In this edition of SASSI Online Tips and Tricks we highlight setting up a questionnaire and the delivery options. When administering a questionnaire, you have six options. This volume will cover the first five in depth. The last one, SASSI to Go, will get its own volume, so watch for that!
Tag: Substance Use Disorder
“Fentapills,” Fentanyl, illicit opioids & the Black-Market Internet: A Perfect Storm of Danger and Death
The underlying headline is that we, as a group, must unify our efforts on all fronts to protect all of these individuals, which unfortunately include friends, family, and loved ones. Substance Use Disorder indeed does not discriminate! Let’s up our awareness, prevention efforts, and of course interdiction.
Creation of the SASSI & Fine-tuning of the SASSI
To understand the SASSI, you need to understand how the subtle items were selected. Dr. Glenn A. Miller considered several thousand potential items. First, he excluded items that reflected either general maladjustment or, conversely, obvious social desirability. He gave questionnaires containing potential items to both individuals in treatment for substance use and to control subjects. Then he looked for items that the members of one group usually answered differently from the members of the other. Although no single question could identify every person who had a substance use disorder, statistical analyses detected a set of questions that people with substance use disorders consistently answer differently than other people.
The only reason any question was included was that it worked to identify substance use disorders, not that it seemed to be related to substance misuse.
Dr. Miller did not base the SASSI upon a theory of substance use disorders, but rather used statistical analyses to empirically select those items that distinguished between known criterion groups of individuals with and without the disorder. For the purposes of screening, we do not need to understand why people with substance use disorders are more likely than other people to answer True to “I have been tempted to leave home.” What matters is that responses to this question can help us identify people who are likely to need further evaluation for a substance use problem. Research has shown that people who answer the questions similarly to people with substance use disorders have a relatively high probability of having a substance use disorder.
To further deal with the resistance that so often characterizes substance use disorders, individuals with known substance use disorders were asked to answer the questionnaire as if they were applying for an important group membership and were directed to try to hide signs of their shortcomings and problems, particularly those related to the misuse of alcohol and drugs. Analyses of answers given under these “fake good” instructions identified two types of items — those items that distinguished people who had substance use disorders from people without such disorders even when people were instructed to conceal problems, as well as items that helped identify defensive responding.
Statistical analyses revealed that the SASSI could most accurately and usefully identify individuals with substance use disorders if the items were compiled into scales, and decision rules were created for analyzing the scores.
Items were tested with various groups and selected to minimize the effects of gender, age, socio-economic status, ethnicity, and drug of choice.
Extracted from:
Lazowski, L. E., Kimmell, K.S., & Baker, S.L. (2016). The Adult Substance Abuse Subtle Screening Inventory-4 (SASSI-4) User Guide & Manual. Springville, IN: The SASSI Institute.
SASSl-4 Profile Analysis – DOT Client
We frequently receive calls requesting clinical interpretation of profiles done on Department of Transportation (DOT) clients. These clients have failed their drug/alcohol screening and their license to drive has been suspended pending an evaluation. In this particular case, the client is a 68-year-old female whose alcohol level registered above the DOT threshold. Her SASSI result indicated a high probability of a substance use disorder based on Rule 9. As you see on the graph, most of the scale’s clinical results fall within the norm. DEF, at 11, is above the 98th percentile and FAM, at 12 is above the 85th percentile. The OAT score of 1 falls in the 15th percentile. The high-DEF score is not unusual in DOT evaluations. It is incumbent on the evaluator to determine what the defensiveness is about. The SAM scale is no help in this case because it is not elevated. An elevated DEF coupled with an elevated SAM indicates the defensiveness is related to substance use. The elevated FAM score indicates someone who is not comfortable looking at their own issues. And the low OAT score indicates someone who has difficulty acknowledging their personal limitations and shortcomings. The combination of these three scales provides information to the evaluator that most likely, this client is not going to be forthcoming in disclosing issues or problems. During the evaluation, another piece of information disclosed was the client’s admission of trying to manage or monitor her drinking to try to stay below DOT’s threshold of alcohol use. That certainly may be a red flag.
Since the SASSI is a screening inventory and does not diagnose, the evaluator needs to reference the DSM-5 to determine if, indeed, the client meets the criteria for a substance use disorder and if so, what level – mild, moderate, or severe. Based on that, the evaluator has a couple of options to consider. If possible, work individually or refer to an individual substance abuse counselor to establish rapport and work to get the defensiveness down. Motivational Interviewing is a good asset to pull out in this case. Another option is to refer her to an outpatient group setting with the goal of connecting her to other clients and also have access to individual counseling as well. Regardless, outpatient treatment seems to be the most likely intervention.
It would be helpful to acknowledge the financial impact on the client that suspension of driving privileges is having on her. That certainly could be triggering the extreme defensiveness we see in the results and the consequences for the client could be significant.
We hope these reviews are helpful and whether you are a new user or a very experienced one,
clinicians are here to help with any questions you might have. Clinicians are available M-F, 11-5 (EST). Call us at 800-726-0526 or 888-297-2774.
Addressing the Ethical Issues of Mandated Client
This sample profile is about a 27-year-old, Sally, who is a single mother of two small children. Sally was ordered by the court to report for a substance abuse assessment following an arrest for illegal possession of a controlled substance. Sally is also being investigated by the county’s Child Protective Services Agency, who has placed her children into foster care pending the outcome of the case.
An initial review of Sally’s scores indicates that, although she apparently understood the SASSI items and most likely responded in a meaningful way (RAP=1), there is evidence of significant defensive responding (DEF=9). Despite her defensiveness, the results indicate that she has a high probability of having a substance use disorder (SUD) based on Decision Rule 8 and 9. To put it another way, there is a 93% chance that Sally will meet the DSM-5 diagnostic criteria for having a substance use disorder once a more comprehensive evaluation is completed.
For now, however, the SASSI has provided us with important information concerning Sally’s illegal act; her behavior is likely to be related to a serious addiction problem. In this light, we can now shift to looking for additional features on her profile that might help us to understand Sally better and develop a more empathic point of view. Learning more about her perspective and how she is dealing with this entire process, including the new information from the SASSI, certainly is one way to provide supportive and effective care to her during a mandated process of evaluation.
A prominent aspect of Sally’s SASSI results reflects her similarity to people with SUDs who were instructed to conceal and minimize any evidence of their substance use problems (DEF=9, SAM=12). In addition, an elevated DEF coupled with an elevated SAM indicates her defensiveness is related to her substance use. One inference that can be drawn from this is that she is likely to have significant difficulty in disclosing personal information about her misuse of substances, as well as other problematic behaviors. Other SASSI scale scores may be reflecting this mind set. For example, she does acknowledge some misuse of alcohol and other drugs but no more so than the average person in the general population (FVA=5, FVOD=7). Her SYM score of 2 is also average, indicating no significant similarity to people with substance use disorders who do report experiencing many of the behaviors correlated with addictions. However, given that each of these scales is derived from face valid items that can be easily manipulated, it would be reasonable to suspect that Sally may be underreporting or misrepresenting problems in each of these areas.
It is easy to imagine that Sally may harbor some resentment towards the evaluation process and the practitioners involved. After all, she stands to lose not only her freedom but her two children as well. Underlying the overt anger and resistance may be an extreme sense of fear, apprehension and powerlessness in the face of feeling helpless to influence decisions that will undoubtedly affect the rest of Sally’s life. When viewed from her standpoint, it then becomes easy to see Sally’s defensiveness as a somewhat natural response to the threat she must be feeling. It’s no wonder that she is having difficulty acknowledging her substance use problems.
If further diagnostic evaluation for substance use disorder does indicate that Sally has an SUD, the following treatment approaches may prove useful based on insight gained from Sally’s SASSI scores. Despite Sally’s lack of ability and willingness to recognize the impact of her substance use on her life, it is our ethical responsibility as counselors to use our knowledge, skills and experience to lead her to an accurate understanding of the nature of her substance use disorder. This should be accomplished in a climate of respect and acknowledgement of the pressures that she is currently facing. An attitude of respect is particularly important when attempting to build a therapeutic alliance with clients like Sally that are mandated for assessment and treatment.
One way to engender open communication in a respectful way is to invite Sally to join you in a process of reviewing her responses on the SASSI face valid items. Acknowledging that it is important for you to understand her point of view, perhaps asking for further clarification or details as you actively listen is one way to cultivate trust and rapport. This communicates genuine concern and interest that may help Sally feel supported and empowered as she describes her experiences. Empathic responses that demonstrate a good understanding of the difficulties she is facing while helping her to gain insight regarding the nature of her substance use problems would be useful in making her an active partner in creating a treatment plan that she can accept.
Another effective way to increase Sally’s awareness of her substance use problems while maintaining a respectful relationship is to provide cognitively based educational programming. Didactic presentations of alcohol and drug information generally are viewed by clients as less threatening and often tend to elicit a more favorable response. Sally may particularly benefit from content that describes the impact of substance abuse on families and how, with proper treatment and aftercare, recovering individuals are often able to be reunited with their children and other family members.
SASSI Online Tips and Tricks: Volume 1 | Support Materials
In this edition of SASSI Online Tips and Tricks we highlight the documents located under the Support Materials page. Access the Support Materials through the Account Dashboard’s, My Clients tab. The Support Materials button is to the right of the Administer button. There are four quadrants on the Support Materials page, the top left is for Adult SASSI-4 documents, the top right contains the Adolescent SASSI-A3 materials, and the bottom left is for the Spanish SASSI. The bottom right section provides general information.
Recent Article Investigating Denial Among Adolescents
The SASSI Institute is proud to announce our newest manuscript addressing adolescent substance abuse. The title of this article is Mandated Treatment for Troubled Adolescents and Substance Use Disorder: Identifying and Breaking Through Defensiveness and Denial. It provides an investigation of the defensiveness demonstrated by teens who are mandated to participate in treatment as compared to their non-mandated peers. Part of the data set we collected for The Substance Abuse Subtle Screening Inventory (SASSI) Institute’s third iteration of the Adolescent SASSI-A3, the present study focused on data from 164 mandated teens that participated in the principal study. As in the principal study, these cases were drawn from substance use treatment, criminal justice programs, community corrections, and private clinical practices, among other venues, and all cases were provided by clinicians working within these service settings throughout all U.S. Census Regions. In addition, we review cases demonstrating high-levels of defensiveness and denial in these mandated teen clients, and ethical ways to break through that barrier towards effective treatment engagement. Finally, we present two brief de-identified treatment case studies, aptly demonstrating defensiveness and denial from a clinical standpoint. We at The SASSI Institute are very proud of this work, and I want to personally thank my co-authors for making this work possible. The article is available free of charge as it was submitted as an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows readers to copy, redistribute, remix, transform, and reproduce in any medium or format, as long as the original authors are properly cited.
Psychopharmacology and the Biology of Addiction Webinar
Increase your understanding of how drugs of abuse interact with each other as well as what takes place in the brains of experimenters, abusers and addicts. Improve your ability to communicate with medical professionals and your clients.
On March 29th and 31st, 2022, Dr. Donald R. Osborne, Jr., author of the newly released book “You Can’t Fall Out of a Hole: Ripping the Band Aid off of Our Addiction Epidemic,” will be hosting a live webinar to increase your knowledge on the subject of Psychopharmacology and the Biology of Addiction.
Information that will be presented and discussion will be about the following:
| Central Nervous System | Peripheral Nervous System |
| Autonomic Nervous System | Somatic Nervous System |
| Sympathetic Nervous System | Parasympathetic Nervous System |
| How the Brain Works | Tolerance and Cross-Tolerance |
| Rebound / Withdrawal | Drug Half Life / five to eliminate |
| THIQ in Alcohol Metabolism | Dopamine Depletion by Cocaine |
| Determining BAC by number of drinks consumed |
The following drugs/drug classes will be examined:
| Opioids | Alcohol |
| Sedative-Hypnotics | Cannabis Sativa |
| Cocaine | Sympathomimetics |
| Inhalants | Hallucinogens |
| Club Drugs | Caffeine |
| Nicotine |
For each of the drugs/drug classes, the following information will be provided and discussed
- Examples
- Route of Administration
- Absorption
- Distribution
- Effects
- Metabolic Half-Life
- Elimination
- Rebound/Withdrawal
The webinar will be live from on March 29th, 9:30-1pm ET, and March 31st, 1:30-5pm ET. The webinar will be available on-demand afterwards.
To register, click the date you are interested in below:
Reviewing an Adolescent SASSI-A3: Vaping Issue
This is an issue that may be turning up in your clinical practice. The caller wanted help with a profile interpretation on a 13-year-old male who had turned in a vaping pen. The school was mandated to do a substance use evaluation as a result. The online report indicated “inconsistencies” in the results so the counselor wanted more information. The client was instructed to complete the FVA/FVOD side for his whole lifetime.
The overall result, based on all the rules being ‘no’, came up with a Low Probability of a substance use disorder. The Prescription Drug Scale was zero. However, the Validity Check Scale was 6 so further evaluation was recommended. Elevated VAL and DEF scores coupled with a Low Probability result increases the possibility of the SASSI missing individuals with a substance use disorder.
Looking at the graph on the profile sheet helps to pull out additional information. Note the very low (below the 15th percentile) OAT and SAT scores. The low OAT can indicate someone who has a hard time acknowledging personal limitations or shortcomings. The low SAT can indicate someone who has a chip on their shoulder, feelings of rejection and hypersensitivity to others. Interestingly, the DEF score is within the norm and does not indicate the student was defensive completing the SASSI. The FRISK score is above average but within the norm and because it is a Face-valid scale, content analysis of those items may be useful. The other Face-valid scales, ATT and SYM with their scores of 1 can also be examined.
The student who turned in the vaping pen indicated it was not his. It was not clear from the caller what substances they suspected were being used. Clinically, the best thing to keep in mind is that the student has a hard time opening up and is probably very concerned about how he is viewed by teachers, counselors, etc. and very quick to feel rejected. Interacting with him in an accepting and affirming way is probably the best approach.
Substance use issues: The VAL of 6 is a red flag so further evaluation with this student is warranted. It could be on-going oversight within the school, i.e. school counselor or referral to a Substance Use counselor who could do a more formal and comprehensive assessment.
We hope this is useful for you.
As usual, don’t hesitate to call the Clinical Helpline at 800-726-0626 with any clinical questions. Live clinicians are available M-F, 11-5 pm (EST). Otherwise, feel free to leave a message and we will get back to you the next business day.
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?