Last month, Dr. Hugh Marr, a longtime trainer on the SASSI and clinical psychologist in the private practice of psychotherapy in the Washington, DC area gave an interview on the Shrink Rap Radio podcast. Dr. Marr has taught both substance abuse counseling and psychotherapy at area universities; and has worked in all phases of community mental health, culminating in running a partial hospital program for clients with the co-occurring disorders of substance use and major mental illness. He is the author of A Clinician’s Guide to Foundational Story Psychotherapy: Co-changing Narratives, Co-changing Lives (Routledge, 2020); and the coauthor of the books What Story Are You Living? (CAPT, 2009) and Introduction to Archetypes (CAPT, 2002). His forthcoming workbook for a general audience, also to be published by CAPT, will be titled Finding Your Story. You can view a clip from that interview here or a link to the interview in its entirety can be found here.
The SASSI Institute is excited that Dr. Marr has developed a workshop based on his five-star rated book: A Clinician’s Guide to Foundational Story Psychotherapy: Co-changing Narratives, Co-changing Lives. This workshop is being offered through The SASSI Institute’s Professional Development Platform. A link to a flyer with additional information on the workshop can be viewed here.
We hope you enjoy the interview and that you will join us for this informative webinar.
Now in its fourth iteration (SASSI-4), this article discusses the SASSI screening tools’ utility with criminal offenders and reviews a case study of a young male’s clinical evaluation while incarcerated. While SUD is not the only contributing factor to criminality, it significantly increases the likelihood of legal infraction and violations, placing these individuals at a higher risk of re-offending. Thus, identifying SUD as early as possible in the clinical relationship helps provide tailored treatment to those who need it, while simultaneously reducing the risk of future legal difficulties.
For this case study, we reviewed the SASSI-4 screening results of a 24-year-old male. The case presents an excellent example of the value of early identification of substance use disorder and potential problems in criminal justice settings.
We hope you enjoy the article, and as always, we look forward to your submissions and comments.
Carlos C. is a 36-year-old Mexican-American male who’s Spanish SASSI results indicate that he has a high probability of having a substance use disorder based on “yes” answers to Rules 1, 2, 3, 4 and 6 and because his FPOS score is 5 or less (FPOS=2). Validation studies indicate that 86% of the people who have substance use disorders are correctly classified by the Spanish SASSI based on the Decision Rule (High Probability) and the False Positive Check (5 or less).
In addition, Carlos has an SCS score of 8 or more (SCS=9) indicating that he is more likely to have a substance dependence disorder than substance abuse. In validation studies, the majority of people (77%) who are test positive on the Spanish SASSI and have SCS scores of 8 or more have a substance dependence disorder rather than substance abuse or no disorder.
The Administration and Scoring Instructions and Development and Validation of the Spanish SASSI provide detailed information on interpreting the Decision Rule results, the False Positive and False Negative Check (FPOS and FNEG) and the Supplementary Classification Scale (SCS).
Three of the Spanish SASSI scales, FVA, FVOD and SYM, are composed of “face valid” items that address substance misuse in an apparent or obvious manner. Some questions address inability to control usage. For example, on one of the FVA items, Carlos acknowledged that on several occasions he has had more to drink than he intended to. Other items on these scales reflect usage in order to better cope with negative feelings or other problems. Carlos, for example, reported on one of the SYM items that when he is anxious, he feels the need to drink. The face valid scales also include items that address negative consequences of substance misuse, such as physical, emotional and relationship problems. Carlos indicated on an FVA item that on several occasions his drinking has led to problems with friends and family members, and on a SYM item he acknowledged that he has had a drink first thing in the morning to steady his nerves or get rid of a hangover.
As you can see, by reading clients’ answers to specific questions on the FVA, FVOD, and SYM scales, it is possible to gain greater understanding of the types of problems they may be having with alcohol and other drug usage. Also, providing feedback to clients on the types of problems they have identified on the face valid items of the Spanish SASSI may be useful in the process of establishing treatment goals.
The remaining scales, OAT, SAT, DEF and SAM are subtle scales — i.e., the items that comprise these scales do not address substance misuse in an obvious or apparent manner. Therefore, Carlos’ responses to questions on those scales cannot be readily interpreted. The SASSI Institute provides guidelines for interpreting four similar scales as they appear on the English versions of the SASSI. However, the subtle scales on the Spanish SASSI are not identical to the English scales, and there is not enough information available to formulate guidelines for interpreting them for clinical purposes. The SASSI Institute, therefore, does not recommend interpreting scores on the subtle scales for clinical purposes. We will however, be delighted to help you with scoring or administering the questionnaire.
Bob is a 43-year old male who was referred by his attorney for a substance evaluation following a traffic fatality in which he was driving under the influence. Bob seems to have understood the items and responded in a meaningful way (RAP = 0). There is no significant evidence that Bob was defensive (DEF = 7).
The most salient feature of the profile is the significantly elevated SAT score, which is a key feature in both decision rules that lead to a test positive on the SASSI (Decision Rules 4, 5, 6, and 7). His responses were highly similar to substance dependent individuals regardless of their ability or willingness to report symptoms relevant to substance misuse. Given the lack of evidence of defensive responding, it’s likely that Bob falls in the category of those who are unaware of the full impact of substance use problems in their lives.
Individuals with this configuration of scores are often willing to acknowledge some behavioral problems related to their substance use. Bob demonstrates this by acknowledging significant current and/or past alcohol (FVA=14) and drug (FVOD=12) use. His pattern of responding also indicates some awareness of behavioral problems that are commonly associated with individuals with substance use disorders: low frustration tolerance, self-centeredness, grandiosity, etc. (OAT=7). However, given the elevated SAT, he will most likely not be able to make any connection between his acknowledged use and behavioral problems and their impact on other areas of his life.
He also responds in a fashion similar to individuals who live in an environment dominated by substance abuse (SYM=6). Although the SYM is not extremely elevated, it does tend to support the notion that Mr. B. may view his substance use as normal. Further content analysis may reveal additional factors about his life circumstances that might be important to consider in treatment planning.
Bob may be relatively well presented. He may also appear to be emotionally detached while maintaining a sense of pragmatism regarding his situation. Relatively poor insight and self-awareness are commonly present in these types of profiles. It’s not that Bob refuses to understand or is intentionally resistant; he literally doesn’t grasp that his substance use may be a problem that requires further exploration. In his mind, external factors or stressors may be to blame for his current predicament. The possibility that this tragic incident may be directly related to a substance use problem would be quite difficult for Bob to understand at this time.
This has been an interesting year hasn’t it? I’ve worked in the behavioral health field, primarily substance use disorder, since 1989. During those 31 years I’ve never come across the types of challenges I’ve seen this year, for those struggling with substance addiction and for those healthcare providers trying to help them.
“Social isolation” is the new mantra in the culture and yet it is the very thing that is anathema to behavioral health counselors trying to help individuals coping with addiction. Resources are going out of business and events which once brought enjoyment, support, solidarity and an alternative to substances for having fun are being cancelled one after another. Fear is paramount, and it’s drastically shaping the face of addiction and recovery. We are seeing more initiation of substance abuse, more cycles of relapse and overdose, and more barriers to successful recovery in order to cope with a world in chaos. While outpatient treatment programs have successfully used technology to transition to online counseling groups, this has presented a barrier for those without the resources to purchase the technology needed to participate. For the last 10 years, I’ve worked for a local non-profit treatment center for women and adolescent girls here in Dallas, Texas called Nexus Recovery Center. Recently, the Executive Director, Heather Ormand, wrote the following in a blog post:
“COVID-19 has stripped so many sober women of our community. Twelve-step meetings are no longer being held in churches. Churches are closed or access is limited and people are afraid to sit shoulder to shoulder right now. For those with long-term sobriety and a strong support system, we can probably get by with Zoom twelve-step meetings, reading literature and connecting with other sober women via text or calls. But what about the woman struggling in her disease? The woman isolated in an unsafe home without the resources to leave and get treatment? The woman without a place for her children to go while she tries to piece together continuous days of sobriety and start rebuilding their lives?”
But there is hope. Treatment staff have proven that they are indeed essential, and programs like those at Nexus Recovery Center are showing that recovery staff are willing to risk getting sick themselves in order to help another human being break the cycle of addiction. They are showing that empathy and compassion and hope can still be conveyed through a mask or through a live, online group or individual counseling session. We can still find innovative ways to connect and share our experience, strength and hope with those who are struggling to find someone who cares.
I’ve also been associated with The SASSI Institute as a trainer for the past 25+ years and have found them to be an organization that strives hard to give agencies effective and easy to use resources for helping identify individuals struggling with a substance use disorder and guiding them to the most appropriate path for their recovery journey. I’m also proud to have been allowed to help people on The SASSI Institute’s Clinical Helpline for the past few years. One consistent thing I hear from callers is how much they appreciate the fact that they can reach out in frustration or puzzlement over a client they are working with, and how those on the Clinical Helpline are always there to help them work through a SASSI screening result, craft how to phrase the results to the client or in a report, and guide them in helping clients discover things about themselves, in order to initiate their recovery process. The SASSI Institute, though at a “social distance,” is there for me like a warm blanket on a cold night and for many other behavioral health workers in the US and in other countries who sometimes just need a willing ear to process some of their cases and SASSI results. Working together we can get through 2020 and beyond, despite any obstacles.
One of the trickier aspects of incorporating the SASSI results in a substance use assessment is extracting the clinical interpretation of what elevated scores mean and the relationship between the scales. If you have taken SASSI training, especially the Clinical Interpretation session, you were introduced to ‘Profile Configurations.’ This section gets more in-depth into interpreting the scales and clinically drawing on information that can better inform how to work with your client as well as consideration of treatment modalities.
Starting with the Face Valid Alcohol and Other Drug Scales versus Subtle Scales, which when one of those is elevated can make a big difference on how you approach your client with the results. A high probability result based on only Face Valid scales can indicate good treatment readiness, life-style issues (that is, how they are functioning at work, school, home, etc. and been acknowledged by the client), with behavioral consequences being greater than psychological addiction. The client can readily tell you how their life has become unmanageable. With this client, group therapy and/or support groups could be considered.
A high probability result based only on Subtle Scales is going to feel more like a brick wall. The client exhibits less awareness and may not be able to, or doesn’t want to acknowledge a problem. This could be based on having experienced only a few negative consequences so they do not feel the impact of their addiction. They could also come across as defensive. Finally, they could be ‘sincerely deluded’ and at this point, unable to connect the dots for themselves. This client will need a lot of support to become aware that their use of substances is having an impact on their life functioning. Individual therapy may be the initial therapeutic intervention working towards other modalities as needed.
If you have attended Session II of SASSI Training, you received an outline of scale interpretation. But we would like to make sure all SASSI users have access to this valuable resource. You can download a copy by clicking the following link: “SASSI Scales in Interpretation & Feedback.”
Hope this information is instructive and assists you in your practice. And remember, as usual, we are here to help, so give the clinical line a call at 888-297-2774 or 800-726-0526, press 2.
The Substance Abuse Subtle Screening Inventory (SASSI) has been used successfully in correctional screening in multiple settings since its release. These include outpatient evaluations of offenders as well as assessments of incarcerated individuals in federal, state, and local correctional centers.
Many clients served in behavioral health and substance abuse treatment programs have histories of involvement with the criminal justice system in addition to mental health and substance use disorders. Samples in the SASSI-4 validation study included assessments in community corrections, probation and parole and drug courts, as well as cases from DWI and DOT education and screening programs. SASSI-4 overall screening accuracy in criminal justice settings was 95%; in DWI and DOT education programs SUD screening accuracy was 91%, and these accuracy levels were found not to differ significantly from the overall accuracy rate for all settings (92%). In addition, many cases included routine information on clients’ number and types of arrests and blood alcohol levels. Analyses revealed that SASSI-4 screening accuracy was 92% for clients with a history of criminal offenses, and 90% for clients who had no such histories.[i]
Interestingly, of those who had been diagnosed with a substance use disorder, criminal offenders acknowledged significantly less illicit drug use and consequences as well as less alcohol use and consequences on the SASSI-4 face valid scales than did clients with diagnosed substance use disorders in settings other than criminal justice programs — suggesting offenders minimized reported use and substance-related problems. By contrast, offenders with substance use disorders showed no differences in their endorsements of subtle items on the SASSI-4 compared to individuals with substance use disorders in other types of assessment settings. Despite offenders’ attempts at minimization, SASSI-4 overall accuracy in the offender samples was 94%. Together these findings illustrate strengths of using SASSI-4 to screen criminal offenders as compared to entirely face valid screens such as the AUDIT, CAGE or DAST. That is, the inclusion of subtle items on the SASSI-4 as well as a scale to identify clients’ level of defensive responding strengthens the ability of the SASSI-4 to accurately identify clients with substance use disorders.
In addition to legal offenses and possible substance use disorders, offenders also often have other mental health problems, which can affect their responses on many types of assessments they are given. Research on the SASSI-4 has shown its screening sensitivity is 98% in dual diagnosis clients; specificity is 93% in persons diagnosed with nonsubstance-related psychological disorders only, for an overall accuracy rate of 97% in people suffering from other psychological disorders. Moreover, accuracy was shown to be unaffected by ethnic background, and other demographic variables such as age and education.
For information on integrating the SASSI-4 into correctional programs, contact us at 800.726.0526.
[i] For additional validation information please refer to: Lazowski, L.E. (2016). Estimates of the reliability and criterion validity of the Adult SASSI-4. Springville, IN: The SASSI Institute.
Through the years, we have had the opportunity to share inspirational stories with our colleagues about their experience using the SASSI. One such story came recently from a psychologist who uses the SASSI in his practice. This was a gratifying story for us to hear and we are pleased that he has allowed us to share it with you.
The mother of a 22-year-old woman called me because she felt very strongly that her daughter Aimee (not client’s actual name) had an alcohol problem. But Aimee was adamant, no question about it, “I don’t have a problem.”
After some persuasion, Aimee agreed to come into my office, and I invited her mother to stay in the office during the interview, with Aimee’s permission. I really think Aimee was very certain that there wasn’t a problem, and that having Mom there during the process would convince her mother of this, too. I said, “You know, Mom can be a bit of a reality check here, but I’m listening to what YOU are saying.” Aimee’s mother agreed to just listen, since she had had her say when making the referral.
We talked about it, and Aimee restated that she didn’t have a problem. She was just not aware of any bad consequences coming from drinking. Aimee really seemed to believe what she was saying, “My friends and I, we don’t have any consequences; we just enjoy drinking.” I told her that was fine and asked, “Would you like to find out if you, in fact, do have a problem, or would you rather not know?” Of course, this is right in front of Mom. And she thought about it, seeing herself as being free to say “no.” But she did say, “Yeah, I think I would want to know.” When asked about each of the DSM diagnostic criteria for substance use disorders, Aimee answered no to all symptom questions.
Then, I brought out the SASSI-4, and told her a little bit about how it would compare her responses to two known groups of people: those who have a problem and know it, own it, and the other group that is just as aware that they do not have a problem, and own that. And we will see how your responses go. She agreed that that sounded good. She took the SASSI-4, and her responses showed a high probability of having a substance use disorder. This was very surprising to her. Then I went back and showed Aimee her scores on the FVA and the SYM.
When she looked at those scores, she could see by the profile that the consequences she was getting were way out of line compared to ordinary people who drink. She runs with folks whose norm is to drink a lot, and there is a history in her family of substance use issues. She just said, “It’s almost like thinking about it and realizing that you are surrounded, and your best bet is to give up!” She surrendered to the idea that, “Yes, I’ve got a problem.” From there on she was willing to do something about it. Aimee made an appointment to see me again, and we went on from there.
Let’s say that the SASSI did not exist, and I would have had only the DSM criteria and her history. I would have had her mother’s reflections and thoughts and observations, and—I don’t feel certain, but I’m guessing—she would have walked away with the understanding that she did not have a problem. She would have gone on as she had been—because I would not have been able to make a case that she did have a problem, because there would have been no data to base that on. She may well have been one of those who left the interview, and for the rest of her life said, “No, I don’t have a problem, so get off my back.” In a sense, I really believe that the SASSI saved this young woman’s life, or at least spared her significant pain. I have always been impressed by the accuracy of the SASSI. It picks up on people who really are “sincerely deluded.” It’s interesting that her score on the Defensiveness (DEF) scale was not particularly elevated, so it was not that she was being defensive, she was just unaware of how her drinking and symptoms associated with it were beyond the norm. Her elevated SAT score – at the 98th percentile – supports the interpretation that Aimee has little insight into what may be motivating her to drink with her friends, or the negative consequences that follow from spending time that way. I am very grateful for the SASSI, and I wouldn’t do an assessment or a screening without it. I literally would refuse, because just the verbal reports can be so misleading, although not intentionally misleading, necessarily. Clients will compare themselves with the people they know who are much further along in the addiction process, and not really understand that their own behavior is a problem, just because their own behavior is not yet as severe as what they see in others. The SASSI can put a client’s use into a broader, and often more realistic context.
Original depiction, written by Nancy Winningham, M.A. based on an actual experience a clinician had using the SASSI with a client. Adapted to reflect SASSI-4 information.
We had the opportunity
to consult with a treatment provider who had called in SASSI-4 scores for a
Native American couple residing in Canada. Since both profiles nicely
illustrate important clinical features of each client, we decided to present
the interpretations in this sample. We are grateful to the treatment agency in
Northern Canada that granted us permission to use the information included in this
sample. To facilitate the presentation of the profiles in a confidential
manner, we have created fictitious names for each of the clients.
Mary, a 25-year-old
Native American female, and her husband John, a 28-year-old Native American
male, were referred to the agency for a substance use evaluation. They live in a
very small community where the base rate of substance misuse is extremely high.
Their children were recently removed from the home as child protective services
suspected alcohol abuse to be a serious problem for both parents. Mary lost her
mother, father and siblings in a tragic accident that occurred just a few
months prior to the evaluation.
Upon first glance at
Mary’s profile, she appears to have responded in a meaningful manner (RAP=0),
and there is no evidence of defensive responding (DEF=1). Given this low DEF
score, she is likely to be in considerable emotional pain. She acknowledges
significant problematic use of alcohol over her lifetime (FVA=13) and reports
behaviors and experiences that are highly correlated with substance abuse SYM=8).
In fact, her SYM score is the sole basis for classifying her as test positive
on the SASSI-4 (Decision Rule 2).
A quick look at John’s
SASSI results reveals a similar profile but with some noteworthy differences.
Although he too shows no evidence of defensive responding (DEF=4), his RAP
score of 2 raises immediate concerns of random or non-meaningful responding.
Fortunately, the treatment provider had investigated this potential problem and
was satisfied that John fully understood the items and that he responded in a
meaningful manner. The counselor attributed the elevated RAP to cultural
differences and circumstances surrounding the nature of the evaluation.
John also acknowledges
significant alcohol problems (FVA=18, decision rules 1, 2, 6, 10). Like Mary,
his responses are highly similar to individuals with substance use disorders
who report life circumstances and experiences commonly associated with substance
abuse (SYM=9). This score likewise results in a test positive on the SASSI-4 (Decision
Rule 2).
Having established
that Mary and John both have a high probability of a substance use disorder, we
can now proceed to examine the salient clinical aspects of the SASSI results,
hopefully illuminating more specific treatment needs for each client. Notice
that Mary’s and John’s SYM scores are highly consistent with the milieu in
which they are reported to have lived. The treatment provider made specific reference
to the high rate of alcoholism in their community. Individuals who have substance
use disorders with high SYM scores frequently live in environments where the abuse
of alcohol and/or other drugs and the associated consequences are common and
normal experiences. In fact, it can be such an accepted way of living in the
community that most of its inhabitants would be flabbergasted to have their drinking
behavior characterized as unhealthy or problematic. Consequently, it is
perfectly understandable that Mary and John may have difficulty recognizing the
precarious nature of their alcohol misuse, especially as it relates to their
current difficulties with the child protective agency.
Despite the similarity
of the two profiles, one important difference is Mary’s significantly low DEF
score. This score would certainly seem to fit in with the recent trauma she
experienced. Unresolved loss and grief issues may be strong contributing
factors to Mary’s emotional pain. Moreover, the thought of now losing her
children because of her substance use may be adding significantly to her
distress. The risk of depressive symptoms possibly related to a mood disorder
may indicate the need for a comprehensive mental health evaluation, especially
to rule out clinical depression or suicidal ideation.
Individuals with this
high a level of emotional distress are often overly self-critical and can
become immobilized with feelings of helplessness and hopelessness. However,
it’s also possible that Mary’s pain may act as a catalyst in helping her
recognize the need to do something about her drinking. Indeed, the treatment
provider confirmed this to be the case and described Mary as a willing
candidate for substance use disorder treatment.
On the other hand,
John’s focus may be less internally directed with a tendency to see people,
places or things outside himself as the major cause for his problems.
Individuals with low SAT scores often present as victims of circumstances,
powerless to change their behavior because of a perceived lack of influence and
control over their immediate environment. In John’s case, the treatment
provider reported that John perceived his wife as the major cause of his
problems. He was content to focus on Mary’s drinking, grief issues, and
possible infidelity as the sole source of difficulties in the family. Despite
his acknowledgment of significant symptoms related to his drinking (FVA=18
& SYM =9), he remained unwilling and unable to accept this as an important
causal factor.
A viable treatment
plan for this couple will have to take into consideration a number of issues.
Mary seems primed for substance use treatment but may need additional
behavioral health services. A comprehensive mental health evaluation would be
helpful in identifying the nature and extent of any concurrent problems.
Interventions directed at processing loss and grief and those that provide
support would undoubtedly be important actions to consider. Efforts should be
made to provide bonding opportunities with a treatment provider and other
sources of encouragement and affirmation. In this regard, community self-help
support groups would be a valuable adjunct to relatively intensive substance
use disorder treatment. Pending the results of the mental health evaluation,
additional behavioral health care services may be added as required.
Although John is also
in need of substance use disorder treatment, he does not appear to be a willing
candidate at this time. Efforts should be made to increase awareness and
understanding of his alcoholism and how it contributes to his relationship and
family problems. The SASSI-4 results could be used as a graphic illustration of
the serious nature of his drinking problems. Using the high SYM score, the
treatment provider may be able to convey some understanding of how John may
have difficulty seeing the unhealthiness of his drinking. A content analysis of
the FVA and SYM scales may help him to see specific ways in which his alcohol
misuse has affected his life. It would be important to keep John focused on his
own needs by helping him to accept responsibility for his life and to make
choices that are in his own best interest. Attendance at self-help support
group meetings could help to reinforce this notion. Conjoint or family therapy
may need to be deferred in order to reinforce self-focus and to discourage John
from externalizing blame to Mary.
This case emphasizes
the importance of recognizing and assessing the impact of environmental factors
when developing effective treatment planning. It is true that substance
dependent individuals often live in an environment where the abuse of alcohol
and other drugs is commonly practiced and accepted as a normal way of life. In
these situations, individuals frequently engage in heavy substance usage as a
means of maintaining acceptance and approval in the community. It’s no wonder, then,
that clients living in this type of environment are amazed when we begin to
identify their misuse of alcohol or other drugs as problematic. Given their
life experience, it would never have occurred to these clients that anyone
would view their drinking or drugging as a sign of serious problems.
As we were able to see from the above discussion, the SYM scale on the SASSI-4 can often help you to recognize this phenomenon as a potential issue to explore further. In cases where the SYM is significantly elevated, clients may express puzzlement and surprise at your suggestion that their substance use is contributing significantly to their problems. However, the knowledge that this reaction most likely stems from the normalization of substance abuse in a client’s milieu provides an opportunity for you to communicate empathetic understanding and develop further rapport with the client. Once an appropriate bond is established, efforts should be directed at helping the client achieve some awareness of and insight into the full nature of his/her substance misuse and its relationship to other presenting problems.
Due to the continuing
outbreak of COVID-19 cases throughout the world, infectious disease experts
have recommended reducing face-to-face contact and social distancing as much as
possible to avoid spreading the virus. Many counseling and treatment providers are
now looking to boost their adoption of virtual communication (telehealth) as a
tool during this time. Congress also recently passed legislation allowing
professionals to bill Medicare for patient care delivered by telehealth during
the current coronavirus public health emergency (congress.gov).
Because early
intervention saves lives, it is vital that screening individuals for SUD
not get delayed during this pandemic and that access to treatment be available.
If you are not already aware, the adult, adolescent, and Spanish SASSI screening
tools can be administered to a client remotely via SASSI Online. Choose the
“Email direct link to client” option when assigning a questionnaire
administration, and your client can complete it at their location via the
internet.
If you are
not currently a SASSI Online user and would like to try it risk-free, please
contact our customer service team at 800.726.0526 or sassi@sassi.com.
