Tag: Substance Use Disorder Screening Instrument

Enhancing Your Clients’ Insight and Motivation Using the SASSI

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.

Defensiveness and Non-voluntary Clients

The Importance of Additional Assessment Data

The client is a 38-year-old male named Jim (not his real name), who was referred for a substance use evaluation following a second arrest for domestic violence. The practitioner calling in the profile reported having collateral evidence substantiating a significant history of alcohol abuse for this client.

The SASSI results indicate that Jim has a low probability of having a substance use disorder. He is not acknowledging any significant problematic use of alcohol (FVA=0) or other drugs (FVOD=2). In fact, he denies having any of the symptoms commonly associated with individuals who have substance use disorders (SYM=1). However, note that Jim’s responses are highly defensive (DEF=9) and significantly similar to individuals who are instructed to minimize and conceal problems. Given that his report on the FVA and FVOD is in direct conflict with information from other sources, it is likely that he is minimizing the degree to which he has experienced alcohol and other drug problems or related symptoms. This increases the risk that the SASSI classification of low probability may be in error – in other words, the accuracy of the decision rules may be slightly decreased. As in most assessment situations where the client is relatively defensive, augmenting self-reported alcohol and drug history with data from external sources is advisable before ruling out substance use problems.

Experienced SASSI users working in criminal justice, EAP, DOT, child protection, and other similar settings will recognize this profile as relatively common for clients who are mandated for assessment. Indeed, Jim has been charged with assaulting his partner for a second time. One possibility is that he fears a harsh punishment may be coming if he does not present himself in a favorable way. He may also be convinced that he is not to blame for his behavior, explaining that his partner provoked him or that he was acting in self-defense. While the SASSI does not reveal the exact cause or reason, the high DEF score is a strong indicator that Jim approached the assessment in a defensive manner.

Notice also that Jim’s OAT score is significant given that it falls below the 15th percentile (OAT=1), meaning that only 15% of the general population would score this low. A score in this range usually indicates a person does not identify with any of the problematic behaviors typically associated with substance abuse (for example, anger management problems, negativity, self-centeredness, etc.). Jim is not likely to acknowledge having these behaviors and probably wants to be viewed as being completely different from people who do. Individuals with a family history of addictive or violent behavior often cope by distancing themselves from the addict or perpetrator as if to say, “I’m nothing at all like my alcoholic mother or physically abusive father.” In fact, the caller reported that Jim’s mother is an active alcoholic.

Jim’s FAM score of 12 is also significantly elevated (above the T 60 line or the 85th percentile). His responses are similar to family members of substance dependent individuals. It is likely that he shares many of the characteristics and traits commonly associated with individuals living in addictive family systems – obsession with controlling the thoughts, feelings and/or actions of others, lack of adequate or healthy psychological, emotional and physical boundaries in relationships, and inability to trust others. Certainly, one theme for individuals with high FAM scores involves their sense of happiness and self-worth being dependent on fixing or controlling the behavior of others. Jim may have learned early on the false perception that the only way he can have a sense of well-being is when he is in complete control of his partner. This need often can result in the perpetration of violence in cases where poor interpersonal boundaries and lack of trust exist in a person with serious impulse control problems. Thus, like other perpetrators of domestic violence, Jim may feel enmeshed at every level with his partner, seemingly unable to restrain himself when he feels like he is losing control of his partner’s behavior.

To summarize, Jim’s profile is similar in many ways to that of other known perpetrators of domestic violence who have completed the SASSI. Although he is classified as having a low probability of a substance use disorder, his responses are characterized by a significant degree of defensiveness. This, along with other assessment evidence, increases the risk that he has minimized his alcohol and other drug problems and that the SASSI results of low probability of substance use disorder may be inaccurate. Jim does not recognize or accept responsibility for his own behavioral problems. Like other domestic violence offenders, he tends to focus almost exclusively on controlling his partner’s behavior as a way of achieving happiness and contentment in life. Jim’s family history of alcoholism is likely a significant contributor to his behavioral problems and also increases the risk that he may have, or may be developing, a substance-related disorder.

Ongoing assessment will be necessary to completely rule out the possibility of a substance use disorder. Because of the impact that most psychoactive substances tend to have on reducing impulse control, Jim’s risk for reoffending is greatly increased if he has a substance-related disorder that is left untreated. Collateral sources of information concerning Jim’s alcohol and drug history seem to indicate that his problems with alcohol and other drugs may be more serious than he is reporting on the SASSI. If further assessment results confirm a diagnosis of a substance use disorder, his treatment plan would need to include some form of addictions therapy. In addition, a no-use contract and regular toxicological screens could be useful ways to lower his risk of using and support a period of abstinence.

Jim’s defensiveness could be a serious barrier to engaging him in a therapeutic relationship, let alone making any significant progress in helping him to change any of his problematic behaviors. Establishing rapport and gaining Jim’s trust and confidence would be important steps in creating and maintaining a therapeutic alliance with him. Didactic, cognitively based educational approaches are often viewed by defensive clients as less intrusive and non-threatening. Initially, he may respond more favorably to presentations, films, books, etc., emphasizing the impact of addictions on the individual and their families. This may help to increase Jim’s awareness of his own misuse of substances and provide him with some insight into the dynamics of his own family’s behavior, including his alcoholic mother. Family involvement in his treatment may also be beneficial.

Referral to a practitioner or program that specializes in treating perpetrators of domestic violence should be strongly considered. Remember that Jim may have little or no awareness that he is responsible for his own violent behavior. His perceptions may be completely dominated by the belief that he has a right to behave in this manner with his partner. Such deeply ingrained patterns of thought and associated impulse control problems are often difficult for clients to begin to recognize, much less change. Support and process groups facilitated by behavioral health professionals trained in the treatment of domestic violence offenders are often an effective approach in helping perpetrators begin to acknowledge their behavioral problems and to effect some healthy changes.

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Adolescent SASSI-A3 Research Update

The SASSI Institute conducted a validation project on the accuracy of the adolescent SASSI substance use screening measure with respect to the most current nationally accepted diagnostic standards for substance use disorders, the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria (DSM-5). We are delighted to report that our data analyses is complete and presently we are preparing our findings for peer review submission and subsequent publication and dissemination.

Decision rules were formulated that would provide a good degree of accuracy using our development sample. Yet, the crucial issue is whether the SASSI-A3 scoring rules would be accurate when applied to a sample not used in formulating the decision rules. That is, how well does the SASSI-A3 cross-validate? When tested, we are pleased to report that the SASSI-A3 decision rules on the cross-validation sample results indicated an overall accuracy of 93.41%, 15.01% gain in sensitivity, 0.83% loss in specificity, and 9.75% gain in overall accuracy!

When released, SASSI-A3 will now include updated language reflecting current teen drug trends, a prescription drug abuse scale, as well as additional items. Once the publication review process is finalized, we are looking forward to making this updated tool available to professionals in the field.

We want to once again acknowledge and thank all the individuals and organizations who provided us with their valuable contributions.

Scarlett Baker, A.A. – SASSI A-3 Project Director, and SASSI Institute Director of Training

SAM Contributes to SASSI-4 Accuracy

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 8.

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.

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SYM Scale and Environmental Factors

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 Rule 2).

Having established 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 causal factor.

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.

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SUD Screening, Telehealth, and the Coronavirus Pandemic

Due to the continuing outbreak of COVID-19 cases throughout the world, infectious disease experts have recommended reducing face-to-face contact and social distancing as much as possible to avoid spreading the virus. Many counseling and treatment providers are now looking to boost their adoption of virtual communication (telehealth) as a tool during this time. Congress also recently passed legislation allowing professionals to bill Medicare for patient care delivered by telehealth during the current coronavirus public health emergency (congress.gov).

Because early intervention saves lives, it is vital that screening individuals for SUD not get delayed during this pandemic and that access to treatment be available. If you are not already aware, the adult, adolescent, and Spanish SASSI screening tools can be administered to a client remotely via SASSI Online. Choose the “Email direct link to client” option when assigning a questionnaire administration, and your client can complete it at their location via the internet.

If you are not currently a SASSI Online user and would like to try it risk-free, please contact our customer service team at 800.726.0526 or sassi@sassi.com.

Thank you for all the work you do!

Article Accepted for Publication, One Step Closer to the Release of SASSI-A3

We are pleased to announce our most recent publication: “ Detecting “Faking good” with the Adolescent Substance Abuse Subtle Screening Inventory- SASSI-A3: A Clinical Response to Alcohol & Other Drug Use Minimization among Teens in Alcoholism Treatment Quarterly.

This article compares honest and “fake” responses from participants with known Substance Use Disorders (SUDs).  It is the first publication using data from our most recent validation study to monitor the concordance and accuracy of the adolescent SASSI screening measure.  The data used for this publication was collected during our Adolescent (SASSI-A3) Validation Study.  Watch for more articles, as well as the release of our updated adolescent instrument later this year. 

If you would like a copy of this publication, please email us at research@sassi.com. We have a limited number of e-prints available to share with our friends and colleagues so reach out early to reserve your copy.