In a previous post, we discussed how the COVID-19 crisis is affecting the substance use disorder field throughout the country. Unfortunately, last week showed a dramatic increase in the number of reported cases nationally, particularly towards the end of the week (more than 40,000 additional reported cases, mostly from the west coast and southwest). As a result, many colleagues that had reopened for business to provide clients with critically needed services, unfortunately, had to close their doors again. Locally, we also experienced spikes. Not unexpectedly, we have seen a larger number of conference and venue cancellations than the already high numbers of cancellations reported previously. Fortunately, several venues have opted to hold teleconferences, thus allowing for a return to some semblance of normalcy.
Our number one concern at The SASSI Institute is maintaining the safety and care of those in the greatest need of help, the clients under your care. To do so effectively and efficiently, counselors, therapists, doctors, nurses, and all of us collectively, that engage in the work we do, must prioritize taking care of ourselves and practice the necessary precautions to enable those protections. We must adhere to the recommended CDC guidelines, including practicing social distancing, and engaging in frequent hand-washing.
We want to report that internally, as a result of some local area infection spikes, regretfully we had to postpone the dates when we expected full operational in-house staffing. Despite this needed precaution, we have maintained our shipping capacity of paper products and our SASSI-Online platform is fully operational. All other departments remain available during normal work hours to answer questions and provide assistance.
We are also very happy to report that our research department has three articles submitted for publication. And perhaps most importantly, we continue to ardently work on the upcoming release of the third iteration of our adolescent screening tool (SASSI A3). As previously reported, our adolescent “Fake Good” article was published in Alcoholism Treatment Quarterly in late December 2019.
The SASSI Institute remains committed to helping you stay connected and supported during the COVID-19 crisis and these other periods of strife. As always, please accept our heartfelt wishes that you and your families remain safe.
We at The SASSI Institute wanted to update you on the COVID-19 crisis and how we see it affecting the substance use disorder field, not only here in southern Indiana, but also as reported from our many contacts throughout the country. The unfortunate reality is that many private practitioners, and even some long-standing programs, have had to furlough operations or sadly, cease operating altogether. We have lost many colleagues and personal friends to this devastating disease from the substance abuse, treatment, and correctional field/s, and our hearts and prayers go out to their families. Another grim reality is that those in greatest need of our help, our patients, are most at risk during these precarious times of calamity. Sadly, many of our gathering spots, conventions, and venues have been cancelled or postponed, in some cases, for several months. These venues allow us to dialogue, and although we may not always agree, the sharing of information and ideas is what ultimately makes us stronger.
Internally, within the coming weeks, we will increase our shipping capacity for paper products to three days a week, depending on demand. And as I said in an earlier post, we are all looking forward to getting back to full operational capacity soon, but first and foremost, our greatest concern is the safety and well-being of our staff and customer base. During normal work hours, we remain available to answer questions, assist with order placement, and provide clinical support. Our SASSI-Online platform is fully operational, and staff remain available to offer assistance, technical support, and guidance as needed.
I would be remiss if I didn’t call attention to the racial, political, and criminal justice divisions that are currently affecting our country in so many devastating ways. Black lives DO matter, as do the lives of us all. These and so many other serious issues are affecting our country presently. It is no longer acceptable for us to simply state words; indeed it is now a time more than ever for us to unite and not divide. Regardless of race, creed, color, religion, sexual orientation, or political persuasion, we must focus our energies on that which will make us all collectively stronger. We must infuse a greater awareness of injustice in its many forms and manifestations, address these whenever possible, and enhance the dialogue leading to collective, constructive action. For us to become a greater part of the solution in creating a more just society, we must first understand that all of us can and must play a role.
The SASSI Institute remains committed to helping you stay connected and feel supported during the COVID-19 crisis and these other periods of strife. We will be informing you of developments as they occur on our end. But for now, please accept heartfelt wishes from all of us, that you and your families remain safe. #alonetogether
The client is a 38-year-old male named Jim (not his real name), who was referred for a substance use evaluation following a second arrest for domestic violence. The practitioner calling in the profile reported having collateral evidence substantiating a significant history of alcohol abuse for this client.
The SASSI results indicate that Jim has a low probability of having a substance use disorder. He is not acknowledging any significant problematic use of alcohol (FVA=0) or other drugs (FVOD=2). In fact, he denies having any of the symptoms commonly associated with individuals who have substance use disorders (SYM=1). However, note that Jim’s responses are highly defensive (DEF=9) and significantly similar to individuals who are instructed to minimize and conceal problems. Given that his report on the FVA and FVOD is in direct conflict with information from other sources, it is likely that he is minimizing the degree to which he has experienced alcohol and other drug problems or related symptoms. This increases the risk that the SASSI classification of low probability may be in error – in other words, the accuracy of the decision rules may be slightly decreased. As in most assessment situations where the client is relatively defensive, augmenting self-reported alcohol and drug history with data from external sources is advisable before ruling out substance use problems.
Experienced SASSI users working in criminal justice, EAP, DOT, child protection, and other similar settings will recognize this profile as relatively common for clients who are mandated for assessment. Indeed, Jim has been charged with assaulting his partner for a second time. One possibility is that he fears a harsh punishment may be coming if he does not present himself in a favorable way. He may also be convinced that he is not to blame for his behavior, explaining that his partner provoked him or that he was acting in self-defense. While the SASSI does not reveal the exact cause or reason, the high DEF score is a strong indicator that Jim approached the assessment in a defensive manner.
Notice also that Jim’s OAT score is significant given that it falls below the 15th percentile (OAT=1), meaning that only 15% of the general population would score this low. A score in this range usually indicates a person does not identify with any of the problematic behaviors typically associated with substance abuse (for example, anger management problems, negativity, self-centeredness, etc.). Jim is not likely to acknowledge having these behaviors and probably wants to be viewed as being completely different from people who do. Individuals with a family history of addictive or violent behavior often cope by distancing themselves from the addict or perpetrator as if to say, “I’m nothing at all like my alcoholic mother or physically abusive father.” In fact, the caller reported that Jim’s mother is an active alcoholic.
Jim’s FAM score of 12 is also significantly elevated (above the T 60 line or the 85th percentile). His responses are similar to family members of substance dependent individuals. It is likely that he shares many of the characteristics and traits commonly associated with individuals living in addictive family systems – obsession with controlling the thoughts, feelings and/or actions of others, lack of adequate or healthy psychological, emotional and physical boundaries in relationships, and inability to trust others. Certainly, one theme for individuals with high FAM scores involves their sense of happiness and self-worth being dependent on fixing or controlling the behavior of others. Jim may have learned early on the false perception that the only way he can have a sense of well-being is when he is in complete control of his partner. This need often can result in the perpetration of violence in cases where poor interpersonal boundaries and lack of trust exist in a person with serious impulse control problems. Thus, like other perpetrators of domestic violence, Jim may feel enmeshed at every level with his partner, seemingly unable to restrain himself when he feels like he is losing control of his partner’s behavior.
To summarize, Jim’s profile is similar in many ways to that of other known perpetrators of domestic violence who have completed the SASSI. Although he is classified as having a low probability of a substance use disorder, his responses are characterized by a significant degree of defensiveness. This, along with other assessment evidence, increases the risk that he has minimized his alcohol and other drug problems and that the SASSI results of low probability of substance use disorder may be inaccurate. Jim does not recognize or accept responsibility for his own behavioral problems. Like other domestic violence offenders, he tends to focus almost exclusively on controlling his partner’s behavior as a way of achieving happiness and contentment in life. Jim’s family history of alcoholism is likely a significant contributor to his behavioral problems and also increases the risk that he may have, or may be developing, a substance-related disorder.
Ongoing assessment will be necessary to completely rule out the possibility of a substance use disorder. Because of the impact that most psychoactive substances tend to have on reducing impulse control, Jim’s risk for reoffending is greatly increased if he has a substance-related disorder that is left untreated. Collateral sources of information concerning Jim’s alcohol and drug history seem to indicate that his problems with alcohol and other drugs may be more serious than he is reporting on the SASSI. If further assessment results confirm a diagnosis of a substance use disorder, his treatment plan would need to include some form of addictions therapy. In addition, a no-use contract and regular toxicological screens could be useful ways to lower his risk of using and support a period of abstinence.
Jim’s defensiveness could be a serious barrier to engaging him in a therapeutic relationship, let alone making any significant progress in helping him to change any of his problematic behaviors. Establishing rapport and gaining Jim’s trust and confidence would be important steps in creating and maintaining a therapeutic alliance with him. Didactic, cognitively based educational approaches are often viewed by defensive clients as less intrusive and non-threatening. Initially, he may respond more favorably to presentations, films, books, etc., emphasizing the impact of addictions on the individual and their families. This may help to increase Jim’s awareness of his own misuse of substances and provide him with some insight into the dynamics of his own family’s behavior, including his alcoholic mother. Family involvement in his treatment may also be beneficial.
Referral to a practitioner or program that specializes in treating perpetrators of domestic violence should be strongly considered. Remember that Jim may have little or no awareness that he is responsible for his own violent behavior. His perceptions may be completely dominated by the belief that he has a right to behave in this manner with his partner. Such deeply ingrained patterns of thought and associated impulse control problems are often difficult for clients to begin to recognize, much less change. Support and process groups facilitated by behavioral health professionals trained in the treatment of domestic violence offenders are often an effective approach in helping perpetrators begin to acknowledge their behavioral problems and to effect some healthy changes.
The SASSI Institute conducted a validation project on the accuracy of the adolescent SASSI substance use screening measure with respect to the most current nationally accepted diagnostic standards for substance use disorders, the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria (DSM-5). We are delighted to report that our data analyses is complete and presently we are preparing our findings for peer review submission and subsequent publication and dissemination.
Decision rules were formulated that would provide a good degree of accuracy using our development sample. Yet, the crucial issue is whether the SASSI-A3 scoring rules would be accurate when applied to a sample not used in formulating the decision rules. That is, how well does the SASSI-A3 cross-validate? When tested, we are pleased to report that the SASSI-A3 decision rules on the cross-validation sample results indicated an overall accuracy of 93.41%, 15.01% gain in sensitivity, 0.83% loss in specificity, and 9.75% gain in overall accuracy!
When released, SASSI-A3 will now include updated language reflecting current teen drug trends, a prescription drug abuse scale, as well as additional items. Once the publication review process is finalized, we are looking forward to making this updated tool available to professionals in the field.
We want to once again acknowledge and thank all the individuals and organizations who provided us with their valuable contributions.
Scarlett Baker, A.A. – SASSI A-3 Project Director, and SASSI Institute Director of Training
The SASSI Institute takes the health and safety of our employees very seriously. With the spread of COVID-19, the Company must remain vigilant in mitigating the outbreak. We are committed to helping people who suffer from substance use problems and the professionals who serve them. In order to be safe as we reopen operations, we have developed this COVID-19 Exposure, Prevention, Preparedness, and Response Plan. Of course, we will continue to monitor the related guidance that CDC and OSHA provide.
The SASSI Institute wishes to express our appreciation for those working in correctional settings, criminal justice and juvenile services. This is an unprecedented time for all, and especially hard for those working in correctional settings and their family members. Thank you for staying strong!
We also send our condolences to the family and friends of those who have lost their life during this pandemic.
This SASSI-4 profile of a 37-year-old female was called in to our clinical support line. As we look at her results, it appears that she answered the items in a meaningful manner (RAP=0). She is likely to have a high probability of a substance use disorder (SYM=6, SAM=8) based on decision rule 8.
Notice that despite the relatively low DEF score and apparent lack of defensive responding, the SAM scale score, when combined with the elevated SYM score, leads to a test positive result. While it is true that the SAM scale score plays a vital role in the accuracy of the decision rules in this case, it is important to remember that the clinical meaning of this score is unclear. Therefore, it would be inappropriate to draw any clinical inference from the fact that the SAM score is elevated.
The client acknowledges significant problems related to her use of drugs other than alcohol. She is likely to have experienced some loss of control, negative consequences, and increased tolerance as a result of her substance misuse. However, her average OAT score (OAT=3) may be an indication of some limited ability or willingness to acknowledge behavioral problems commonly associated with individuals who have substance use disorders.
The moderately elevated SYM (SYM=6) is consistent with clients who often are not able to recognize the manner in which substance use is manifested in their lives. Her responses are similar to individuals who live in a social milieu where substance abuse and its related consequences are fairly routine and normalized. This experience may limit her ability to characterize her substance usage as problematic. Indeed, she may be somewhat surprised that the SASSI results could even indicate an addiction problem.
The client’s responses are similar to those of individuals who are experiencing emotional pain (DEF=3). Individuals who score in this range tend to be overly self-critical, may experience depressive symptoms and sometimes report a history of trauma. She may be quite limited in her ability to recognize personal strengths, focusing more on limitations, failures and feelings of low self-worth.
This client is likely to have a high probability of a substance use disorder and should be considered for relatively intensive addictions treatment. A comprehensive behavioral health evaluation may be necessary to rule out the need for additional psychiatric intervention. Although she demonstrates some ability to acknowledge relevant behavioral symptoms of her addiction, a viable treatment plan should include initial efforts to increase her self-awareness and insight into the full nature of her substance use problems. Education and other cognitively based interventions may be helpful.
Most likely, she will need help in recognizing that her misuse of alcohol and other drugs is similar to that of other substance dependent people. A content analysis of her responses on the FVOD and SYM items may be one way to help her realize that it is in her best interest and within her capacity to change.
Community-based self-help support groups could provide additional encouragement and support.
In addition, evaluation for depressive symptoms and its relationship to her substance us would be important to consider.
Stevie joined SASSI as a Customer Service Representative in April 2019. She previously worked as a dispatcher with our local law enforcement and with a shelter helping women and children in need. She is a mother of 3 young children, two boys and one girl.
When Stevie is not at work, she loves binge watching TV episodes with her mom, whom she considers her best friend. She also keeps very busy with her children’s extra curriculum activities like pageants, sports, dance and whatever else is on the family calendar.
Stevie’s team members describe her as energetic and a ton of fun to work with.
The SASSI Institute is committed to helping you stay connected and feel supported during the COVID-19 crisis. The sudden changes and disruptions to our daily lives coupled with the unknowns about the immediate future can be scary and stressful. For those in the substance use disorder field, these disruptions can be particularly stressful as we are already addressing the critical needs of our clients.
As you can see by visiting our site, blogs or other social media outlets, although presently all our staff members are telecommuting because of state mandated “stay at home” policies, we remain available during normal work hours to answer questions, assist with order placement, clinical support and technical guidance as needed. Our SASSI-Online platform is fully operational, and our teams remain available to offer assistance and support. On April 6th, our Governor modified the stay at home ordinance such that we are now capable of shipping paper products one or two days a week. At some point soon, we are hoping to get back to full operational capacity.
We will be informing you of developments as they occur. But for now, please accept our heartfelt wishes that you and your families remain safe.
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
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
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.