A substance use evaluation administered on an individual involved in a custody suit can reliably be fraught with issues. This one presents a number of them.
This 39-year-old client was instructed to complete the FVA/FVOD questions for his whole lifetime.
A significant issue was his history of 4 DUI’s from 2020 – 2021 while in the process of separation and divorce. He denies his current use is anything like it was during that period.
The SASSI result indicated a Low Probability of a substance use disorder.
His RAP was 1 but not enough to flag the results and his Prescription Drug Scale was zero.
Looking at how his scores compare on the graph; we first see the average scores of his FVA and FVOD scales which may be suspect given his DUI history. His average SYM score suggests he does not acknowledge significant symptoms or consequences of his use despite 4 DUI’s. Face Valid Scales are easy to manipulate or minimize if the client chooses as they directly relate to substance use.
Moving on to the subtle scales starting with OAT, we see it is very low but within the norm. If it were any lower, it would indicate he has a hard time acknowledging personal limitations and shortcomings so there may be a hint of that going on. It is the next two subtle scales which contribute the most. The SAT scale is below the 15th percentile and when it is this low can indicate the client is hypersensitive to what others think of him, maybe experiences feelings of rejection so comes across as having a chip on his shoulder.
The extremely high-DEF score (above the 98th percentile) questions the Low Probability Result. As suggested, If the DEF is 8 or more, that increases the possibility of the SASSI missing individuals with a substance use disorder. It does not invalidate the result. There are many reasons for a high DEF – it could be situational – and it is not unusual in custody disputes to see a high DEF. It could be the client was defensive around their substance use. It could be that he has a defensive personality in general. The administrator is tasked with determining the meaning of the DEF scale score. It also tells you how to clinically approach a client who has difficulty opening up, is hypersensitive to others and is defensive.
The SAM score, though low, is the only scale which does not have an individual clinical interpretation. It is used in the decision rules to increase the validity and accuracy of the other scales it is paired with. It is also used to ascertain if the client is defensive around their substance use if both the DEF and SAM are elevated.
The FAM and COR results are not clinically significant.
In this kind of a case, the question of what timeframe to use with the FVA and FVOD scales comes up. It depends on several factors. Lifetime does give you an overall baseline of substance use but if you want a more “focused” timeframe, the last twelve months should be considered. Sometimes there is the issue of missing someone who had a significant issue in the past but is not currently using it, so a high probability result becomes a risk statement. A reminder: the SASSI cannot determine what a client is currently doing. This inventory is part of the information gathered by the administrator which is incorporated into the whole assessment.
We regularly get inquiries about the acceptability of reading the questionnaire to a client who may have difficulty with their reading skills. We discourage the evaluator from reading the questionnaire to the client for a variety of reasons, but the primary one concerns the validity of the results. No matter how careful the reader might be, the tone of voice or emphasis on a particular part of the question may lead the client in one direction or another. Or the client may interrupt with a question regarding the meaning of a word or intention of a particular question. This is why we offer a professionally read audio CD of the SASSI-4, Adolescent SASSI-A3 and Spanish SASSI paper and pencil versions for clients who have reading difficulties. We hope in the future to be able to offer this for the online platform as well. Please contact our customer service department for ordering information.
Another frequent question is related to the clinical interpretations of the “low” scores on the profiles. These mostly relate to the subtle scales which include the OAT, SAT, DEF and SAM scales. Most callers know what a low DEF indicates. And SAM has no clinical interpretation.
So what about those low OAT and SAT scales? What does “low’ mean? A low score is anything below the 15th percentile on the graph. In the example to the right, the caller indicated that she was doing an assessment on a health care professional who had been arrested for her one and only DWI the previous year, had completed her alcohol education class and needed this evaluation as a final step for probation. She was not in trouble in her job and in fact, highly regarded in her profession. Given the client was at the end of her requirements, the evaluator was somewhat concerned with the results and what it meant. The instructions were given to answer the FVA/FVOD side for the last twelve months. Her RAP is zero. Her Prescription Drug Scale is zero. She has ‘no’ on all the rules so came up with a Low Probability of having a Substance Use Disorder. However, her DEF of 9 is highly elevated. Elevated DEF scores increase the possibility of the SASSI missing individuals with a substance use disorder. Elevated DEF may also reflect situational factors. Note that the SAM is within the norm so it is probably more likely that her DEF is situational given the context. She also has an OAT score of ‘O’ and a SAT score of ‘2’. Both are below the 15th percentile. A low OAT indicates someone has difficulty acknowledging personal limitations or shortcomings. A low SAT indicates someone who might have a ‘chip’ on her shoulder, a hypersensitivity to others or feelings of rejection.
So even though this client is nearing the completion of her probation requirements, we still get a picture of someone who is highly guarded (DEF), has a hard time acknowledging shortcomings (OAT) and may continue to exhibit resentment (SAT) for the situation she is in. Perhaps this is due to her profession, or perhaps it is her personality. What the results give the evaluator is clinical direction on how to approach the client to help reduce her defensiveness and give her permission to open up. Affirming how demanding her job is and how on top of things she must be could be a pathway to discussing her feelings of shame related to the DWI and how it might be affecting her self-esteem. Could she be minimizing her use of alcohol and drugs? Perhaps, but as we strongly express, the SASSI is only one part of a clinician’s assessment. Hopefully, with the input of all the information you have, the clinician can evaluate the results which fit the context for this client.
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.
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.