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.
Tag: SUD
Substance Use Disorder
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.
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:
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?
In-Person SASSI Training and other Professional Development Courses
Many of our SASSI trainers and other instructors have expressed a desire to get their boots back on the ground and start offering live in-person, hands on workshops again. While we have all been adapting to with what has become a new social norm of online training, webinars, and conference events, many have decided that they are ready to embrace in-person events again.
If you have a group that you would like to discuss arranging a live on-site SASSI Training for, please let us know. You can reach us at training@sassi.com and we can have the trainer/s in your area reach out to you for planning. You can also find a list of available trainers and their contact information at https://sassi.com/sassi-training-us/ and https://sassi.com/sassi-training-canada/. As always, training online for groups and individuals is available.
We also offer professional development webinars on various topics found at https://sassi.com/other-training-online/. On the top of that page there is a link to complete a form to request a quote for a private in-person or online training.
Stay safe and be well.
SASSI Identifies Rx Abuse (with video)
‘Reggie’ is a 37-year-old married man. He and his wife have two children. He works as a warehouse worker where he was recently injured in a shipping dock accident. He recently returned to work after being on worker’s comp for several months during which time he was prescribed opioids for his pain. He was sent to his employer’s EAP provider for evaluation after returning to work and struggling with coping with the continued pain and poor job performance.
Reggie T’s responses illustrate another profile often seen in people who acknowledge that they use drugs excessively and that it negatively impacts on their functioning and relationships.
Given Reggie’s high level of drug use and consequences, you might consider a more comprehensive evaluation to determine whether he may need supervised detoxification or other intensive intervention.
You may find Reggie ready to acknowledge that he uses drugs frequently and that he may also drink too much. However, he may not see that his behavior varies dramatically from others who don’t have a substance use disorder. Feedback on where his scores fall on the profile sheet may help him see that his behaviors are not typical. It may be useful to know that Reggie’s wife is currently in treatment for drug and alcohol abuse due to a DUI. Their mutual abuse of substances may help promote their beliefs that their substance use is normal. Examining the items that Reggie endorsed on the FVA, FVOD, SYM and Rx scales may provide useful insight into his motivations for using and help him see the consequences that result from his use.
In this first video watch Reggie’s initial EAP visit in which he was asked to take the SASSI.
This second video is the follow-up session where he discusses his SASSI results with the EAP provider.
A SASSI-4 Profile Analysis: Reading Aloud the Questionnaire and Interpretation of Low Scores
We regularly get inquiries about the acceptability of reading the questionnaire to a client who may have difficulty with their reading skills. We discourage the evaluator from reading the questionnaire to the client for a variety of reasons, but the primary one concerns the validity of the results. No matter how careful the reader might be, the tone of voice or emphasis on a particular part of the question may lead the client in one direction or another. Or the client may interrupt with a question regarding the meaning of a word or intention of a particular question. This is why we offer a professionally read audio CD of the SASSI-4, Adolescent SASSI-A3 and Spanish SASSI paper and pencil versions for clients who have reading difficulties. We hope in the future to be able to offer this for the online platform as well. Please contact our customer service department for ordering information.
Another frequent question is related to the clinical interpretations of the “low” scores on the profiles. These mostly relate to the subtle scales which include the OAT, SAT, DEF and SAM scales. Most callers know what a low DEF indicates. And SAM has no clinical interpretation.
So what about those low OAT and SAT scales? What does “low’ mean? A low score is anything below the 15th percentile on the graph. In the example to the right, the caller indicated that she was doing an assessment on a health care professional who had been arrested for her one and only DWI the previous year, had completed her alcohol education class and needed this evaluation as a final step for probation. She was not in trouble in her job and in fact, highly regarded in her profession. Given the client was at the end of her requirements, the evaluator was somewhat concerned with the results and what it meant. The instructions were given to answer the FVA/FVOD side for the last twelve months. Her RAP is zero. Her Prescription Drug Scale is zero. She has ‘no’ on all the rules so came up with a Low Probability of having a Substance Use Disorder. However, her DEF of 9 is highly elevated. Elevated DEF scores increase the possibility of the SASSI missing individuals with a substance use disorder. Elevated DEF may also reflect situational factors. Note that the SAM is within the norm so it is probably more likely that her DEF is situational given the context. She also has an OAT score of ‘O’ and a SAT score of ‘2’. Both are below the 15th percentile. A low OAT indicates someone has difficulty acknowledging personal limitations or shortcomings. A low SAT indicates someone who might have a ‘chip’ on her shoulder, a hypersensitivity to others or feelings of rejection.
So even though this client is nearing the completion of her probation requirements, we still get a picture of someone who is highly guarded (DEF), has a hard time acknowledging shortcomings (OAT) and may continue to exhibit resentment (SAT) for the situation she is in. Perhaps this is due to her profession, or perhaps it is her personality. What the results give the evaluator is clinical direction on how to approach the client to help reduce her defensiveness and give her permission to open up. Affirming how demanding her job is and how on top of things she must be could be a pathway to discussing her feelings of shame related to the DWI and how it might be affecting her self-esteem. Could she be minimizing her use of alcohol and drugs? Perhaps, but as we strongly express, the SASSI is only one part of a clinician’s assessment. Hopefully, with the input of all the information you have, the clinician can evaluate the results which fit the context for this client.