She just said, “It’s almost like thinking about it and realizing that you are surrounded, and your best bet is to give up!” She surrendered to the idea that, “Yes, I’ve got a problem.” From there on she was willing to do something about it. Aimee made an appointment to see me again, and we went on from there.
Let’s say that the SASSI did not exist, and I would have had only the DSM criteria and her history. I would have had her mother’s reflections and thoughts and observations, and—I don’t feel certain, but I’m guessing—she would have walked away with the understanding that she did not have a problem. She would have gone on as she had been—because I would not have been able to make a case that she did have a problem, because there would have been no data to base that on. She may well have been one of those who left the interview, and for the rest of her life said, “No, I don’t have a problem, so get off my back.” In a sense, I really believe that the SASSI saved this young woman’s life, or at least spared her significant pain. I have always been impressed by the accuracy of the SASSI. It picks up on people who really are “sincerely deluded.” It’s interesting that her score on the Defensiveness (DEF) scale was not particularly elevated, so it was not that she was being defensive, she was just unaware of how her drinking and symptoms associated with it were beyond the norm. Her elevated SAT score – at the 98th percentile – supports the interpretation that Aimee has little insight into what may be motivating her to drink with her friends, or the negative consequences that follow from spending time that way. I am very grateful for the SASSI, and I wouldn’t do an assessment or a screening without it. I literally would refuse, because just the verbal reports can be so misleading, although not intentionally misleading, necessarily. Clients will compare themselves with the people they know who are much further along in the addiction process, and not really understand that their own behavior is a problem, just because their own behavior is not yet as severe as what they see in others. The SASSI can put a client’s use into a broader, and often more realistic context.
Original depiction, written by Nancy Winningham, M.A. based on an actual experience a clinician had using the SASSI with a client. Adapted to reflect SASSI-4 information.
This SASSI-4 profile of a 37-year-old female was called in to our clinical support line. As we look at her results, it appears that she answered the items in a meaningful manner (RAP=0). She is likely to have a high probability of a substance use disorder (SYM=6, SAM=8) based on decision rule 6.
Notice that despite the relatively low DEF score and apparent lack of defensive responding, the SAM scale score, when combined with the elevated SYM score, leads to a test positive result. While it is true that the SAM scale score plays a vital role in the accuracy of the decision rules in this case, it is important to remember that the clinical meaning of this score is unclear. Therefore, it would be inappropriate to draw any clinical inference from the fact that the SAM score is elevated.
The client acknowledges significant problems related to her use of drugs other than alcohol. She is likely to have experienced some loss of control, negative consequences, and increased tolerance as a result of her substance misuse. However, her average OAT score (OAT=3) may be an indication of some limited ability or willingness to acknowledge behavioral problems commonly associated with individuals who have substance use disorders.
The moderately elevated SYM (SYM=6) is consistent with clients who often are not able to recognize the manner in which substance use is manifested in their lives. Her responses are similar to individuals who live in a social milieu where substance abuse and its related consequences are fairly routine and normalized. This experience may limit her ability to characterize her substance usage as problematic. Indeed, she may be somewhat surprised that the SASSI results could even indicate an addiction problem.
The client’s responses are similar to those of individuals who are experiencing emotional pain (DEF=3). Individuals who score in this range tend to be overly self-critical, may experience depressive symptoms and sometimes report a history of trauma. She may be quite limited in her ability to recognize personal strengths, focusing more on limitations, failures and feelings of low self-worth.
This client is likely to have a high probability of a substance use disorder and should be considered for relatively intensive addictions treatment. A comprehensive behavioral health evaluation may be necessary to rule out the need for additional psychiatric intervention. Although she demonstrates some ability to acknowledge relevant behavioral symptoms of her addiction, a viable treatment plan should include initial efforts to increase her self-awareness and insight into the full nature of her substance use problems. Education and other cognitively based interventions may be helpful.
Most likely, she will need help in recognizing that her misuse of alcohol and other drugs is similar to that of other substance dependent people. A content analysis of her responses on the FVOD and SYM items may be one way to help her realize that it is in her best interest and within her capacity to change.
Community-based self-help support groups could provide additional encouragement and support.
In addition, evaluation for depressive symptoms and its relationship to her substance us would be important to consider.
We had the opportunity
to consult with a treatment provider who had called in SASSI-4 scores for a
Native American couple residing in Canada. Since both profiles nicely
illustrate important clinical features of each client, we decided to present
the interpretations in this sample. We are grateful to the treatment agency in
Northern Canada that granted us permission to use the information included in this
sample. To facilitate the presentation of the profiles in a confidential
manner, we have created fictitious names for each of the clients.
Mary, a 25-year-old
Native American female, and her husband John, a 28-year-old Native American
male, were referred to the agency for a substance use evaluation. They live in a
very small community where the base rate of substance misuse is extremely high.
Their children were recently removed from the home as child protective services
suspected alcohol abuse to be a serious problem for both parents. Mary lost her
mother, father and siblings in a tragic accident that occurred just a few
months prior to the evaluation.
Upon first glance at
Mary’s profile, she appears to have responded in a meaningful manner (RAP=0),
and there is no evidence of defensive responding (DEF=1). Given this low DEF
score, she is likely to be in considerable emotional pain. She acknowledges
significant problematic use of alcohol over her lifetime (FVA=13) and reports
behaviors and experiences that are highly correlated with substance abuse SYM=8).
In fact, her SYM score is the sole basis for classifying her as test positive
on the SASSI-4 (Decision Rule 2).
A quick look at John’s
SASSI results reveals a similar profile but with some noteworthy differences.
Although he too shows no evidence of defensive responding (DEF=4), his RAP
score of 2 raises immediate concerns of random or non-meaningful responding.
Fortunately, the treatment provider had investigated this potential problem and
was satisfied that John fully understood the items and that he responded in a
meaningful manner. The counselor attributed the elevated RAP to cultural
differences and circumstances surrounding the nature of the evaluation.
John also acknowledges
significant alcohol problems (FVA=18, decision rules 1, 2, 6, 10). Like Mary,
his responses are highly similar to individuals with substance use disorders
who report life circumstances and experiences commonly associated with substance
abuse (SYM=9). This score likewise results in a test positive on the SASSI-4 (Decision
that Mary and John both have a high probability of a substance use disorder, we
can now proceed to examine the salient clinical aspects of the SASSI results,
hopefully illuminating more specific treatment needs for each client. Notice
that Mary’s and John’s SYM scores are highly consistent with the milieu in
which they are reported to have lived. The treatment provider made specific reference
to the high rate of alcoholism in their community. Individuals who have substance
use disorders with high SYM scores frequently live in environments where the abuse
of alcohol and/or other drugs and the associated consequences are common and
normal experiences. In fact, it can be such an accepted way of living in the
community that most of its inhabitants would be flabbergasted to have their drinking
behavior characterized as unhealthy or problematic. Consequently, it is
perfectly understandable that Mary and John may have difficulty recognizing the
precarious nature of their alcohol misuse, especially as it relates to their
current difficulties with the child protective agency.
Despite the similarity
of the two profiles, one important difference is Mary’s significantly low DEF
score. This score would certainly seem to fit in with the recent trauma she
experienced. Unresolved loss and grief issues may be strong contributing
factors to Mary’s emotional pain. Moreover, the thought of now losing her
children because of her substance use may be adding significantly to her
distress. The risk of depressive symptoms possibly related to a mood disorder
may indicate the need for a comprehensive mental health evaluation, especially
to rule out clinical depression or suicidal ideation.
Individuals with this
high a level of emotional distress are often overly self-critical and can
become immobilized with feelings of helplessness and hopelessness. However,
it’s also possible that Mary’s pain may act as a catalyst in helping her
recognize the need to do something about her drinking. Indeed, the treatment
provider confirmed this to be the case and described Mary as a willing
candidate for substance use disorder treatment.
On the other hand,
John’s focus may be less internally directed with a tendency to see people,
places or things outside himself as the major cause for his problems.
Individuals with low SAT scores often present as victims of circumstances,
powerless to change their behavior because of a perceived lack of influence and
control over their immediate environment. In John’s case, the treatment
provider reported that John perceived his wife as the major cause of his
problems. He was content to focus on Mary’s drinking, grief issues, and
possible infidelity as the sole source of difficulties in the family. Despite
his acknowledgment of significant symptoms related to his drinking (FVA=18
& SYM =9), he remained unwilling and unable to accept this as an important
A viable treatment
plan for this couple will have to take into consideration a number of issues.
Mary seems primed for substance use treatment but may need additional
behavioral health services. A comprehensive mental health evaluation would be
helpful in identifying the nature and extent of any concurrent problems.
Interventions directed at processing loss and grief and those that provide
support would undoubtedly be important actions to consider. Efforts should be
made to provide bonding opportunities with a treatment provider and other
sources of encouragement and affirmation. In this regard, community self-help
support groups would be a valuable adjunct to relatively intensive substance
use disorder treatment. Pending the results of the mental health evaluation,
additional behavioral health care services may be added as required.
Although John is also
in need of substance use disorder treatment, he does not appear to be a willing
candidate at this time. Efforts should be made to increase awareness and
understanding of his alcoholism and how it contributes to his relationship and
family problems. The SASSI-4 results could be used as a graphic illustration of
the serious nature of his drinking problems. Using the high SYM score, the
treatment provider may be able to convey some understanding of how John may
have difficulty seeing the unhealthiness of his drinking. A content analysis of
the FVA and SYM scales may help him to see specific ways in which his alcohol
misuse has affected his life. It would be important to keep John focused on his
own needs by helping him to accept responsibility for his life and to make
choices that are in his own best interest. Attendance at self-help support
group meetings could help to reinforce this notion. Conjoint or family therapy
may need to be deferred in order to reinforce self-focus and to discourage John
from externalizing blame to Mary.
This case emphasizes
the importance of recognizing and assessing the impact of environmental factors
when developing effective treatment planning. It is true that substance
dependent individuals often live in an environment where the abuse of alcohol
and other drugs is commonly practiced and accepted as a normal way of life. In
these situations, individuals frequently engage in heavy substance usage as a
means of maintaining acceptance and approval in the community. It’s no wonder, then,
that clients living in this type of environment are amazed when we begin to
identify their misuse of alcohol or other drugs as problematic. Given their
life experience, it would never have occurred to these clients that anyone
would view their drinking or drugging as a sign of serious problems.
As we were able to see from the above discussion, the SYM scale on the SASSI-4 can often help you to recognize this phenomenon as a potential issue to explore further. In cases where the SYM is significantly elevated, clients may express puzzlement and surprise at your suggestion that their substance use is contributing significantly to their problems. However, the knowledge that this reaction most likely stems from the normalization of substance abuse in a client’s milieu provides an opportunity for you to communicate empathetic understanding and develop further rapport with the client. Once an appropriate bond is established, efforts should be directed at helping the client achieve some awareness of and insight into the full nature of his/her substance misuse and its relationship to other presenting problems.