2. Client Description
23 year old, white female
Court ordered to Treatment by 1st District Drug Court
Completed the ninth grade
Self-reports as victim of complex trauma
Self-reports prior diagnosis of PTSD in 2008
Completed detox at Behavioral Health in Tupelo
Recent arrest for prostitution and possession of a
controlled substance
3. Purpose of Assessment
Intake/Assessment:
Biopsychosocial conducted by assessment therapist
Used by primary counselor for:
Case-conceptualization
Treatment planning
Identifying potential strengths, stressors , and overall level of functioning
SASSI–3:
Assesses probability of client having Substance Dependence
Disorder
Provides useful clinical information in regard to potential
underlying issues and client-specific Tx planning.
Burns Anxiety Inventory:
Track client’s level of anxiety throughout therapeutic process
Provide client with insight into stressors
Monitor effectiveness of anxiety reduction techniques
4. Assessment Procedures and Protocol
Intake/Assessment
Establish rapport while conducting a structured interview
SASSI-3
Brief, objectively scored
Decisions rules for identification
Face Valid Scores FVA and FVOD can assess specific time period either
entire life, past six months, or a period the clinician determines. FVA and
FVOD clients rank statements from 0-3 for accuracy.
Remaining 8 scales determined from 62 true/false questions
RAP score of 2 or more suggest results might not be meaningful
Burn’s Anxiety Inventory
Self-administered or clinician administered checklist
Three categories: anxious feelings, anxious thoughts, physical symptoms
Ranks 0-3 “not at all” – “a lot”
Total score represents anxiety on a continuum from mild to extreme.
5. Medical/Developmental History
Client reported:
No significant medical issues
Potential learning disability
Repeated sexual abuse from age 5 until 13
Multiple sexual assaults related to drug use in teenage years
Social isolation due to peer shaming during school
Began using alcohol age 9, marijuana age
11, methamphetamine age 14
6. Family Psychiatric History
Client Reported:
Mother suffers from depression and a long history of
alcohol consumption.
Father is absent from life, but mother reports that he is a
drug addict.
History of addiction on both sides of family.
7. School/Academic History or Work history
Client Reported:
Completed ninth grade
Difficulty in reading comprehension and writing
Limited work history, reports working in fast food for
short periods
Prostitution was her means to support her drug usage
8. Home Behavioral/Social
Client Reported:
Basically homeless, sleeps in various locations usually
“crack houses”
Virtually no support system, because “mother is still
drinking”
Only friends are gang members
Only child DHS put foster care in 2009
9. Assessments used and appropriate interpretations
Intake/Assessment:
Presenting problem
Diagnosis
Medical, psychological, family, social, occupational, educational, substance abuse, and personal history
Interpretation potentially biased by clinician’s worldview and accuracy of client disclosure
SASSI-3:
“Test-retest stability coefficients ranged from .92 to 1.00, accuracy of the SASSI-3 was not significantly
affected by gender, racial or ethnic group membership, occupational status, marital status, age, and
educational level, the levels of accuracy for males and females were 96% and 97% respectively.”
(Lazowski, Miller, Boye, and Miller, 1998).
Identifying probability of substance dependence
Identifying potential treatment barriers
Treatment planning
Clinical hypotheses
Burn’s Anxiety Inventory:
Determines level of current anxiety as: minimal/none, borderline, mild, moderate, severe, or extreme/panic
Differentiates feelings, thoughts, and symptoms of anxiety
Monitor anxiety levels, gain insight into stressors, and track effectiveness of reduction strategies.
“The scores of 498 outpatients seeking treatment for mood disorders suggested excellent reliability and internal
consistency with an alpha score of .94. The BAI scores correlated highly with the anxiety subscale of the
Hopkins Symptom Checklist” (Marcus & Dubi, p. 224, 2011)
Common and assessable instrument
10. Summary of Findings
Intake/Assessment:
Substance Dependence resulting in legal consequences
No reported medical issues
Family history of substance abuse and depression
Survivor of chronic childhood trauma (sexual, emotional,
and physical); traumatic occurrences continued into
adulthood
Reported prior PTSD diagnosis
Deficient educational experience
Only child is in DHS custody
Lacks sufficient support and has limited work experience
11. Summary of Findings
SASSI-3:
FVA 30, FVOD 40 (High probability of having Substance Dependence Disorder)
SYM 11 (Consider client’s world and environmental norms of substance use; encourage client
feedback on SYM applicable items, mutually working toward insight about the negative effect of
substance use on their life)
OAT 7 (Suggests client is willing to consider the negative effects of continued substance use)
SAT 5 (Suggest limited insight into presenting problem)
DEF 1 (Suggests low self-esteem, negative self-talk, helplessness, and shame based thinking
strategies)
SAM 10
FAM (Suggests need to explore codependency/ boundaries/emotional insight and modulation)
COR 9
Burn’s Anxiety Inventory:
Scored 42 on initial scale indicating severe anxiety: Anxious Feelings 13, Anxious Thoughts
23, Physical Symptoms 6
Scored 21 prior to exiting program indicating moderate anxiety on the cusp of mild.
Mindfulness techniques of meditation, grounding, and self-affirmations proved most effective to
alleviate existing anxiety and recurring episodic anxiety.
Cognitive reframing assisted in overall symptom reduction and prevention
12. DSM Diagnosis
Axis I:
304.4 Amphetamine Dependence
303.9 Alcohol Dependence
304.30 Cannabis Dependence
309.81 Posttraumatic Stress Disorder, Chronic
Axis II: V71.09; R/O Borderline Personality; Strong Cluster B Traits
Axis III: None
Axis IV: Long term Hx of Sexual, Physical, Emotional Abuse;
Lacks Support System, Financial Means, Housing, Job Skills
Axis V: GAF = 40 (on admission)
13. Treatment Plan and Recommendations
Plan:
Holistic, strength-based, collaborative treatment approach aimed at gaining insight into
the consequences of continued substance use, reframing distorted cognitions, developing
healthy boundaries, building emotional modulation skills, developing safety, improving
relational skills, empowering her to build a cohesive sense of self, and changing her frame
of reference from victim to survivor. (Clinician will utilize relational-empowerment
model, Stage 1 trauma techniques, mindfulness practices, and cognitive reframing to
increase choices and control over recovery)
Recommendations:
Long-term residential treatment
Individual counseling (weekly)
Women’s trauma group (2x per week)
Group therapy (daily)
Psychoeducational classes
Aftercare
12-step meetings
Continued weekly individual session after discharge
14. References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders:
DSM-IVTR. Washington, DC: American Psychiatric Association.
Lazowski, L. E., Miller, F. G., Boye, M. W., & Miller, G. A. (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.
Marcus, S. & Dubi, M. (2011). The relationship between resilience and compassion fatigue in
counselors. American Counseling Association, (50 )223-225, Retrieved from
http://www.counseling.org/Resources/Library/VISTAS/vistas06/vistas06.50.pdf
Miller,G.A.(1985,1999). The Substance Abuse Subtle Screening Inventory (SASSI) Manual,
Second Edition. Springville, IN: The SASSI Institute.