Feedback to clients on SASSI profiles is useful in increasing awareness, eliciting further information, and establishing rapport. Presenting the results of the decision rules and discussing scale scores can help people come to grips with the significance of their substance usage and identify treatment goals.

Responses on face valid scales provide direct information about the aspects of substance misuse that clients are able and willing to acknowledge. The SASSI Institute recommends that you review clients' responses on the face valid items prior to providing feedback.

The Adult SASSI-3 contains three face valid scales - FVA, FVOD, and SYM. The Adolescent SASSI-A2 contains five face valid scales - FVA, FVOD, FRISK, ATT, and SYM.

Feedback on FVA and FVOD can be a powerful tool in building a bond between you and your clients and increasing their awareness of the impact of substance misuse on their lives. The key is to let clients know that you are working with them to gain an understanding of what is significant in their lives. Before sessions begin, read the responses to the items on the face valid scales. During the feedback session, summarize the endorsed items, ask for clarification, and try to elicit further disclosure. Try to convey the sense that you are joining with your clients in exploring substance-related behaviors that have an impact on the quality of their lives.

For example, some clients may endorse the following two face valid items: "Taken a drink or drinks to relieve a tired feeling or give you energy to keep going." "Taken drugs to forget school, work, or family pressures." You might provide feedback to the effect that the test indicates that they are not simply using alcohol and other drugs for social or recreational purposes, but rather to cope with the stress and strain of life. You might remind them that it wasn't like that when they first began using, but things may have progressed to the point that they are using drugs to just feel okay. Try to involve your clients in the process by asking for clarification from them. You can enhance rapport and elicit greater disclosure by creating a context of conversation rather than interrogation. For example: "I'd like to hear a little more about your history of using. Tell me how things have developed or changed since you started using."

Although both the adult and adolescent SYM scales are composed of face valid items, their content is different.

The Adolescent SASSI-A2 SYM scale is similar to the FVA and FVOD scales in that it provides an indication of the client's willingness to disclose loss of control and negative consequences of substance misuse. The process of providing feedback on the SASSI-A2 SYM scale is therefore similar to providing feedback on FVA and FVOD. Identify the endorsed SYM items prior to giving clients feedback. Try to paraphrase their responses in a manner that is meaningful to them and likely to elicit further disclosure. For example, if a client endorsed items dealing with excessive use or loss of control, you may say something like, "Your results on the questionnaire suggest that you might be the type of person who goes to a party intending to have just a little beer or a few hits of pot, but you use a lot more than you meant to and end up getting wasted. Tell me about that." Feedback is likely to be most effective if it stimulates the client to increased disclosure and greater self-awareness.

The Adult SASSI-3 SYM items were included in an effort to identify early-onset substance abusers who are likely to be part of a family/social system that has a strong focus on the use of alcohol and other drugs. This can be an important consideration in conducting an addictions assessment and in providing feedback on the SASSI-3. Some people with elevated SYM scores who misuse substances and experience significant negative consequences may view their involvement with alcohol and other drugs as normal, no different than most of their friends and family. It may therefore be difficult for people with elevated scores on the Adult SASSI-3 SYM scale to appreciate the extent to which their usage brings them pain, and it may be even more difficult for them to see an alternative. Thus, it is particularly important that the feedback be presented in a fashion that is respectful and meaningful to the individual. If, indeed, people with elevated SYM scores see extensive and problematic use of alcohol and other drugs as normal, it is important to structure and pace feedback and confrontation regarding usage in a manner that will promote change rather than mobilize defenses. For example: "Your responses on the SASSI indicate that you started drinking (or drugging) at a young age and that that there are other members of your family who use a good bit. I'd like to hear more about that."

Content analysis of the FRISK items suggests that adolescents who have elevated FRISK scores are likely to be part of a family and social system that promotes rather than prevents substance misuse. They may therefore have difficulty recognizing and accepting the consequences of their substance misuse. Since FRISK is composed of face valid items, feedback can begin by asking clients to talk more about some of the endorsed items - "Tell me more about what you mean when you say that you have felt bad or scared because of the drinking or drug use of someone in your family." Try to elicit statements about their feelings in regard to the items they endorsed on the FRISK scale -"It sounds like it must have been hard to have to deal with worrying about your father's drinking." Try to summarize what you learn from clients in a manner that may increase their recognition that the consequences of substance use are real and painful - and that they can be changed.

The items on the ATT scale address adolescents' attitudes toward substance use, e.g., "Drugs help people to be creative." "I think many adults who say they are against drugs probably use some kind of drugs themselves." Content analysis of the ATT items suggests that clients who score high on the scale are likely to be defensive if they are confronted regarding the consequences of their substance use. Caution should be exercised in attempting to give clients feedback on elevated ATT scores. They may be quite eager to expand on their views, and arguing with them is likely to be counterproductive. They know what their attitudes are, and they are not likely to change those attitudes without a structured program that includes peer support for behavioral and attitudinal change. Avoid debating.

The subtle items on the Adult SASSI-3 and the Adolescent SASSI-A2 do not have an apparent relationship to substance misuse and related behavioral characteristics. Therefore, the SASSI Institute recommends against reading and trying to interpret clients' responses to the items on the subtle scales. However, it is useful to draw clinical inferences and provide feedback on the basis of scores on five of the subtle scales - OAT, SAT, DEF, FAM, and COR.

OAT scale scores reflect an individual's tendency to endorse statements of personal limitation, particularly those that are commonly and stereotypically associated with substance abusers (e.g., impatience, low frustration tolerance, grandiosity, etc.). High scorers may be relatively able to recognize in themselves what are sometimes termed "character defects," and they tend to endorse statements suggesting personal limitations. Low scorers are likely to be reluctant to acknowledge personal shortcomings - human foibles.

The type of information contained in the OAT scale is sensitive and should therefore be shared with clients in a sensitive manner. The discussion of feedback on the face valid scales emphasized the importance of communicating an understanding of what is going on in clients' lives in order to promote bonding with clients, thereby helping them gain insight and overcome defensiveness. This type of empathetic communication is also important in providing feedback on the OAT scale. Being accurate and incisive in your feedback to clients is effective only if they are receptive to the feedback, and the way the feedback is presented by the therapist affects clients' receptivity.

Remember, a key element in understanding OAT scores is that the significant issue is not whether individuals are particularly prone to the various problem behaviors and attitudes; the important thing is whether or not they are likely to acknowledge them. Therefore, it is not appropriate to tell clients who have a high OAT score that they have various character defects; rather, the feedback should focus on exploring the possibility that they tend to see themselves as having traits such as impulsiveness, low frustration tolerance, etc. This can be done in a spirit of good humor and can engender a sense of camaraderie. It is not useful to agree or disagree with clients' self-appraisals. It is more valuable for you to convey an understanding that they may have a tendency to focus on personal limitations and encourage them to explore that with you.

In providing feedback on low OAT scores, it is important not to engender defensiveness by implying that clients do not have an adequate capacity for critical self-examinations. Bonding can be achieved by empathic reflection on the pain associated with harsh internal, as well as external, criticism.

Test feedback can be useful in helping clients set goals for treatment. During the course of providing feedback on OAT scores, clients can be encouraged to talk about how they deal with internal and external voices of criticism and how this affects the quality of their lives. From this vantage, you can help them develop healthier, more realistic, and more stable self-images.

Feedback on the SAT scale can help some clients recognize the pervasive and deluding nature of their substance abuse problems. Many of us who work in the substance abuse field have developed a keen appreciation for the phrase "sincerely deluded." It refers to the phenomenon that some people focus a great deal of their energy on use of alcohol and other drugs, they suffer serious negative consequences as a result of their usage, but they genuinely do not perceive the extent to which their lives are dominated by their substance use. When they report to their counselors that the problem is not their usage, they are telling the truth as they know it. It is no wonder that substance dependence has been referred to as a "cunning" disorder.

The SAT items were selected because they discriminated between people with a substance use disorder and control subjects regardless of whether the items were administered with standard instructions or with instructions to conceal evidence of substance misuse. It is therefore not surprising that the SAT scale identifies people who have particular trouble recognizing the nature of their substance misuse.

There is great potential clinical value in providing feedback on the SAT scale, but it is also a challenging process. Providing feedback on the various face valid scales and the OAT scale is comparatively easy. Those scales measure clients' ability to acknowledge problematic behavior; elevated scores suggest that the individuals have awareness of problematic behaviors. When we provide feedback on those scales, our task is to use the clients' insight to increase their self-understanding and motivation for treatment and to help them develop personally meaningful treatment goals. When we are giving feedback on an elevated SAT score, we face the challenge of helping people see what they do not see. It is a difficult task but an important one; it is a first step.

Before discussing strategies for giving feedback on elevated SAT scores, let us first consider the broader issue of feedback. There is no point in giving people messages that are too strong and too discrepant from their points of view. On the other hand, there is also no point giving a message unless it promotes positive change. Successful feedback depends on starting from a point that clients can accept and then increasing the breadth of their understanding. It is counterproductive to tell people with elevated SAT scores that they have a problem but don't see it; it is disrespectful and likely to mobilize resistance. The challenge is to get their attention with something they may be able to accept. This requires giving them basic information in a neutral, non-threatening manner. For example: "Some of us center our lives on use of alcohol and other drugs." The choice of wording is important; it must be appropriate and meaningful for them. Another example might be: "For some of us, drinking and drugging is one of the main things in our lives. It's what we do most and what we think about a lot of the time when we aren't doing it."

After presenting the information, process it with the clients to get them invested in the topic. Then try to increase the clients' involvement in the process by giving examples. Again, the wording and the choice of examples must be appropriate and meaningful: "When some of us check the clock and look forward to getting off work, the first thing that enters our minds is getting home and having a drink." "For some of us, when a friend calls up and asks us to go fishing, we immediately think: `Great, I'll pick up a 12-pack and meet you.' It's like beer is tied to fishing." "For some of us, when we consider going to a party, we figure out how we can smoke a joint first so we can get there lit." The goal is to stimulate clients and get them fully involved in the discussion. Elicit examples and affirmations from them. Often clients will volunteer their own personal examples.

Once you and your clients have established a shared understanding of the phenomenon, suggest that many people who have a lot of regular life-activities tied to substance usage do not see how important that usage is in their lives. Let your clients know that this is a common phenomenon and not a sign of personal failure or weakness; and, again, try to draw them into the discussion to elicit further self-understanding.

This type of feedback can have a powerful effect on clients with elevated SAT scores. Although the intervention is not invariably effective, it is astonishing how often it facilitates clients in the process of recognizing that their usage is central in their lives. It helps them begin the process of gaining a personal understanding of the whole concept of addictions. Effective feedback on elevated SAT scores can also promote a bond of understanding between the therapist and clients.

As is true with other psychological tests, when we look at a SASSI profile, we typically begin by making note of scales that have elevated scores. However, low scores can sometimes be significant as well. Take a look at a SASSI profile sheet. Note that a T score below 40 on any scale means that the client's score on that scale is below the 15th percentile (i.e., the client scored lower than 85 percent of the normative sample). While low scores on psychological tests do not necessarily signify a psychological problem, they can be an indication of an important clinical issue.

The primary purpose of the DEF scale is to identify defensive clients who are trying to conceal evidence of personal problems and limitations. Whether it is due to life events or to personality characteristics, excessive defensiveness can be problematic, and it must be taken into account in treatment planning. Now, consider the opposite case. Clients who have a T score below 40 on the DEF scale have endorsed a relatively large number of negative self-statements, suggesting a tendency to focus on personal limitations and faults. If so, that could be a significant clinical issue that can have an impact on any therapeutic intervention.

A low DEF score is an indication that the individual has endorsed a lot of negative self-statements, suggesting the possibility of low self-esteem. Like excessive defensiveness, low self-esteem can be caused by external circumstances such as legal, personal, family or financial problems. It can also reflect a general personality characteristic. Regardless of the cause, if addictions treatment is to be effective, issues related to low self-esteem need to be addressed.

Individuals with low DEF scores may be experiencing a sense of hopelessness, inability to enjoy positive experiences, lethargy, general bad feelings, impaired functioning in vital areas such as sleeping and eating, and even suicidal ideation. While low DEF scores do not necessarily mean that clients are experiencing these things, the possibility should be explored. Appropriate use of feedback on a low DEF score can help the therapist gain a more thorough understanding of the scope of the problem.

When providing feedback on a low DEF score, it is vital to acknowledge and validate clients' feelings. People who feel badly about themselves often feel isolated and alienated from others; they have the sense that no one understands what they are experiencing. At the start of the session, it is important not to be too specific. Do not try to tell clients what they are feeling. Begin by providing a general acknowledgment of their bad feelings. The goal is to get the clients to start talking. Once they appear to feel safe in disclosing, it is valuable to reframe and feed back what they said. This enhances the clients' sense of being understood and provides an opportunity to gain clarity regarding the problem.

As the session progresses and clients become comfortable, it may be productive to probe for more specific information. The goal is to provide a sense that you understand without judging. This can help you and your client gain a greater understanding of what may be underlying the tendency to endorse negative self-statements. The interactive feedback may reveal that the low DEF score simply reflects a temporary reaction to negative life events, or it may reveal a more pervasive, chronic problem.

As rapport develops, you can take a more active role, directing clients toward setting goals that address the areas of discomfort they have identified. If clients feel validated and respected, you can profitably explore the possibility of substance misuse, pointing out its impact on mood problems. The ultimate goal is to convey the sense that, as the therapist, you and your clients are colleagues in the task of breaking a cycle of regrets, bad feelings, and low self-esteem.

The challenge in providing clinically effective feedback on elevated SAT scores is also present for elevated DEF scores. It is hard to help someone gain insight and self-awareness by pointing out lack of insight and self-awareness. People who have elevated DEF scores are demonstrating a response pattern that is similar to research participants who were instructed to take the SASSI as if they were trying to conceal any evidence of a problem, i.e., to "fake good." Elevated DEF scores are therefore an indication that clients may be attempting to conceal problems. It is almost a bad joke to consider the prospect of trying to help defensive people by giving feedback that they are defensive. You know the response - "Who?" "Me?" "Defensive?"

Let us begin consideration of ways to provide feedback on elevated DEF scores with a brief discussion of the purpose and process of test feedback per se. The intent is to help clients identify areas for growth and set useful and realistic treatment goals. It is pointless to provide a message that they will be unable to accept and assimilate. It is important to be sensitive to the danger of mobilizing defenses, particularly when dealing with highly defensive clients. It is equally important for the message to be strong enough to stimulate change; it is a serious mistake to support problematic behaviors and cognitions in the interest of establishing rapport. Providing useful feedback requires finding a line between ineffective confrontation and enabling.

Simply telling defensive clients that they are being dishonest is inaccurate, disrespectful and counterproductive. Defensiveness implies that an area of vulnerability is being guarded, not just from others, but from the self as well. Defensive clients may be avoiding a source of pain by keeping it beyond the range of focus. A key element in helping clients overcome defensiveness is establishing a sense of joining them as colleagues in the task of processing and healing pain.

Begin the feedback session by helping clients find a way to acknowledge the value of change. It is easier to do so by approaching the issue from the perspective of working together to enhance the quality of their lives rather than by implying that there is anything wrong with them. Avoid labeling. Avoid a tone that suggests that you are the expert telling the clients what is wrong with them.

Defensive clients expect to be judged by therapists. Whenever there is any indication that this is what clients are doing, reframe the situation, allowing them to see that they are doing the judging.

Client: "I know this sounds bad, but............"

Therapist: "It does not sound bad to me, but it appears to bother you. Tell me what it is about it that bothers you."

That type of interaction conveys the message that the therapeutic situation is safe and supportive. It also opens up a possibility for clients to talk about an area of discomfort. It is often useful to tell clients that if they are wondering what the counselor is thinking, the best thing to do is ask. This gives added opportunity to help clients see that they may be projecting critical self-judgments onto others.

Note in the example above that it is usually better to request that clients talk about something, rather than asking a question. A defensive person in a scary situation is likely to answer a question such as, "Why does it bother you?" with a shoulder-shrugging, "I don't know."

Ultimately, it is important for clients to see that there is something they can do to improve the situation that led to the referral. It is important for clients to learn that this does not mean that there is something wrong with them, something that they must hide. Most people, particularly defensive clients, think in terms of fault and blame. Overcoming defensiveness is facilitated by not focusing on blame, but rather by thinking in terms of acknowledgment and by learning to assume responsibility to do whatever possible to improve the situation. Addictions therapists have a powerful aid in this process by virtue of the fact that the serenity prayer is an established tool in the process of recovery. The courage to change comes from recognition and acceptance.

As clients gain in their courage and in their capacity to consider ways in which they can change their behavior, celebrate with them. There is a powerful release in the act of acknowledging parts of the self that have been concealed through shame; it is a great relief not to have to hide. If you can share this feeling with your clients, you can deal more directly with defensiveness per se.

A primary consideration underlying effective feedback on elevated DEF scores is for the therapist to recognize that defensiveness is an understandable coping mechanism for clients who are in pain. There will always be cases in which the therapist is unable to find a way to help clients move from a "stuck" place. It is important for the therapist not to take it personally and to avoid falling into an antagonistic relationship with clients. An intervention that seems ineffective can have a beneficial impact at a later date. Regardless of the apparent impact of providing feedback on defensiveness, it is important for the therapist to maintain a sense of respect for the clients.

SAM - Supplemental Addiction Measure (adult & adolescent scale):

The SASSI Institute does not recommend interpreting and providing feedback on SAM scores.

FAM - Family vs. Control Subjects (adult scale only):

The FAM scale was developed by choosing items that distinguished individuals who were known to be family members of substance abusers from control subjects. FAM is not part of the decision rules. It is included in the SASSI-3 as a provisional scale that does not have as strong an empirical base as the other scales. FAM should only be used to generate ideas or hypotheses that may be explored further as part of the assessment process. Given its limitations, the FAM scale can be a valuable clinical aid. It is useful in helping clinicians identify problem areas to be addressed in treatment. It is also useful in helping clients recognize ways in which they can make behavioral changes that will allow them to deal with difficult social and family situations more effectively.

FAM is not intended to be used as a screen to identify individuals who are likely to come from social and family systems that include a substance abuser. FAM is intended to flag individuals who may display a constellation of behaviors that are often associated with having a significant other who has a substance-related disorder - e.g., problems with setting limits, self esteem, assertiveness, awareness of feelings, compulsive behaviors, and stress-related illness. In choosing to use FAM as part of the assessment process, it is important to understand that those types of problems are neither an invariant nor an exclusive product of being part of a social/family system that includes someone with a substance-related disorder.

In providing feedback to clients who have elevated FAM scores, focus on behaviors rather than on assumptions regarding the causes of those behaviors. Start with general statements that are not likely to be perceived as threatening. Some examples are:

"Your score on the FAM scale suggests the possibility that in many social situations, you are highly concerned with how other people are doing." "It looks like you are the type of person who has a lot of concern for the welfare of others." "From the looks of your FAM score, I would guess that sometimes when you go out with other people, the thing that is most important to you is that they have a good time. You may be the type of person who is happy when those around you are happy."

The key element is to determine if clients identify with the notion of being people whose primary focus is on others. Work toward eliciting active acknowledgment from the clients. When this occurs, the nature of the feedback session can change; it becomes a situation in which clients talk about themselves and their reality, rather than the clinician using the test to tell clients about themselves. The FAM score is used as a stimulus to get clients oriented toward increased awareness of their tendency to focus on others and to share this insight with the therapist.

Once clients are engaged in this process, it becomes possible to help them explore the possibility that there are times in which their focus on others may prevent them from getting what they want and need in family and social situations. As they are talking, help them explore the possibility that their tendency to focus on other people's needs sometimes leads to feelings of frustration and resentment. See if they can identify situations in which they were more active in taking care of another person than the person him/herself. Ask them if they ever find themselves caught in the middle of disagreements and anger between other people. Find out if they regularly experience themselves as being in no-win situations as they negotiate other people's relationships. See if they can identify things that they want that are independent of other people's wants and needs.

The next step in this process is to help clients identify specific goals to work toward. Move the discussion to concrete, current situations that they are able to recognize as being problematic or painful. Then join them in exploring new ways to respond to those situations. It is important to help clients set concrete realistic goals, thereby avoiding additional confusion and frustration. Remember that many people have a life-long history of being oriented toward meeting other people's needs at the expense of their own. Some people automatically respond to social situations by analyzing the needs and motives of others, without any awareness of their own feelings. As you work with clients who have this tendency, help them set challenging and reasonable goals.

The COR scale measures the extent to which an individual’s responses on the SASSI are similar to people with relatively extensive histories of problems with the legal/judicial system. However, at this time there is not sufficient information to make any inferences about the reasons clients with a high score may be at risk for ongoing legal difficulties. Therefore, the SASSI Institute recommends against providing feedback to clients based on any assumptions about the underlying meaning of the scale.

Clinical judgment should dictate whether general feedback on COR should be given. Feedback on COR may be useful in promoting discussion of the basis of clients’ prior legal difficulties and consideration of ways to avoid future problems. It is important to avoid giving clients the impression that the instrument is predicting that they will have further law violations.