Newsletter Volume 4, Number 2; May 1996

In this Issue...

• Quick Reference to the SASSI-2. Note: The SASSI-2 is no longer being supported. However, when the SASSI-3 revision was done, great care was taken to make sure that the scales worked the same way as on the SASSI-2. Therefore, these tips for using the SASSI-2 will work just as well for interpretting the SASSI-3. The only new scale, Symptoms (SYM) is discussed a later newsletter. If you have any questions, please call the Clinical Help Line at 888-297-2774.
• Research and Development

The following is intended as a quick reference guide for SASSI users desiring assistance with the administration, scoring, and interpretation of the SASSI-2. For more detailed information, you may want to refer to the SASSI manual or simply contact us at 800-726-0526, and we will be happy to assist you.

PURPOSE OF THE SASSI-2

SASSI-2 was designed as a substance abuse screening measure that: a) does not require a professional's time to administer; b) is brief; c) is objectively scored; d) leads to classification of individuals by the use of clear decision rules; e) is accurate; and f) is composed primarily of "subtle items" that appear to be unrelated to substance abuse, thus enabling the instrument to identify some individuals with substance-related disorders even if they are unable to acknowledge relevant symptoms.

The primary purpose of the SASSI-2 is to identify individuals with a high likelihood of having a substance-related disorder. The decision rules identify individuals who have a high probability of having a substance dependence disorder. The available data indicate that approximately 88% of individuals with a psychoactive substance-dependence disorder will be test positive on the SASSI. Also, about 88% of individuals who are not substance dependent are correctly classified by the SASSI. Thus, individuals who are test positive by the SASSI-2 decision rules are highly likely to meet criteria for a diagnosis of psychoactive substance dependence. The process of assigning a DSM-IV or ICDM diagnosis requires information about the use of specific substances and the presence or absence of specific symptoms.

A secondary purpose of SASSI-2 is to provide clinical information that can be useful in the process of helping identify problem areas, set treatment goals, and develop treatment plans. Use of the SASSI for the past seven years has led to tentative conclusions regarding the clinical meaning of some of the scale scores and profile configurations. These findings have not been subjected to full empirical investigation. Therefore, broad interpretations of SASSI scales and profiles should be viewed as providing a supplementary source of information to aid in the clinical process. Depending on the availability of resources and the goals and values of the treatment provider and client, interpretations of the SASSI-2 scale scores and profiles can be used as a source of information for formulating treatment plans.

In light of the broader social and economic impact of substance-related disorders, there is an increase in substance abuse screening being conducted outside the health-care field. Some of the settings in which substance abuse screenings are being conducted are legal/judicial, employment, sensitive industries, and government services. The SASSI Institute supports use of SASSI-2 in those contexts to the extent that the instrument is used to promote the health and well-being of the individual and that it is not used as a basis of discriminating against people. The staff at The SASSI Institute are available for consultation on specific applications of the instrument. In some instances, arrangements can be made for developing customized programs to meet specific program needs.

DEMOGRAPHIC CONSIDERATIONS

The samples that were used to collect the data for formulating and cross-validating the SASSI included members of minority groups. The SASSI scales do not correlate with age, sex, and socioeconomic status. Thus, the SASSI is likely to be effective with a wide range of clients. However, the possibility exists that an individual's unique demographic characteristics may have an effect on the probability of an erroneous classification.

ADMINISTRATION

No detailed instructions are required when administering the SASSI-2 in either individual or group assessment situations. It is advisable to put clients at ease by eliciting their cooperation in providing information that can be of value in addressing their needs. To avoid defensiveness, refer to the SASSI-2 as a questionnaire rather than a test. Also, ask the clients to complete the 62 true/false items prior to turning the questionnaire over to complete the 26 items that directly address substance abuse. If clients are going to be given feedback, it is a good idea to let them know they will have an opportunity to discuss the results with a counselor, as this tends to lower anxiety and increase cooperation.

Remind clients to complete every item and to give only one response to each item. Acknowledge that the decision to answer "true" or "false" may be difficult on a few questions but that it is important that they choose only one response on each item. Do not give advice to help a client choose on any given item. Rather, inform them that there are no right or wrong answers and that you are interested in their opinion. If possible, check to see that the client has provided a single answer to each item.

If clients have literacy or vision limitations, it is permissible to read the items or use the available audio tape. When possible, it is preferred that clients mark the answers on their own copies without the person administering the questionnaire being able to see their individual responses.

SCORING PROCEDURE

Scoring the SASSI-2 involves obtaining numerical scores for each of the nine scales. The scale scores are then transferred to the profile sheet. You may use the sample test that is included in the Introductory Kit while going through the following instructions.

FACE VALID ALCOHOL (FVA):
Turn to the side of the SASSI-2 that contains the 12 alcohol items and the 14 other drug items. Note that a response of "never" is assigned a value of 0, "once or twice" is assigned a value of 1, "several times" is assigned a value of 2, and "repeatedly" is assigned a value of 3. To obtain a scale score for FVA, simply add the client's responses on all 12 alcohol-related items (on the left half of the page). Write the result on the profile sheet under the FVA column in the graph, and mark the corresponding number on the graph. Extreme scores will not fit on the graph; if the client's raw score is greater than 13, write it above the top of the graph as a visual aid in interpreting the profile.

FACE VALID OTHER DRUG (FVOD):
Follow the same procedure for the 14 FVOD items and transfer the information to the FVOD column on the graph on the profile sheet.

THE REMAINING SEVEN SCALES ARE TAKEN FROM THE 62 TRUE/FALSE ITEMS AND ARE SCORED WITH THE PLASTIC SCORING TEMPLATE.

OBVIOUS ATTRIBUTES (OAT):
Locate the squares above and below the OAT Scale on the template. Align them with the four squares on the questionnaire. Count the number of circles that are filled in. OAT scores range from 0 to 17. Write the result on the profile sheet under the OAT column on the graph. Mark the appropriate number on the graph. It is essential that you line up the template accurately, that you score both the left and the right columns, and that you count both the true and the false items that are keyed. To insure that you are scoring correctly, compare the OAT score you obtain with the OAT score printed on the sample test.

FOLLOW THE SAME PROCEDURE FOR THE REMAINING FIVE SCALES.

SUBTLE ATTRIBUTES (SAT): The scores range from 0 to 11.

DEFENSIVENESS (DEF): The scores range from 0 to 14.

SUPPLEMENTARY ADDICTION MEASURE (SAM): The scores range from 0 to 15.

FAMILY (FAM): The scores range from 0 to 14.

CORRECTIONAL (COR): The scores range from 0 to 16.

RANDOM ANSWERING PATTERN (RAP): The scores range from 0 to 6. The space provided for the RAP score is located within the first decision rule in the upper left of the profile sheet.

INTERPRETATION

PROFILE SHEET:
After plotting the raw scores on the graph, it is possible to see the corresponding T-score and percentile ranking for each scale score (except RAP). For example, an OAT score of 12 corresponds to a T-score slightly greater than 70 and a percentile ranking greater than 98. This means that 98% of the subjects who provided the normative data in the development of the SASSI had an OAT score less than 12. An OAT score of 3 corresponds to a T-score below 40 and a percentile ranking below 15. This means that 85% of the subjects who provided the normative data had an OAT score greater than 3. This information is useful in providing a context within which to identify scale scores that are unusually high or low in order to better understand an individual client's profile.

PROFILE VALIDITY:
SASSI-2 has approximately an 88 percent rate of accuracy in identifying substance dependence. There are three ways to check on the validity of individual profiles.

1. If the paper and pencil version was used, check to determine if the client skipped or double-marked any items. If possible, ask the client to clarify any such items. If the client is not available to clarify ambiguously marked items, determine if a clear response could change the results of the decision rules. If so, the decision rules should not be viewed as an adequate measure of the relative probability of a substance-related disorder.

2. If the RAP score is two or greater, the client may not have responded to the SASSI-2 items in a meaningful manner, and therefore the results may not be clinically useful. In some instances an elevated RAP score may be due to misunderstanding the directions, literacy problems, or other test administration factors that can be corrected if SASSI-2 is administered again. Elevated RAP scores may also reflect noncompliance which can be addressed as a clinical issue.

3. A DEF score of T-60 or greater is an indication of defensive responding on SASSI-2. (The SAM Scale is used as a correctional factor to identify clients whose defensiveness is likely to be related specifically to substance abuse.) If the profile includes an elevated DEF score, the results should be viewed as tentative. It is commonly believed that defensive clients generally attempt to conceal evidence of substance-related disorders. Thus, a client who has an elevated DEF and is classified as chemically dependent has a high likelihood of having a substance-related disorder. However, If the client has an elevated DEF score and the profile does not meet criteria for chemical dependence, the results are more questionable. If there is other information suggestive of a substance-related disorder, a more comprehensive assessment may be advisable. The defensiveness can also be addressed as a clinical issue. In some instances it may be valuable to readminister SASSI-2 after rapport has been established, and the client is able to view the assessment process in a positive light.

DECISION RULES:
After plotting the scale scores and considering the validity of the individual profile, refer to the decision rules on the right side of the profile sheet. Follow the decision rules in sequence. If the profile meets any of the criteria, the client is test positive on the SASSI. If the profile does not yield a positive result on any of the decision rules, the client is test negative. Approximately 88% of clients with a substance-dependence disorder are test positive on the SASSI; about 88% of clients who do not have a substance-dependence disorder are test negative on the SASSI.

SCALE SCORES:
It is important to recognize that the SASSI items were chosen because they differentiate between people with substance-related disorders and controls (i.e., people who do not have substance-related disorders). The SASSI is an empirically-derived screening instrument. It is not a personality test in which the scales were designed to identify certain types of people. However, interpretations of SASSI scales and profiles provide a supplementary source of information to aid in the clinical process. The following is a set of guidelines for interpreting client's scores on FVA, FVOD, OAT, SAT, AND DEF. SAM is a relatively new scale, and The SASSI Institute does not yet have sufficient information regarding its clinical significance beyond its role in the decision rules.

FVA and FVOD:
SASSI-2 is composed of both face valid items and subtle items that do not directly address substance usage. The face valid items are relatively easy for clients to manipulate. Clients who are motivated to conceal evidence of a substance-related disorder may under-report symptoms on FVA and FVOD; clients who are motivated to demonstrate that they have a substance-related disorder, may over-report symptoms on FVA and FVOD.

The instructions to clients for completing the face valid items do not specify a time frame. Thus, individuals who have been abstinent, or who have not experienced problematic usage for an extended period of time, may be classified as chemically dependent on the basis of acknowledging past behavior. For many clinical applications, it is important for the clinician to determine the recency of the behaviors acknowledged on FVA and FVOD.

OAT:
The OAT items were selected because they discriminated between people with a substance-dependence disorder and controls when the items were administered with standard instructions to be candid and honest in responding.

Clinical experience has shown that elevated scores on OAT reflect a tendency to acknowledge behaviors and personality characteristics commonly associated with substance abuse, e.g., impulsiveness, low frustration tolerance, impatience, resentment, self-pity. Clients with elevated OAT scores are often readily able to relate to and identify with substance abusers, including those in recovery (for example, in addictions films and self-help groups). They tend to be open to feedback, although they are not always receptive to the idea that it is in their best interest and within their capability to change.

SAT:
The SAT items were selected because they discriminated between people with a substance- dependence disorder and controls, regardless of whether the items were administered with standard instructions or instructions to conceal any evidence of a problem ("fake good").

Clinical experience has shown that elevated scores on SAT reflect a tendency for individuals to be detached from their feelings and to have relatively little insight into the basis and causes of their problems. People who have a substance-related disorder and high SAT scores often find it difficult to fully accept the significance of substance usage in their lives. Particularly when SAT is the highest elevated scale, the client may present as having few symptoms.

DEF:
The DEF items were selected because they discriminated between people who were given the items under standard instructions and people who were given the items with instructions to "fake good."

Clinical experience has shown that elevated scores on DEF reflect a tendency to avoid acknowledging any signs of personal limitations and faults. Individuals with high DEF scores may focus on blaming other people and external circumstances for their problems. They may therefore find it difficult to fully engage in a treatment process.

Clinical experience has also shown that a low DEF score is indicative of emotional pain. A DEF Score below T-40 may not simply reflect low defensiveness, but rather a tendency to be overly self-critical. This can result from problems with self-esteem and can be related to symptoms of depression such as a loss of energy, a sense of hopelessness, and suicidal ideation.

SUPPLEMENTAL SCALES (FAM AND COR)

FAM:
The FAM items were chosen on the basis of their ability to discriminate between family members of people in treatment for substance dependence and control subjects. The FAM Scale has not been subjected to cross-validation. However, it has been found by SASSI users to be helpful in the clinical process.

FAM is not used in the decision rules. It is included in SASSI-2 as a source of supplementary clinical information. Clinical experience has shown that high FAM scores are indicative of a tendency to focus on others. Clients who have elevated scores on FAM are likely to have problems in such areas as establishing a sense of personal power and setting limits with others.

COR:
The COR Scale was developed by selecting the SASSI true/false items that best discriminated between subjects who were above versus below the mean on an index of criminality. The index was based on number of felonies, number of aggressive crimes (disorderly conduct, battery, and assault), number of arrests, probation violations, prior incarcerations, and juvenile record. The available data suggest that people who score above the COR cutoff of 11 are more than twice as likely to have a broad range of legal problems than those who score below the cutoff.

The COR Scale is not part of the SASSI-2 decision rules for chemical dependence. The scale identifies individuals who may be at relatively high risk for legal difficulties. It is intended to be used as a source of information that can be useful in identifying treatment needs and developing treatment plans. It is not intended as a tool for diagnosing any type of psychopathology, including psychopathy, sociopathy, and antisocial personality disorder. COR is a relatively new scale; at this time The SASSI Institute is unable to provide recommendations for more detailed interpretation of the clinical meaning of the COR Scale score.

CLINICAL CONSIDERATIONS

SASSI-2 profiles provide information that can be useful in suggesting possible treatment issues.

DETOXIFICATION:
Depending on the recency of usage, clients with elevated face valid scale scores may need supervised detoxification.

FURTHER RISK IDENTIFICATION:
The criterion groups that were used to develop the SASSI decision rules were made up of individuals in intensive treatment for substance dependence. Thus, the decision rules target dependence rather than abuse. Clinical experience suggests that individuals who are not test positive on the SASSI and have elevated scores on FVA, FVOD, OAT or SAT may be at risk for substance abuse. Further evaluation and consideration for substance abuse education may be valuable for non-chemically dependent clients who have face valid scale scores greater than a T-score of 70, or OAT or SAT scores greater than a T-score of 60.

LEVEL OF ACKNOWLEDGEMENT:
Scale scores on FVA, FVOD, OAT, SAT, and DEF provide information that can be useful in the process of deciding on the optimal level of intervention and treatment intensity. The face valid scales reflect an ability and willingness to acknowledge problematic substance usage. Some clients have elevated face valid scores and non-elevated scores on the subtle scales. Clinical experience supports the logical expectation that those clients are often able to profit from psycho-education and other relatively non-intensive treatment modalities. OAT reflects an ability to acknowledge some of the problematic behaviors commonly associated with substance abuse. Clinical observation suggests that clients with elevated OAT scores are often readily able to identify with other substance abusers who are in a process of recovery. Thus, clients with elevated OAT scores should be considered for group treatment and appropriate support groups and self-help groups. Clients whose primary scale elevations are on SAT and DEF are likely to require relatively intensive interventions to begin an effective recovery process, even though they may present as not having serious problems in adjustment and functioning. They may need specific help in overcoming resistance to treatment.

DEF:
Clients who have elevated DEF scores are likely to have approached the assessment in a defensive posture. This may be situational, resulting from the circumstances leading to the assessment, or it may be a more general trait. An elevated DEF suggests the possibility that defensiveness may be an important issue during treatment.

Clients who have DEF scores below the T-40 line may be in considerable emotional pain. A DEF score that low may reflect more than a low level of defensiveness; it may reflect a tendency to be overly self-critical. This can result from problems with self-esteem and can be related to symptoms of depression such as a loss of energy, a sense of hopelessness, and suicidal ideation. It is often important to explore these possibilities in a more comprehensive assessment. Clients with low DEF scores typically respond well to a therapeutic approach based on acknowledging their pain.

COR:
The COR Scale is intended to help in making decisions regarding referral for treatment and supervision. Clients who score above the cutoff of 11 show response patterns similar to individuals who have relatively extensive criminal histories; therefore, it is appropriate to consider relatively intensive rehabilitative and supervisory services for them. COR Scale scores can also help make decisions regarding allocation of treatment and supervision resources in an effort to decrease recidivism in judicial systems, while enhancing the quality of individuals' lives.

Because the COR Scale is so powerful, misunderstanding or misinterpretation could have serious consequences. It is important to recognize that although the COR Scale has proven to be quite powerful in cross-validation, the available data reflect on its concurrent validity. Hopefully, longitudinal research will further clarify the predictive power of the scale. In other words COR has been shown to be highly associated with a history of criminal behavior, but it has not been tested as a predictor of future criminal behavior. It is also important to recognize that the COR Scale is presented as a measure of relative risk of criminality; it should not be used to make specific predictions about the likelihood of criminal behavior.

FAM:
The FAM Scale is not intended to be used to attempt to identify family members of substance abusers. The FAM Scale items were selected because they discriminated between family members of people in treatment for chemical dependence and control subjects. However, other samples have also yielded elevated FAM scores - a group of people in a weight control program, a group of psychiatric patients, and a group of mental health care providers.

Elevated FAM scores appear to be related to a tendency to focus on others in a variety of ways. Some clients find it difficult to recognize and address their own needs; some clients have a tendency to act in a blaming and judgmental manner; some clients fixate on the frustrating task of getting other people to change; many will appear to be similar to "enabling care givers." Treatment is often enhanced by providing education in family systems theory. It is often challenging to help these types of clients get past their goal of becoming more effective in influencing and controlling others. It is important to orient these clients to the idea that they are in treatment to find ways in which they can make changes in themselves to enhance the quality of their lives.

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RESEARCH AND DEVELOPMENT

PROVISIONAL SPANISH SASSI AVAILABLE FOR FINAL TESTING

by Frank Miller, Ph.D., Research Coordinator

The SASSI Institute is pleased to announce that a provisional Spanish SASSI has been sent to the printer for production. Following extensive testing, we are able to endorse use of the provisional Spanish SASSI for clinical purposes.

To further ensure the accuracy of the Spanish SASSI, we have decided to conduct a final round of testing. We are therefore providing it to clinicians who conduct diagnostic assessments on Spanish-speaking clients and are able to share data with us. We welcome contact from service providers who regularly conduct addictions assessments on monolingual Spanish-speaking clients (contact Mike Boye or Frank Miller at The SASSI Institute, 800-726-0526 or send E-mail to sassi@sassi.com).

As I indicated in prior issues of News and Reports, we have been highly aware of the need for an addictions screening instrument for Spanish-speaking clients. We have received calls from many clinicians who said that they need one now. We regret that we have not been able to meet that need. However, we wanted to provide you with a well-developed and well-tested instrument and therefore have been involved in a lengthy research process. We have made the final turn into the home stretch and are excited by the prospect of making a Spanish version of the SASSI available for your use.

Glenn, Linda, Mike and I are grateful for all the support SASSI users have given the research department. Our aim is to provide you with as useful an instrument as possible, and we rely on your help to do so. Thank you.

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