The SASSI Institute recently published an article in Women’s Health on early intervention and resources for expectant mothers with substance use problems and service shortages in the present age. Within it, we discuss the need for more research and collaboration in regards to substance use disorder and criminal Justice, especially to assist women avoid the stigmatization and ostracizing they may experience; many simply by virtue of having experienced the disease of addiction. When combined with the criminalization of drug use, society inevitably finds itself entrapping these women in a revolving door fed by the “drug-crime” connection, but now also including newborns. Babies should NOT be born in prison, especially sick babies; however, when they are, quality prenatal care, early intervention, and community support upon release from prison are imperative to help those babies and their mothers have positive long-term outcomes. Please consider this a call to action, we welcome your interest in collaborative efforts.
Courtney Hupp, MSW, LCSW, CADC will be presenting a live webinar on implementing the A-CRA treatment model on November 14th. On December 1st she will be presenting how to implement Family Sessions using this model.
The treatment model known as Adolescent-Community Reinforcement Approach (A-CRA) recognizes that, at least initially, alcohol and drug use is about reinforcing consequences — that make us more likely to repeat actions. This is true whether we are hanging out with friends, playing a favorite game, eating a good meal, or using alcohol or other drugs. People who use alcohol and drugs get something out of it – or they wouldn’t keep doing it.
The overall goal of A-CRA is to help individuals reconnect with or discover new sources of positive reinforcement within their community to compete with alcohol or drug use. How do A-CRA clinicians do this? By listening to and learning from their clients what is important to them. They then help them connect to pro-recovery activities that have meaning and value to their client. In addition, A-CRA clinicians help their clients identify goals and learn how to achieve them. A-CRA clients also learn a variety of new skills, such as problem-solving and positive communication (with partners, friends, and others), which help them attain a better quality of life. Practicing new skills is a critical component of the skills training used in A-CRA. Every session ends with a mutually-agreed upon homework assignment to practice skills learned during sessions. A-CRA clinicians engage caregivers or other family members to support the client and to learn skills that can be used with the entire family.
This intervention has been implemented in outpatient, intensive outpatient, schools, prevention services, and residential treatment settings. This research-tested intervention has been used in over 500 organizations across the United States and Canada. Courtney Hupp will provide an introduction to the A-CRA model, a summary of the research base, and details about how to use a variety of A-CRA skills during sessions.
What You Will Learn:
• An Introduction to the A-CRA model
• History of A-CRA research and implementation
• Goals of A-CRA treatment
• An overview of the A-CRA session structure and treatment guidelines
• How to use some of the A-CRA procedures during sessions like a Functional Analysis for substance use, Happiness Scale, Sobriety Sampling, and Increasing Prosocial Recreation
• General clinical skills necessary to implement A-CRA
Engaging caregivers and other healthy family members into A-CRA treatment to strengthen social support. A-CRA clinicians help clients and families learn skills that can be used with the entire family. A-CRA skills are simple, behavioral, and easy for families to repeat during the family sessions and outside of treatment. In addition, the positive, supportive approach of A-CRA allows participants to focus on the positive aspects of the family and build upon family strengths to improve the relationship.
On addition to bullets above you will also learn:
• How to use the A-CRA skills during family session. Family session skills include: three positives exercise, relationship happiness scale, problem solving, communication skills, and daily reminder to be nice.
Be sure to register for one or both of these webinars at: www.sassi.com/other-training-online
A recent caller wanted help in interpreting a profile completed by a 33-year-old male. He was instructed to complete the FVA/FVOD side of the questionnaire for the last 12 months. The administrator revealed during the call that the assessment was a pre-employment screening for the Department of Transportation. The helpline does receive regular calls from counselors who administer the SASSI-4 for the Department of Transportation after a driver has failed a drug or alcohol test for substances, but not for pre-employment screening.
In review, the client comes up with a high probability of a substance use disorder based on Rules 2,5,6 and 9. The RAP is 0 and the Rx Prescription Drug Scale is 0.
The FVA is below average use, the FVOD is on the 50th percentile. The SYM scale of 7 is above the 85th percentile, considered elevated and thus Rule 2 meets the criteria of a High Probability of a Substance Use Disorder. The rest of the scale scores are within the norm (between 15-85th percentiles) so clinically are not significant but are significant in meeting the criteria of a Substance Use Disorder if accounting for the additional rules of # 5, 6 and 9. The SAT of 5, being in the norm indicates the client was not in denial about his usage.
Although the results do not account for current or actual use, further assessment may include urine screens that would give a more accurate representation of current use of substances. He does come up with a high probability of a Substance Use Disorder, so deeper inquiry is necessary.
The administration of this SASSI was part of a pre-employment screening and our position on the proper use of the SASSI in this regard, is very explicit:
From our User’s Guide and Manual: *
“The purpose of the SASSI is to help identify people who are likely to have substance use disorders so that early intervention and treatment can be initiated when appropriate.”
“To use the SASSI to discriminate against individuals violates the intent of the authors and may even violate the law.”
“SASSI results should not be used to abridge the rights of individuals or to disqualify applicants for positions, such as jobs or benefits, such as public assistance programs.”
Thus, it is extremely important to use the results in the most therapeutic way possible with the best intentions of helping individuals with a substance use disorder.
If you have any questions, please contact the Clinical Director, Kristin S. Kimmell, LCSW, LCAC at email@example.com.
*SASSI -4 User Guide & Manual – Chapter 1 (overview), pg.7
SASSI-4 Online User Guide – Proper Use of the SASSI. pg. 8
As discussed in a prior blog, we are expanding our free clinical phone service by offering free live clinical Q&A sessions online. These Q&A sessions are open to everyone. The Q&A will be hosted by our Clinical Director, Kristin Kimmell, LCSW, LCAC, and will last one-hour. We invite you to ask questions or share experiences regarding unusual or difficult profiles you may have come across, but all questions are welcome. You can also join just to listen to the group discussion.
Our first free Q&A session is scheduled for Tuesday, October 4th from 1-2 pm ET. Click here to register today. Due to time restraints, the session will be limited to the first 25 registrants. As new dates are added we will post them to our blog or you can check the registration page via the link above in this blog.
Note that this Q&A does not provide CEUs and is not a substitute for SASSI Training.
We hope you will join us!
Since the release of the original SASSI in the late 80’s we have had the pleasure of providing free clinical consultation and support for those using our instruments via our toll-free phone line. Our clinicians have enjoyed speaking with professionals about SASSI results and strive to make it a useful and pleasant experience. We are planning to expand on this service by offering free live clinical Q&A sessions online. We invite users of our instruments, those considering implementing our instruments, and students, to join our Clinical Director, Kristin Kimmell, LCSW, LCAC, for these FREE live one-hour sessions. Here you will be able to ask questions or share experiences regarding unusual or difficult profiles you may have come across, but all questions are welcome. You can also join in simply to listen to the group discussion and are not required to ask questions.
We hope this will be a useful expansion of our clinical service and look forward to having engaging group discussions. We believe we can learn from you as well and these discussions will help us be sure that our research is up to date with current concerns in the field of SUD. We will be announcing the date, time and registration information for our first Clinical Q&A next month on our Blog so be on the lookout for it!
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.
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.
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.
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.
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.
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.