In this Issue...
Quest for Camelot
It has long been the dream of Glenn Miller, founder of The SASSI Institute, and his wife Margie to have a place where their business could grow and their family could live in close proximity to each other and to nature. Today we are celebrating the actualization of that dream. Like most visions, this one has been nurtured for many years.
Glenn earned his Ph.D. in Clinical Psychology with a specialization in assessment from Southern Illinois University in 1967. Three years later, while working as a consultant to the court system that ran the first federally funded DWI program in the country, Glenn was confronted with a particularly difficult assessment challenge. As the number of DWI offenders far exceeded expectations, he recognized the need to develop a brief, objective, and accurate means of identifying individuals in the court system who were likely to have substance abuse problems so that they might be referred to treatment. After 18 years of clinical research, Glenn published the Substance Abuse Subtle Screening Inventory (SASSI) in 1988, an addictions screening instrument which was an efficient, cost effective, easy-to-administer and empirically validated tool to identify those with a substance dependence problem. The SASSI Institute was formed that same year with the goal of providing a screening instrument that helps human service practitioners promote early intervention and treatment of substance use disorders and ultimately, to save lives. In keeping with that mission, the adult SASSI has been revised twice since its initial publication, the adolescent SASSI was developed and made available, and current research is ongoing to update the adolescent version and to formulate an effective Spanish version of the instrument.
The SASSI Institute began operations over ten years ago in the basement of Glenn and Margie's home with a staff of three employees. By 1992 the staff had increased to 12 employees, and the SASSI was being used in all 50 states and Canada. As the need to provide services to SASSI users grew and additional staff was required, the Institute moved its daily operations to leased office space in 1993. Prompted by the need to expand staff and facilities to accommodate ongoing research, clinical services and added customer support, the Millers began seeking a permanent home for the Institute. Glenn and Margie's dream came closer to fulfillment in the fall of 1996 when they found a peaceful and serene setting in the form of a camel farm sitting high atop a hill in southern Indiana. Margie appropriately named the property "Camelot." Using the existing 12,000 sq. foot barn and adjacent living quarters as a starting point, a unique building project was initiated to transform the camel barn into a new home for The SASSI Institute and for the Millers. Today, as we continue to meet the goals of our mission, we can also celebrate the fruition of the long-held dream of having a permanent home for The SASSI Institute.
Two articles about the SASSI have been published since the last issue of News and Reports -- 1) "Adapting and Using the Substance Abuse Subtle Screening Inventory-2 With Criminal Justice Offenders" by James A. Swartz, and 2) "Efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) in Identifying Substance Dependence Disorders in Clinical Settings" by Linda Lazowski, Franklin Miller, Michael Boye and Glenn Miller.
Dr. Swartz's article presents data on a substance abuse screening program that was developed by Illinois Treatment Alternatives for Safe Communities (TASC). TASC screens, assesses, makes treatment recommendations, and monitors more than 10,000 adult criminal offenders each year. Faced with the task of screening large numbers of people with limited resources (i.e., little time, little money, and few trained clinicians), TASC needed an instrument that was inexpensive, required little time, and was simple to administer, score, and interpret. It also had to classify offenders objectively and reliably, regardless of who administered the instrument and the conditions under which it was administered. Furthermore, many criminal justice clients misrepresent and under-report their drug use and will enter treatment only when coerced to do so (see Swartz, 1998). TASC therefore needed an instrument that would be able to detect substance dependence in people who are unable or unwilling to report relevant behaviors. The SASSI was chosen as the substance abuse screening tool for the legal offenders because it addresses those issues and also because it includes the Correctional (COR) Scale, which provides an index of the client's degree of criminal involvement.
The research described in Swartz (1998) began by analyzing completed SASSI-2s from 300 TASC clients. The goal was to formulate customized rules that would provide a simple, objective method for using SASSI scale scores to refer clients to the available treatment options. Once the customized rules were developed and the screening program was implemented, further data were gathered to assess the utility of the SASSI-2 as a screening tool for a criminal justice population.
Findings indicated that the customized rules designed for making TASC treatment recommendations produced referral results in proportions consistent with original indications of the availability of residential, intensive outpatient, and outpatient treatment resources. In addition, consistent with established estimates of the prevalence of substance dependence among legal offenders, the standard SASSI-2 decision rules produced test positive classifications of 83% in one offender program and 68% in another. Also, findings showed that the nonface-valid items on the SASSI were able to identify 14% of the clients from the entire sample who would not have been identified on the basis of their responses on the face-valid scales.
TASC case managers assessed the severity of use of each individual's primary drug of choice on a five-point scale ranging from no use to severe use. The five-level severity ratings were then collapsed into two categories, dependent (mild, moderate, and severe dependence) and nondependent (no use, nonproblematic use, abuse). When compared to the results of the SASSI decision rules, there were differences in 21% of the cases, with most of the discrepancies being cases that were test positive on the SASSI but not classified as dependent by the TASC case manager. These discrepancies may be due to the fact that the SASSI-2 classifies for lifetime dependence and the TASC case managers may have been assessing for current dependence. Also, the case managers' assessment of dependence was derived from collapsing a range of severity-of-use ratings rather than being based on specific diagnostic criteria.
SASSI classifications were also compared to the results of urine tests. Even though the presence of drugs in a person's system is not a clear indication of substance dependence, the results provided support for the utility of the SASSI in criminal justice settings. SASSI test positive classifications were significantly related to positive opiate and cocaine urinalyses.
The COR Scale was also found to be of value in screening TASC clients. Clients who exceeded the recommended cutoff for identifying individuals with extensive criminal involvement were found to have a significantly higher number of prior arrests.
Overall, the article identified areas for further research, and concluded " that the SASSI-2 be considered for use with criminal justice populations when a brief, objective, and accurate screening tool for chemical dependency is needed."
The article by Lazowski et al. (1998) is a comprehensive presentation of the development and cross-validation of the SASSI-3. The sample that was used to develop and cross-validate the SASSI-3 included 839 cases that had both a valid SASSI test classification and a DSM-based clinical diagnosis. The overall sample was divided into two sub-samples; one was used to formulate the SASSI-3 decision rules, and the other was used to cross-validate the accuracy of those rules. Using the cross-validation sample, results indicated that 97% percent of the people who were diagnosed as being substance dependent were correctly classified by the SASSI-3, and 95% of the people who were diagnosed as not being substance dependent were also correctly classified. The importance of the subtle items was assessed by a comparison of the accuracy obtained with and without them. Using just the face-valid items, an 83% level of overall accuracy was obtained. The subtle items increased the overall accuracy to 96%.
The article includes analyses of the degree to which the accuracy of the SASSI-3 is affected by three factors that are important to consider in making clinical assessments - demographic variables, treatment setting, and level of adjustment and functioning. The demographic variables that were studied are gender, ethnicity, occupational status, marital status, age, and years of education. They were not found to have a significant impact on the accuracy of the SASSI-3. The data that were used to formulate the SASSI-3 were provided to us by SASSI users from a variety of treatment settings - addiction treatment centers, a dual-diagnosis hospital, general psychiatric hospitals, a vocational rehabilitation program, and a sex-offender treatment program. The accuracy of the SASSI-3 decision rules ranged from 93% in the sex-offender treatment program to 98% in the dual-diagnosis hospital. It is interesting to note that an overall accuracy rate of 97% was obtained in a general psychiatric hospital, in which all of the people had psychiatric problems, but only 76% were diagnosed as being substance dependent. Thus, the SASSI-3 can identify substance dependence even within a sample of people who have other types of psychiatric disorders, providing evidence that the SASSI-3 is specifically geared to substance dependence rather than to more general forms of psychiatric maladjustment. Further, findings indicated no significant effect of the clients' level of general adjustment and functioning on the accuracy of SASSI-3 test classifications.
Lazowski, L. E., Miller, F. G., Boye, M. W. & Miller, G. M. (1998). Efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) in identifying substance dependence disorders in clinical settings. Journal of Personality Assessment, 71(1), 114-128.
Swartz, J. A. (1998) Adapting and using the Substance Abuse Subtle Screening Inventory-2 with criminal justice offenders. Criminal Justice and Behavior, 25(3), 344-365.
SASSI Identifies Substance Dependence in Young Offender
In keeping with The SASSI Institute's commitment to the early identification and treatment of substance dependent offenders in the criminal justice system, we would like to present the following profile of a case recently called in to our clinical support service. We are grateful to the counselor and treatment center that granted us permission to share this information with you.
The profile is of a 23-year-old male whom we will call "Ben." Ben was in his 4th week of detention at a local midwestern jail. He was arrested after turning himself in for a prior domestic violence offence committed while under the influence of alcohol and for which he had fled the state. Ben had one prior arrest for receiving stolen property which he had subsequently traded for drugs. The treatment provider conducting the assessment had been meeting with him at the jail for several weeks. The court was particularly interested in determining the level of risk that Ben would again flee the area.
When examining a SASSI profile, it is important to begin by looking at the most basic data-random responding, decision rule results, and defensiveness. Notice that Ben seemed to respond to the SASSI items in a meaningful manner (RAP=0) and that there is no test evidence of defensive responding (DEF=4). The results of the decision rules indicate that he is likely to have a substance dependence disorder ("Yes" on Rules 1,2,3,6,7 and 9).
Ben acknowledges extensive and severe alcohol and drug problems (FVA=23 and FVOD=29). Although he claimed to have been abstinent during several weeks prior to incarceration, his substance use history likely includes substantial substance-related problems including loss of control, negative consequences, and social functioning.
There is significant evidence that Ben's life experiences include living in social environments where the abuse of alcohol and other drugs and associated consequences is a relatively common and routine occurrence (SYM=8). Despite Ben's awareness of behavioral problems related to his drinking and drugging, the normalization of such problems in the milieu in which he lives may make it difficult for him to fully accept the severity of his addiction.
In addition, Ben's responses are remarkably similar to substance dependent individuals who often lack awareness and insight regarding the impact of alcohol and drug use on their psychological and emotional functioning (SAT=5). He may be unaware of related symptoms such as emotional avoidance, fear of intimacy, and obsession with maintaining personal power and control. In spite of these limitations, Ben does seem to acknowledge some awareness of possessing behavioral characteristics and traits commonly associated with substance dependence (OAT=7). These may include such things as low frustration tolerance, impulsivity, self-centeredness, and irritability.
While there may be some moderate risk of ongoing legal problems (COR=9), Ben's score is well below the cutting point. Therefore, it would be prudent to recognize the limitations of the COR scale, especially when making case disposition decisions.
This case presents us with a good example of the value of early identification of substance dependency problems in criminal justice settings. Ben's SASSI results clearly demonstrate a well-established pattern of substance dependency that will require relatively intensive intervention. Therefore, he may be a solid candidate for diversion into an alcohol and drug treatment program as a way of reducing the risk of future offenses.
Treatment planning should include interventions designed to build upon Ben's willingness to be open about his alcohol and drug problems. Efforts to increase his self-awareness and insight regarding the pervasive nature of substance dependence in his life would be valuable. Cognitive approaches may be beneficial in helping Ben to reframe his view of the social environment in which he lives. Community self-help groups and therapeutic group modalities may be particularly helpful in providing an environment that encourages abstinence and in establishing new social support networks.
The recommended level of care should include adequate supervisory support and structure to ensure successful completion of treatment and transition into aftercare. Random toxicological screens, cognitively based behavior management strategies, and possible use of transitional living arrangements may be of benefit In addition, anger management and impulse control issues should be addressed to reduce the risk of continued domestic violence.
Qualification Forms: Not just More "Red Tape"
We at The SASSI Institute would like every one working with clients that may have substance use disorders to have access to the SASSI. The professional ethics of the American Psychological Association allow us to release the SASSI questionnaires only to individuals with adequate training in assessment. We interpret this to include most certified health care professionals and all clinicians who have completed certified SASSI training. We are required to document these qualifications in order to fill your order.
Unfortunately, we do not have a current qualification form on file for some of you. We know that sometimes guidelines established to protect clients can seem like a nuisance, but we need your help to be able to serve you. Your order will be shipped within one day of receiving the necessary documentation. Be assured that we do NOT sell our customer list to anyone, and we do not identify any of our customers without their permission.
As of January 1, 1999, the SASSI-1 and SASSI-2 will no longer be available. Those of you who may be using these versions for research or other reasons should order the amounts you need before that date. We encourage SASSI users to take advantage of the increased validity and improvements of the SASSI-3.
Please Change your records to reflect our new address:
The SASSI Institute
Route 2, Box 134
Springville, IN 47462
Our toll-free numbers have not changed
Q - What do I need to use the SASSI?
A - Others may intend the question to be "How can I learn to use the SASSI?" A person with grounding in assessment and clinical matters can acquire the skills to use the SASSI in a number of ways. We have tried to provide these options because people differ in the extent of information that they already have and the optimal way in which they learn - reading, watching, doing, listening.
For many counselors, one excellent way to learn to use the SASSI is to attend a certified SASSI training. Our two standard half-day workshops are the result of over 10 years experience and hundreds of training sessions to help people learn the basic skills of using the SASSI. Trainings provide a blend of hands-on experience, didactic information, modeling, slides and/or videos. One workshop focuses on administration, scoring and use of the decision rules -- the other on developing clinical interpretations from scale scores and patterns of scores. Even those who prefer learning by reading manuals often find it easier to schedule a half-day workshop than to set aside an equal amount of uninterrupted study time.
For those clinicians who do learn well by reading materials, particularly those with extensive experience in using assessment measures, information from the SASSI Manual, the User's Guide, and related documents on clinical guidelines would be sufficient. However, for more detail on clinical interpretation, it may be of value to attend the training session on clinical interpretation and feedback.
In addition to the above, all users of the SASSI in the United States and Canada have free access to consultation on specific profiles or broader clinical or research issues on our toll-free phone lines. The consultants are experienced clinicians with backgrounds in both the SASSI and addictions. We try to maintain enough available hours of such coverage so that 90% of such calls are immediately connected to the consultant.
Keep in mind that no matter which method of learning you may prefer, we are always eager to hear your questions, comments, suggestions, etc. regarding the SASSI and its related materials.