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.

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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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