In this Issue...
The President's Desk - Promoting Recovery Transcends National Boundaries
I recently had a wonderful opportunity for renewal and rededication. I was privileged to be part of the First Australian Conference on Addiction Disorders and to also meet with a group of SASSI trainers in Canada. I talked with some wonderful counselors from several countries, heard a number of outstanding speakers, and again felt part of a larger movement for positive change. Although Australia and Canada have healthcare systems that differ in many respects from ours in the States, I was once again struck by the fact that the destructive power of addiction disorders and the healing powers of effective intervention, treatment, and "aftercare" truly transcend national boundaries. I am grateful to have been able to witness the vitality of individuals and programs promoting recovery in other countries. As I return to my daily tasks, I am energized by a renewed awareness of a common purpose that unites caring, dedicated people from all cultures.
Indeed, within the broader purpose of our work, we are beset by numerous chores, chief among them being paperwork. Now I am asking that you add a few minutes of paper work to your load by responding to the enclosed information card. The staff at the SASSI Institute wants to do everything possible to enhance the utility of the instrument as you work with your clients. To that end, we would like to know more about people who are using the SASSI and in what contexts. So please take a moment to complete and return the enclosed card to us. I also hope that you will take time out this summer to enjoy some very pleasant and relaxing activities!
One of the points that is made in the FAQs column in this issue of News and Reports is that the SASSI should not be used to draw firm conclusions regarding the cause of clients’ defensiveness. We cannot confidently conclude from the SASSI that defensiveness is rooted in substance dependence, even with people who have elevated DEF and SAM scores. However, it is important to understand the basis of a client’s defensiveness, especially since substance dependence is often a factor.
With years of practice in avoiding painful realities, defensive clients may lose access to their areas of vulnerability. Therefore, the product of their defensiveness becomes their reality, and we are faced with the difficult task of helping them see a new reality. The task is often frustrating. Some clients come to us as masters in the art of defensiveness. It is clear to us that their behavior is self-defeating; it detracts from the quality of their lives. Yet they attribute their problems to circumstances beyond their control, and they continue to engage in the self-defeating behaviors. However, it is important to realize that if a person persists in a behavior, it serves some need. If we wish to help our clients find their way through the maze of their defensive attributions, we must appreciate and respect the needs that are being served by their apparently maladaptive behaviors.
Consider one of the ways in which defensiveness might emerge during the course of the progression of substance dependence. From time to time many of the people who suffer from substance dependence recognize that they cannot live if they continue to use; but they also cannot conceive of not using. Their substance use is the most important thing in their lives, but they know that it is draining them – emotionally, spiritually, socially, financially, etc. Thus, substance dependence often leads its victims to an awesome fear, a sense of being trapped. It is natural to do whatever possible to escape the fear. One way is to defend against awareness of the negative impact of the substance misuse.
Some substance dependent people spend years hiding from the reality that their substance usage is a source of pain in their lives. Then, when they start to recognize the problem and begin a program of change, they may immediately announce that: "It’s no problem. I don’t even feel like using any more. I don’t need to do anything special not to use, and there’s no problem with my going to the bar and drinking cokes to be with my friends." It may be clear to us that their usage has long been out of control and has been an ongoing source pain in their lives. It may be clear to us that, in minimizing the potential for relapse, they are continuing to defend against an awareness of the manner in which the drug has pervaded their lives and that their defensiveness is setting them up for relapse.
As counselors, we respect our clients and recognize that defensiveness is a natural part of the problems they face. Sometimes we encounter clients who are so well defended that they present us with nothing other than a wall of "buts" and impenetrable rationalizations. More often, we are able to penetrate the defensiveness in a caring manner, and we help many people move through their pain. However, in the day-to-day tasks and pressures of our jobs, we may not take time to fully see and appreciate the tender core that resides deep within the maze of defensiveness. I sit here now and think of one of the first lessons I learned about addictions. A recovering person spoke of the overwhelming fear that he felt as he faced the prospect of abandoning alcohol. I do not recall his words, but I recall the vision of a person tortured by the wanderings of his mind; and he hears a distant but persistent voice saying that the only path to relief may be closed. As I contemplate that reality, I feel a sense of being lost in pain. I feel the pervasive inner fear that comes when I sense my smallness and my vulnerability.
When I become frustrated as I work with people who appear impenetrable and aggressive in their defensiveness, I hope to remember that the wellspring of defensiveness is our need for loving assurance.
Clinical Interpretation: SAM Contributes to SASSI-3 Accuracy
Many of you have called in recently asking about the best way to interpret the SAM scale. In the FAQ’s section of this issue of News and Reports, Frank reviews the history of the SAM scale development as well as the proper use of the scale when examining SASSI-3 results. For further illustration, we thought it would be helpful to look at a profile in which the DEF scale is not elevated but the SAM scale plays an important role in determining the probabilty of the client having a substance dependence disorder.
This SASSI-3 profile of a 37-year-old female was recently 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) and there is no evidence of defensive responding (DEF=3). She is likely to have a substance dependence disorder based on Rule 7 (FVOD=15, SAM=8).
Notice that despite the relatively low DEF score and apparent lack of defensive responding, the SAM scale score, when combined with the elevated FVOD 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, its 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=5) may be an indication of some limited ability or willingness to acknowledge behavioral problems commonly associated with substance dependence.
The moderately elevated SYM (SYM=6) is consistent with clients who often are not able to recognize the manner in which substance dependence 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.
She may also have poor insight and self-awareness regarding the way in which substance dependence has pervaded into numerous areas of her life (SAT=5, SAT greater than OAT).
She may need assistance in recognizing the ways in which her substance use has effected her psychological, emotional and spiritual functioning. Her scores are consistent with individuals who tend to present as relatively well functioning, maintaining an illusion of control over their thoughts, feelings and actions.
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.
Treatment Recommendations:
This client is likely to have a substance dependence 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 dependence 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. Interventions geared towards joining her in the process of getting in touch with her emotional pain and how it relates to her substance dependency would be important to consider,
Community-based self-help support groups could provide additional encouragement and support.
Frequently Asked Questions on SAM
Q - How is SAM different in the SASSI-3 than in earlier versions of the SASSI?
A - SAM has an interesting history, and it has gone through a number of name changes since the first version of the SASSI (i.e., DAN, DEF2, SAM). It was initially developed as a correctional factor for the DEF scale. As you know, DEF measures defensiveness, not substance dependence. Therefore, if all the people who had elevated DEF scores were classified as test positive on the SASSI, the SASSI would produce too many false positives. The SAM items were chosen because they differentiated high DEF clients with substance dependence from other high DEF clients. In the original SASSI, the SASSI-2, and the Adolescent SASSI, SAM is used in the decision rules only in combination with elevated DEF scores.
SAM’s role in the decision rules changed when SASSI-3 was developed. It is used in three of the SASSI-3 rules, including one that does not involve DEF. As we work on the SASSI, our main goal is for it to be as accurate as possible, and we were able to maximize the accuracy of the SASSI-3 by using SAM in combination with scales other than DEF. Therefore, SAM is no longer used in the decision rules exclusively with elevated DEF scores.
Q - Under what circumstances should SAM be interpreted?
A - SAM should be used only as part of the decision rules. It should not be used as a source of hypotheses for clinical interpretations. Since the SASSI was first published in 1984, the SASSI Institute has learned a lot about the clinical meaning of some scale scores. For example, we know a good deal about high OAT scores, high SAT scores, high DEF scores, and low DEF scores. However, we have not been able to gain a clear picture of the clinical meaning of SAM scores.
Because SAM was developed to differentiate high DEF people with substance dependence from other high DEF people, it is tempting to conclude that clients with elevated DEF and SAM scores are defensive about their substance dependence. Indeed, that may be the case, but we cannot be sure. It is reasonable to infer that people who have elevated DEF scores are defensive; and if their SAM scores cause them to be test positive on the SASSI-3, it is highly probable that they are substance dependent. But we really cannot be confident that their defensiveness is caused by their substance dependence.
We are currently in the process of examining the relationship between SASSI scales and other clinical information (e.g., indices of general adjustment, criminal histories, work histories, personality measures). We thereby expect to learn more about the clinical meaning of all the SASSI scales, including SAM. In the meantime, The SASSI Institute advises against drawing clinical meaning from examinations of SAM scores.
NOTE: "FAQ’s" is now a regular column in our newsletter. If you have any questions about the SASSI or have a topic that you would like clarified, please let us know.