In this Issue...
As many of you may be new to the SASSI, we thought it would be a good time to briefly describe our free consultation service. We currently have a staff of four clinicians whose primary responsibility is providing assistance with questions related to the administration, scoring, and interpretation of the SASSI. Those just beginning with the SASSI usually find the service is helpful in verifying the accurate use of the decision rules and in gaining new insights into the meaning of the scale scores. Even veteran SASSI users call occasionally with unusual profiles or just to verify their clinical impressions.
When providing consultation, the only information we normally need is the client's gender and age. Sometimes it is helpful to know the referral source or the reason for the referral simply as a way of knowing how to direct our comments. In some cases it is also helpful to know if the client has had previous substance dependence treatment, especially if they score as test positive or if their scores are extreme. This information helps us to be more precise in our feedback and hopefully more useful to you. It is in no way meant to be intrusive or to be a violation of your client's privacy.
Although we have no limit on the number of times you can call, we usually prefer that you review no more than two profiles per call. Our service is available by calling our toll-free clinical line, 888-BY-SASSI, from 8 a.m. to 6 p.m. EST Monday through Thursday and 8 a.m. to 5 p.m. EST on Friday. Additional clinical information is available on our web site at www.sassi.com. We are also pleased to provide this service to our colleagues in Canada. In fact, this month's clinical interpretation is based on a call from a treatment agency in northern Canada.
The SASSI Institute has been privileged to work with criminal justice programs throughout the country that have seen the value of providing addictions services to offenders. The issue truly transcends political ideology. The suffering that stems from alcohol and other drug-related crimes falls on the victims, the victims' families, the perpetrators, the perpetrators' families, and on society as a whole. The costs to society go beyond the direct costs of policing, adjudicating, and incarcerating offenders. The financial burden on society is phenomenal; taxpayers spent $30 billion in 1996 to incarcerate inmates for drug- or alcohol-related crimes. Beyond that, the quality of all our lives can be enhanced by stopping the spiraling cycle of drug-related crime. The SASSI Institute is pleased to contribute to the effort by promoting identification of substance dependent offenders for the purpose of treatment.
Respect Realities of Client's World
One reason why people may have difficulty perceiving that their substance use has a negative impact on their lives is that the substance brings immediate relief from emotional pain, even though greater pain is the ultimate consequence. Many of our clients face the challenge of having to recognize that their ongoing problems are attributable to an important and apparently satisfying behavior - no easy task. As people confront the need to stop their misuse of psychoactive substances, they must let go of what may be a primary and valued aspect of their lives. What we recognize as a major source of their problems, they may see as the only solution. If we wish to help individuals who suffer from substance abuse, we must seek to understand and respect the manner in which they perceive their usage.
Some people do not recognize the impact that substance misuse has on their lives because they do not see an alternative. This phenomenon is not limited to small, geographically isolated communities like Mary's and John's (see Clinical Interpretation). Many people who live in larger towns are members of sub-communities in which substance abuse is the norm - "everybody drinks and drugs, everybody has family fights, everybody has hangovers, everybody has money problems, everybody has legal problems." As helpers and service providers, we have a responsibility to recognize and deal effectively with the realities that confront our clients. It is disrespectful to expect people to easily reject a central aspect of their social milieu and readily embrace a life style that is completely foreign to them.
Providing clients with feedback on the SASSI can promote a collaborative relationship in which we join our clients in the process of exploring their worlds and seeking ways in which to enhance the quality of their lives. Consider Mary's and John's profiles; an outstanding feature is elevated SYM scores. SYM provides a measure of clients' acknowledgement of being involved in a pattern of heavy usage and associated negative consequences. Since it is composed of items that directly address substance misuse, it is valuable to review the salient items with clients and ask them for elaboration. For example, an elevated SYM score may indicate a history of parental substance abuse, early onset of substance misuse, and associated family problems. During the process of providing feedback, it is important to promote discussion to help clients gain a greater understanding of the role of substance use in their lives and to help them increase perspective and insight into the manner in which substance use has affected their lives.
We expect our clients to be receptive to the process of change; so too we must endeavor to understand their worlds in which they live. The act of change is an act of courage. As addictions counselors we are privileged to stand witness to courage shown by our clients as they open themselves to new ways of seeing and being in the world. Through our patience and understanding, we can hopefully be a source of encouragement and support along the way.
(Please note that the SASSI Institute recommends examining specific items on the FVA, FVOD, and SYM scales. We recommend against conducting item analyses on the subtle scales - OAT, SAT, DEF, SAM, FAM and COR.)
SYM Scale Reveals Need to Investigate Impact of Environmental Factors
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 dependence 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-3 (Decision Rule 3).
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) but at a level that is more consistent with a high probability of substance dependence (Decision Rule 1 and Decision Rule 7). Like Mary, his responses are highly similar to substance dependent individuals who report life circumstances and experiences commonly associated with substance abuse (SYM=9). This score likewise results in a test positive on the SASSI-3 (Decision Rule 3).
Having established that Mary and John are likely to have a substance dependence 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. Substance dependent individuals 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 behaving 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 dependence 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 dependence 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 dependence 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 dependence 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 dependence 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-3 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-3 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.
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We are often asked if the SASSI can be used as a screening tool with psychiatric patients. The answer is yes. Based on data from 237 patients in general psychiatric hospitals, the SASSI-3 correctly classified 99% of those who had a substance dependence disorder and 91% of those who did not. Research on the Adolescent SASSI in a dual diagnosis setting (Piazza, 1996) revealed 86% correct classification for patients who were diagnosed as having a substance use disorder and 93% correct classification for those who were not.
It is important to be aware that the SASSI can be used to identify substance dependent patients from within a population of psychiatric patients; however, the SASSI should not be used to identify dual diagnosis patients per se. The primary purpose of the SASSI is to screen for substance dependence, and examinations of individual scale scores provide clinically useful information about various aspects of clients' adjustment and functioning. Therefore, some people may think the SASSI should be used to screen for psychiatric problems as well as substance dependence. Keep in mind that it is important to distinguish between screening for psychiatric illness and screening for substance dependence within a population of psychiatric patients.