SASSI ANALYSIS AND PROFILING
As with all interpretation and psychological profiling, the picture that emerges from the subtle scales of the SASSI must be regarded as a working hypothesis, and not as a representation of absolute reality. The aim is to engage the client in a cooperative process of exploration and assessment, and to assist a discussion of emerging patterns and issues. Feeding back the results to clients in a way that is supportive and motivating is a key feature of the SASSI training.
Adult SASSI S3 analysis Female, 35 years.
(Analysis based on profile only. More detailed information can be provided where the questionnaire is also available).
FVA 31, FVOD 14, SYM 10, OAT 12, SAT 4, DEF 1, SAM 10, FAM 7, COR 14
Overall Result
The SASSI classifies this person as having a high probability of having an Alcohol Dependence Disorder, according to DSM IV criteria (Moderate to Severe Substance Use Disorder DSM V). It is noteworthy that there is nothing in this profile which is within the normal range, either in terms of self-reported consumption and consequences, or in terms of psychological presentation.
FVA / FVOD
The FVA score is extremely high, indicating that fewer than 1 in 100 women would be drinking to this extent and experiencing such a high level of consequences. If this high score represents a current pattern of consumption, it would certainly seem to suggest urgent evaluation for detoxification. (The high FVA could be historical, if the client has been asked to complete the SASSI on the basis of a lifetime’s experience). The FVOD is also high, suggesting that the client has extensive experience of other drug use too, although this does not appear to constitute drug dependency. The distinction is perhaps not overly useful, however, as once a person has developed a severe dependency on one psychoactive substance, the risk of transference of dependency is so high as to normally give rise to a recommendation of complete and permanent abstinence from all psychoactive substances – as a long-term goal. Both the FVA and the FVOD are face valid scales, and are thus open to manipulation.
SYM
This score is again extremely high, suggesting that only perhaps 1 in a 100 adult females would be endorsing as many symptoms and correlates of drinking as this person. It would be useful to read the individual items to see what picture emerges. If there are key symptoms, does the client atttibute them to the substance misuse, or is she unaware of causes and effects? There could be (eventually) some scope for motivational education here. Do any SYM items suggest a peer environment of heavy use, which might bear upon care planning? The SYM is also face valid, of course, and therefore manipulable.
OAT
The Obvious Attributes scale score is very high too; again, perhaps only 1 per cent of an adult female population would yield such an elevated score. Given that this subtle scale score is high enough, by and of itself, to classify the person as having a high probability of dependence (Rule 4), it does tend to corroborate the face valid indications.
People with high OAT scores tend to be willing to acknowledge personality faults and weaknesses, particularly those associated with substance misuse, such as impatience, impulsivity, difficulty deferring gratification, grandiosity, resentment and self-pity. This can be a benefit, in terms of intervention, as an ability to recognise negative character traits implies maturity, absence of resistance and hence treatment readiness; an openness to feedback from other people, even if that feedback is critical. People with high OAT scores may do well in group work situations, as they may identify with other people with similar issues, and are likely to be prepared to learn from them. However, there may be disadvantages too. Someone with an extreme propensity for endorsing their own shortcomings may be overly self-critical, and this can lead to poor self-esteem (see also DEF score).
Some individuals with high OAT scores may see the need for change, but believe themselves incapable of effecting it. Others may actually champion the negative personality characteristics and claim they are helpful to them, e.g. in ensuring they get to the front of the queue, etc. These are possibilities for exploration.
SAT
The score here is slightly elevated, indicating, possibly, some degree of detachment from feelings and lack of skill in self-analysis. It is possible that for this client, the use of alcohol and other drugs represents merely the wallpaper against which her life events are played out. If her social environment is one in which heavy use of substances is commonplace, this may effectively “normalise” it for her and make it more difficult for her to recognise it as problematic. The OAT score is much higher than the SAT, and so it is likely to be the OAT characteristics which predominate here. She may be willing to address her perceived problems, but feel she lacks the skills to address them.
DEF
This score is extremely low. It tends to suggest not just a degree of self-recrimination, but very low self-esteem and self-efficacy, substantial depression, and possibly suicidal ideation. Given that other people with such very low scores have often been found to have experienced physical, emotional and / or sexual abuse in childhood, these are avenues which might need to be explored. The risk of suicide this score flags up, seems urgent enough to deserve priority, in terms of intervention, and low self-esteem and depression are likely to sap motivation and any sense of self-efficacy.
A combination of high FVA, i.e. very high alcohol consumption and very low DEF can be an indicator of “rock bottom”, where the person has just realised the extent of their consumption and its consequences, and that realisation is making them feel really self-recriminatory and dejected, particularly if they can see no way out of their problems. Adding a high COR score to this mix yields a profile similar to that of people who tend to be at risk of absconding from treatment; they are feeling really unhappy, and tending to be risk takers with a less than average regard for the idea of authority, they may be tempted by the idea of a geographical escape. This may or not be true for this client; it is a pointer for discussion.
The SAM is not interpreted, as the DEF is low.
FAM
The client’s score is very low, suggesting a detachment from relationships or a difficulty in engaging in meaningful relations with other people. This can be situational (e.g. narrowing of focus to the need for the next “fix” precludes all other considerations) or it may be a more enduring personality trait. Discussions with the client may yield more information and may bear on later care planning.
COR
This is very high, suggesting that this client shares personality characteristics with people who have extensive criminal histories. If this client has such a history themselves, it would be useful to see whether some or all offences are substance-related. However, the implication of a high COR score is that the client’s offending has its roots in issues which are separate from any problems he/she may have as a result of substance dependence, and that removing the dependence is unlikely, by and of itself, to resolve offending behaviour. In terms of care planning, the client may need to have possible causes of offending addressed as a distinct and targeted part of a comprehensive intervention, which would include, but not be limited to, treatment for substance dependence.
Miscellaneous issues.
Could the client be exaggerating? Yes, possibly, but probably not this much, and the high OAT tends to corroborate the face valid scores.
Drunk at the time and couldn’t help it? I don’t think magistrates take any notice of this “defence” any more. While drinkers may claim that they don’t remember committing the offence, they were not unconscious when they committed it. At the time, they knew very well what they were doing. Alcohol destroys vitamin B1 (thiamine) in the body, and thiamine is essential to the brain’s proper functioning. So even if the absence of memory is genuine, what the client has experienced is a failure of the brain to lay down a memory trace of the events, not an absence of consciousness when those events were taking place.
In-patient detox? Well, lots of questions here. Does she need detox at all, or are we looking at historical consumption?
How much is she drinking? How long has she been drinking at this level? You don’t tend to see physical dependency in a woman unless she’s drinking at least 70 units a week, and she needs to be drinking daily, i.e. about at least 10 units per day. If she’s drinking less than this, and she claims to be experiencing withdrawal symptoms, I would be sceptical, unless she has liver damage. In this case I would refer her to her GP for a Liver Function Test, and take the results into consideration. The top level of possible consumption for a woman would be about 375 units per week. If she claims to be drinking more than this I would be sceptical.
Physical dependency is identified through withdrawal symptoms, commonly: heavy sweating, especially at night, sense of urgency for the first drink of the day, anxiety states, “the shakes” (shaking hands). Severe symptoms: visual or auditory hallucinations, epileptiform fitting, blackouts, delirium tremens, physical complications such as oesophageal bleeding etc.
Decisions about i/p vs o/p detox usually revolve around a) availability b) gravity of withdrawal effects c) level and duration of consumption d) risk of suicide. Whatever other considerations there may be for this client, this latter would seem to evidence the need for in-patient monitoring, if she is physically dependent at this time.
The best predictor of how someone will fare when “coming off”, is how well they fared last time. If the last time was relatively recent, and the amount of consumption is similar, it is a good predictor. If the last time was long ago, and the amount much less, it’s a less good predictor.
I would suggest taking a detailed drinking history, to cross-check what the client is saying. Also, how much does she spend on alcohol per week? Does this fit with the rest of what she’s reporting?
Adolescent SASSI (A2) 16 year old male
(Analysis based on profile only. More detailed information can be provided where the questionnaire is also available).
FVA 5, FVOD 5, FRISK 5, ATT 8, SYM 3, OAT 6, SAT 3, DEF 7, SAM 5, COR 9, VAL 1, SCS 21
Overall Result
The SASSI indicates that this young person has a high probability of having a
Moderate / Severe Substance Use Disorder, according to DSM V criteria (Substance Dependence Disorder according to ICD 10).
FVA & FVOD
Neither of these face valid scale scores is high enough to yield a high probability of Moderate / Severe SUD, in other words, the client is not disclosing sufficient use of alcohol or other drugs to warrant classification. Given the overall result, this would suggest that there is a degree of under-reporting here. Both scores in fact appear very low; around the average for adolescents. The alcohol score suggests a slight preference for alcohol over other drugs, although this may reflect accessibility rather than preference. It is recommended that individual responses are examined, especially in the light of any other collateral information available. It may be helpful to use these responses as a stepping-off point for further open-ended discussion.
FRISK
The Family and Friends Risk scale score is above average, suggesting that family and / or friends provide a social environment in which substance use is either tolerated or facilitated. Again, it is recommended that individual responses are examined, as these will reveal further detail, e.g. whether friends or family are using themselves or encouraging or modelling use, or whether parents are merely providing little supervision of their children. Living within an environment where substance misuse is ubiquitous can lead to its “normalisation” in the mind of the individual, and this could account, at least to some extent, for the apparent under-reporting on the face valid scales.
ATT
Again, the ATT score is above average, indicating that this young person holds a positive attitude towards substance use. (With some individuals, descent into severe addiction is reflected in a low ATT score. Where the ATT score is high, one may infer that severe negative consequences have not yet been experienced). Clearly, if he believes that substance use offers an enhancement to his life experience in some way, he is not likely to be motivated to try to refrain from it. Examination of the individual responses may shed light on exactly what his attitudes are. However, it is not recommended that a young person with a high ATT score be confronted directly on the attitudes they hold, as this may provoke resistance which can be counter-productive, and further embed pre-existing beliefs. Ideally, a programme of peer education might offer the best way of addressing the young person’s attitudes.
SYM
The SYM score is within the average range, indicating that the young person is not acknowledging many symptoms or correlates of substance use at this time. It may be useful to examine individual responses to see what symptoms or correlates the young person does identify, and to ensure that he understands the connection between them and the substance use. Because this score is face valid, it is manipulable, and it is possible that there is some deliberate under-reporting here.
OAT
This subtle score is average. The young person seems to be reluctant to acknowledge personality characteristics which are common in substance misusers, e.g. impatience, impulsivity, difficulty deferring gratification, etc. This is potentially problematic, as it suggests that he may be likely to resist hearing feedback from other people, if he perceives that feedback to be critical. He may not feel that he has much in common with other people who have substance misuse issues, so he may not believe he can learn much from them, and he seems unlikely to benefit readily from group work at this time.
SAT
The SAT score is within the average range, indicating this young person is likely to be in touch with his feelings and to have a capacity for self-analysis. This is clearly a positive sign, suggesting that he has the mental equipment to understand and work on his problems, and that he is capable of learning from emotional experiences. If and when he is motivated to make changes, these characteristics will be important tools to help him fashion a successful outcome.
DEF
The DEF score is within the average range, although it is on the high side of average, indicating some degree of defensiveness. This could be a fixed personality characteristic, or it could be situational, e.g. reflecting the person’s uncertainty about the functions or consequences of the screening. It is possible that the apparent under-reporting on the FV scales might represent an attempt at concealment of the extent of the substance misuse.
SAM
This is not relevant to the profiling exercise.
COR
The COR score is within the average range, indicating that this young person appears to have little in common, psychologically, with young people with substantial offending histories. Thus he seems to be no more likely than the average adolescent to have any serious involvement with the criminal justice system. If he is involved in offending behaviour, it may be useful to look at the nature of his offending, to see if it is perpetrated either under the influence, or in order to fund the habit. If this is so, and given his probable status (Moderate/Severe SUD, DSM V, or Substance Dependence, ICD 10)(“difficulty controlling onset, termination or levels of use” ICD 10), it would seem reasonable to assert that the substance use could be driving the infractions, and that its removal may, by and of itself, preclude further offending.
Summary
This young man appears to have a high probability of substance dependence, although he is likely to be resistant to acknowledging this. Sometimes people do not realise they are dependent because they have never attempted any period of abstinence. The dependence may be recent and not entrenched, and may reflect neuro-adaptation rather than physical addiction. He may therefore not (yet) have experienced many negative consequences. It seems his family or friends may be providing an unhelpful environment. His attitudes to substance misuse seem positive, and therefore he is unlikely to be motivated to change at this time. However, if his resistence were lowered and if he were motivated to re-evaluate the role of substance misuse in his life experience and chances, he would appear to have the psychological equipment to make a success of this. Early 1:1 intervention is therefore recommended, focusing on lowering resistance, on education and motivational work in the first instance.