Tag: Substance Use Screening Inventory

LGBTQA issues: What side of the Profile Sheet to use in cases where gender is in question?

We receive regular phone inquiries regarding which side of the Profile Sheet to use in scoring either the Adolescent or Adult SASSI when the client identifies as transgender or neither male nor female. This comes up whether one is using the paper and pencil or the online version.

To affirm one’s self-identity can be powerful and empowering so a discussion with a client who is either questioning their gender identification or sexual orientation or is very clear about either one can be a very supportive encounter. The message given is one of sensitivity, respect, and validation for their choices.

As a way of addressing this issue the adult SASSI-4, adolescent SASSI-A3, and Spanish SASSI ask for ‘gender’ in the demographics rather than ‘sex.’ This allows the client to indicate their self-identity. What side of the profile sheet used for scoring purposes should either (1) conform most closely to what the client indicates or (2) after discussion with the client, what they feel most comfortable with given the gender limitations of M/F on the SASSI.  The research is based on binary identification and as such, we are limited in adding additional categories. Future research will undoubtedly be more inclusive. Regardless, the results are valid. The overall goal of the inventory is to give both the administrator and the client a compass to follow with useful information regarding the extent that substance use may or may not be a problem.

To be clear, score the side of the profile sheet that the transgender client self-identifies with. Not when or if they started hormones, or in a current state of transitioning, or they identified as a different gender when the legal offense happened.

A client may express a preference to not identify in any way and decline any gender identification. In that case, the administrator may want to score both sides of the SASSI to see if there is any difference in the result. More often than not, the result will be the same. The primary differences in M/F are in the FVA/FVOD scales which impact Rule 1 and Rule 10 in SASSI-4. There are no differences in the SASSI-A3.

The following is a list of LGBTQA terminology and definitions provided from the Prism Youth Community, part of Bloomington PRIDE here in Indiana:

These definitions were borrowed and adapted from several sources including the University of California- LA LGBT Campus Resource Center, the University of California Berkeley Gender Equity Resource Center, the University of Michigan Spectrum Center, and the University of Wisconsin Milwaukee LGBT Resource Center.

Definitions may vary with location, era, and culture. It is very important to respect people’s desired self-identifications. One should never assume another person’s identity based on that person’s appearance. It is always best to ask people how they identify, including what pronouns they prefer and to respect their wishes.

Ally – Typically any non-LGBT person who supports and stands up for the rights of LGBT people, though LGBT people can be allies, such as a lesbian who is an ally to a transgender person.

Androgyne A person appearing and/or identifying as neither man nor woman, presenting a gender either mixed or neutral.

Asexual – A person who is not sexually attracted to any gender or does not have a sexual orientation. Asexuality is not the same as celibacy.

Bisexual or Bi – A person emotionally, physically, and/or sexually attracted to males/men and females/women. This attraction does not have to be equally split between genders and there may be a preference for one gender over others.

Cisgender – A person who feels comfortable with the gender identify and gender expression expectations assigned to them based on their physical sex.

Gender Expression – The way in which a person expresses their gender identity through clothing, behavior, posture, mannerisms, speech patterns, activities, and more.

Gender Identity – A person’s sense of being masculine, feminine, or other gendered.

Genderqueer A gender variant person whose gender identity is neither male nor female, is between or beyond genders, or is some combination of genders.

Homosexual or Gay – A person primarily emotionally, physically, and/or sexually attracted to members of the same sex.

Intersex – A person whose sexual anatomy or chromosomes do not fit with the traditional markers of “female” and “male”. For example: people born with both “female” and “male” anatomy (penis, testicles, vagina, uterus); people born with XXY.

Lesbian – A female-identified person attracted emotionally, physically, and /or sexually to other female-identified people.

LGBTIQA+  – Lesbian, gay, bisexual, transgender, intersex, queer, asexual or ally, and other identities.

Pansexual – A person who is sexually attracted to all or many gender expressions.

Partner – A significant other in an intimate relationship; a gender-neutral alternative to boyfriend/girlfriend, husband/wife, or other binary-based relationships terms.

Queer – 1. An umbrella term for people who are not heterosexual or cisgender. 2. A reclaimed word that was formerly used solely as a slur but that has been semantically overturned by some members of the LGBTIQA+ community, who use it as a term of defiant pride.

Sex – A medical term designating a certain combination of gonads, chromosomes, external gender organs, secondary sex characteristics and hormonal balances.

Sexual Orientation – The desire for intimate emotional and/or sexual relationships with people of the same gender/sex, another gender/sex, or multiple genders/sexes.

Sexuality – A person’s exploration of sexual acts, sexual orientation, sexual pleasure, and desire.

Trans – An abbreviation that is sometimes used to refer to a gender variant person. This use allows a person to state a gender variant identity without having to disclose hormonal or surgical status/intentions.

This term is sometimes used to refer to the gender variant community as a whole.

Transgender – An umbrella term for a person whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth.

Recent Article Investigating Denial Among Mandated 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. You can read this article, as well as other articles related to the SASSI, on our References page.

This article also apears in the Indiana Criminal Justice Association’s, The Comment, Spring Edition.

SASSI Online Tips and Tricks: Volume 2 | Delivery Options

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!

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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.

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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.

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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.

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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.

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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?

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A SASSI-4 Profile Analysis: Prescription Drug Abuse

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.

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