Addictire Behariour~,. Vol. 4. pp. 185 to 191. 0306-4603i7910401-0185S02.

00i0
© Pergamon Press Lid 1979. Printed in Great Britain

"HOOKED" OR "SICK": ADDICTS' PERCEPTIONS

OF THEIR ADDICTION

J RICHARD EISER and MICHAEL R' GossoP

Institute of Psychiatry and Bethlem Royal and Maudsley Hospitals, London

Abstract--In a study concerned with addicts' perceptions of their own dependence on drugs,
40 outpatients (30 male, 10 female) attending a London drug dependence clinic were individually
administered a 15-item attitude questionnaire and an abbreviated (10-item) measure of locus
of control. Subjects' own agreements with most of the 15 items correlated highly with their
estimates of the responses of other drug clinic patients to these items, but showed little relation
to locus of control.
A principal components analysis conducted on these ratings revealed two factors which
together accounted for 31.5% of the variance. Factor I, labelled as "Hooked" loaded most
heavily on items reflecting a perceived inability to give up drugs. Factor 2, labelled as "Sick",
reflected a perception of one's addiction as a sickness which doctors could cure, and an acknowl-
edgement of personal problems generally. The 14 subjects whose preferred drug was heroin
did not differ, on average, from the remaining 26 in terms of their scores on Factor 1, but
obtained significantly lower scores than the others on the "Sick" factor. Implications for treat-
ment, and for the concept of the "sick role" in relation dependence, are discussed.

The deficiencies surrounding assumptions of a unitary "addictive personality" or of

homogeneity a m o n g drug abusers, are now widely recognized, and recent research into
drug dependence has increasingly focused upon behavioural and personality differences
within the drug abusing population. Differences have been found between those receiving
and not receiving prescriptions for opiates (Blumberg et al., 1974), between inpatients
and outpatients (Gossop & Roy, 1976), between oral and intravenous users (Gossop,
1978a), between users of heroin and of other drugs (Teasdale, 1972; Heller & Mordkoff,
1972), and between male and female addicts (Gossop, 1976). Stimson (1973) also looked
at social and behavioural differences within a representative sample of L o n d o n heroin
addicts, and described four distinct sub-groups.
It is, however, becoming increasingly clear the cognitive factors, specifically addicts'
perceptions of their own addiction and their own ability or wish to overcome it, are
an important feature of drug addiction. Robins et al. (1974) found that, of a sample
of 495 American servicemen whose urines were positive for opiates when discharged
from Vietnam, only 7~o still showed signs of dependence when contacted 8-12 months
later. Also, in a study of the variables related to length of stay on an in-patient drug
dependence unit, Gossop (1978b) found that the single most effective predictor was
the addicts' own expressed desire for treatment. Similarly, Eiser & Sutton (1977) have
argued that cigarette smokers' perceptions of the probability that they could give up
smoking if they attempted to do so m a y be an important predictor of whether they
in fact m a k e such an attempt.
The question of a drug-user's perception of his own ability to abstain touches upon
the sociological concept of the "sick role" (Parsons, 1951). Robinson (1972) has pointed
out how the disease concept of alcoholism (Jellinek, 1960) may cast the alcoholic in
the role of a "sick" person, helpless to control his own dependence on alcohol or "cure"
himself without medical intervention. Similarly, Eiser (1978) has suggested that cigarette
smokers' preparedness to label themselves as "addicted" may make it more difficult
to persuade them to stop through their own efforts.
A preliminary attempt has been made to investigate such factors in drug addiction
through the notion of locus of control (Rotter, 1966). Berzins & Ross (1973) suggested
that opiate addicts have a high internal locus of control, and Strassberg & Robinson
(1974) related internality to positive psychological adjustment and self-concept a m o n g
drug users. However, this relationship has not been confirmed by all studies. Indeed
185
186 J. RICHARDEISERand MICHAELR. GOSSOp

Table 1. Classification of subjects by preferred drug: age, sex, marital status, route and prescription frequencies

Prescribed
Marital status Route of abuse drugs by
Mean Sex Divorced/ lntra- clinic"
Preferred drug N age Male Female Single Married Separated venous Oral Yes No
Heroin 14 35.5 I1 3 5 2 7 14 0 13 1
Physeptone 5 22.4 3 2 5 0 0 5 0 5 0
Amphetamines 5 26.2 5 0 5 0 0 3 2 0 5
Barbiturates 2 25.5 1 I 1 0 1 1 1 0 2
I& other sedativesl
Benzodiazepines 4 26.5 2 2 1 2 1 0 4 1 3
Codeine/Chlorodyne 4 26.8 2 2 4 0 0 I 3 1 3
Multiple 5 28.8 5 0 3 1 1 4 1 2 3
Cannabis 1 52.0 1 0 1 0 0 0 I 0 1
40 30.0 30 10 25 5 10 28 12 22 18
;' The drug prescribed is not necessarily the subject's drug of preference.

Currie et al. (1977) found a slight (but statistically significant) negative correlation
between internality and m a r i h u a n a use.
The present study therefore describes the pattern of individual variation occurring
within a specific g r o u p of addicts with regard to their expressed feelings of personal
control, perceived dependence on drugs and expectations for treatment. In addition,
the study takes account of the extent to which an individual addict may identify with,
or seek to differentiate himself from, other drug-users.

METHOD

Subjects
The 40 subjects who t o o k part in this study were seen in the out-patients department
of the D r u g D e p e n d e n c e Clinic at the Maudsley Hospital during the period O c t o b e r
1976 to J a n u a r y 1977.* This clinic sees about 100 individuals with drug problems during
a 12 m o n t h period. O f this number, a considerable p r o p o r t i o n are opioid abusers who
receive some maintenance prescription. A l t h o u g h there are a n u m b e r of patients who
have remained on a stable dose of drugs for some time, it is the clinic's policy to
reduce the prescribed dose wherever possible and in-patient withdrawal and treatment
are offered as the most suitable way of giving up drugs. It is not the policy of the
clinic to prescribe amphetamines, barbiturates or other non-opioid drugs, t h o u g h this
is d o n e in exceptional cases.
A detailed description of the sample is given in Table 1. Divided according to preferred
drug, the heroin users constitute the largest sub-group. The m e a n age of these indivi-
duals, most of w h o m were receiving a prescription from the clinic, was 35.5 yr. The
m e a n age of the other subjects was 27 yr, and of these only nine out of 26 were receiving
a prescription from the clinic--five of w h o m were physeptone users.
The p r e d o m i n a n t pattern of drug-taking a m o n g British clinic attenders at the time
of this study is multiple d r u g abuse. F o r this reason, subjects were categorised in several
different ways regarding their drug-taking habits, including by preferred drug. Thus,
it should not be assumed that say the "heroin" group, or the " a m p h e t a m i n e " g r o u p
used no other drugs in addition. The multiple drug abuse category refers only to those
few individuals whose drug habits were sufficiently variable or indiscriminate to preclude
the possibility of classifying them according to any single preferred drug.

The questionnaire
Each subject was first presented with a small duplicated booklet, with the facing
page presenting instructions with informed subjects that it contained "some c o m m e n t s
of the kind that people attending d r u g clinics m a k e from time to time." The remaining

*We wish to thank Dr P. H. Connell for permitting us to approach his patients.

 Addicts" perceptions of their addiction 187

15 pages of the booklet contained the 15 items listed in full in Table 2, in four separate
r a n d o m orders, printed above two rating scales in the form of continuous 10 cm lines
with no intermediate labels or divisions. The first was labelled " N o t at all the way
I feel" at the left-hand extreme, and "Very much the way I feel" at the right-hand
extreme; the second was labelled correspondingly "Not at all--very much the way 1
think most other people attending this clinic feel". Subjects were instructed to mark
a cross at the appropriate point on each scale, and their responses were coded numeri-
cally from 0 to I00 by measuring the distance in m m of each cross from the left-hand
extreme. Higher scores thus reflect greater endorsement of an item for oneself or others.

Personal control scale

After completing the questionnaire, subjects were handed a single sheet containing
10 pairs of statements selected from Rotter's (1966) I - E scale. Specifically, these were
items number 2, 9, 11, 13, 15, 16, 18, 20, 25 and 28, and were chosen on the basis
of Mirels' (1970) factor analysis of Rotter's scale. The 10 items were among those which
loaded more highly on the first of Mirels' factors, items concerning student grades
and leadership having been discarded as inappropriate. According to Mirels (p. 227):
"Each of these items pits a statement which affirms the respondent's control over his
own destiny against one which assigns such control to external forces". Each subject
was required to indicate which statement in each pair came closer to his own personal
feelings, and the number of items in which he endorsed statements of the former type
was counted. Higher scores within a range from 0 to 10 were thus indicative of a
more "internal" as opposed to "external" locus of control orientation.

Procedure
Subjects were tested individually by either of the two authors, during the normal
hours of the out-patients clinic, which most subjects typically attended at fortnightly
intervals. All were tested immediately before or after their regular interview with a
psychiatrist but the study was presented as a "piece of research" independent of their
interview. Participation was voluntary (three further subjects were approached but
refused to take part), and confidentiality was emphasized so that, for instance, subjects
were assured that their responses would not be shown to the psychiatrists as a basis
for deciding whether or not to let them have drugs on prescription or reduce their
dose.

RESULTS
We first compared the ratings given to each of the 15 items on the "Self" and "Others"
scales by the total sample of 40 subjects. Table 2 shows the means for each item on
each scale, the values of t for the difference between each pair of means, and the values
of r for the correlation between the two sets of ratings on each item. As can be seen
there was a significant positive correlation between the "Self" and "Others" ratings
on all but two of the items. In addition, eight of the items showed significant
" S e l f " - " O t h e r s " differences. Broadly speaking, these differences imply that subjects either
saw, or chose to present themselves, as holding more "cooperative" attitudes than other
patients at the clinic. Bearing in mind that some of these differences might be attributable
to subjects being uncertain over how others felt and consequently tending to give ratings
towards the centre of the scale, the theme that emerges is one of subjects generally
presenting themselves, in comparison to others, as good and grateful patients, rather
than as mere exploiters of the clinic system.
Subjects' ratings for "Self" on the 15 items, and their total internal scores on the
Personal Control scale, were then submitted to a principal component analysis. Table 3
summarizes the results of a two factor solution after varimax rotation. It must be remem-
bered that the number of subjects involved is very small for such an analysis. Our
interpretation of the factors is therefore intended as a tentative basis for future research
and discussion, rather than as a definitive description of underlying structure. Factor 1,
188 J. RICHARDEISERand MICHAELR. GOSSOP

Table 2. Overall mean scores for "self" and "others" on the 15 items

Mean for Mean for "Self" vs. "'Others"

Item "self . . . . others" t (39) r

I. I'm terrified of withdrawal. 61.40 73.40 2.92** 0.663***

2. 1 find drugs help me cope with my
personal problems. 55.95 60.95 1.03 0.597***
3. I'm frightened about what drugs may
be doing to me. 57.50 57.70 0.03 0.364*
4. 1 wouldn't have any personal problems
if there wasn't so much hassle about
getting drugs. 33.80 52.98 3.48*** 0.548***
5. l guess l'm really addicted. 69.43 70.18 0.15 0.525***
6. ! don't think the clinic has anything
to offer me except a script. 24.83 56.05 6.01"** 0.509***
7. Getting stoned is one of the things that
gives me most pleasure in life. 47.75 63.13 2.61" 0.375*
8. If I really wanted to, I could gire up
drugs. 55.33 49.03 1.33 0.607***
9. I've never made a serious effort to
give up drugs on my own, 30.10 38.88 1.46 0.368*
10. 1 don't think I could ever turn down
drugs if someone offered them to me. 44.50 57.65 2.15" 0.408**
11. 1 think of my addiction as a sickness. 56.20 59.50 0.60 0.494***
12. I think other people are to blame for me
being addicted today. 21.70 44.10 3.71"** 0.210
13. l'm sure that doctors can help me give
up drugs. 41.65 56.35 2.60* 0.489***
14. I've got every right to go on taking
drugs if I want to. 55.65 71.83 3.07** 0.494***
15. I don't feel read)' to give up drugs
right now. 60.60 58.53 0.34 0.229

* P < 0.05, **P < 0.01, ***P < 0.001, 2-tailed probabilities.
Note: Scale is from 0 = "'Not at all the way I (others) feel" to 100 = "Very much the way I (others)
feel".

a c c o u n t i n g for 1 9 . 0 ~ of the total variance, is m a r k e d especially by a feeling that one

is n o t ready to give u p drugs, n o r able to d o so, a terror of withdrawal, a p r e p a r e d n e s s
to label oneself as "really addicted", a n d a t e n d e n c y to b l a m e others for one's a d d i c t i o n
(Ready, Give up, W i t h d r a w a l , Addicted a n d Blame items respectively). I n d i v i d u a l s with
higher scores o n this factor also tend to have less confidence in their ability to t u r n
d o w n drugs if offered to them (Offered), a n d achieve rather m o r e external scores o n
the P e r s o n a l C o n t r o l scale. F a c t o r 2, a c c o u n t i n g for 12.5~o of the variance, is associated
p a r t i c u l a r l y with a feeling that one has less right to take drugs, greater confidence
in d o c t o r s ' ability to help, greater fear of the effects of drugs, a feeling that the clinic
has m o r e to offer t h a n a prescription, a n d a p r e p a r e d n e s s to describe one's a d d i c t i o n
as a sickness (Right, Doctors, F r i g h t e n e d , Script a n d Sickness items). O n e item (Hassle)
shows m o d e r a t e l y large loadings in reverse directions o n the two factors. High scorers
o n factor 1 feel that they would not have any p e r s o n a l p r o b l e m s if they could get
drugs easily, whereas high scores o n factor 2 do feel they w o u l d have personal p r o b l e m s
even if they could get drugs easily. I n s u m m a r y , high scorers o n factor I may be said
to see themselves as " h o o k e d " whereas those scoring high o n factor 2 m a y be said
to see themselves as "sick".
As has been m e n t i o n e d , w h e n subjects were classified a c c o r d i n g to their d r u g of
preference, the 14 h e r o i n users c o m p r i s e d the largest s u b g r o u p . W e c o m p a r e d these
14 h e r o i n users with the r e m a i n i n g 26 subjects, b o t h in terms of their i n d i v i d u a l factor
scores, a n d in terms of their ratings o n the separate items. The first factor failed to
d i s c r i m i n a t e the h e r o i n users for the r e m a i n i n g subjects, with seven heroin users o b t a i n -
ing factor scores above, a n d seven below the m e d i a n for the total sample. A p p a r e n t l y ,
therefore, the h e r o i n users as a g r o u p saw themselves as neither m o r e n o r less " h o o k e d "
t h a n the other d r u g users in o u r sample. However, o n the second factor, only three
h e r o i n users o b t a i n e d factor scores above the m e d i a n for the total sample, a n d 11
 Addicts" perceptions of their addiction 189

Table 3. Principal component factor matrix after varimax rotation with Kaiser
normalization, two factor solution

Item Factor 1 Factor 2 Communality

I. Withdrawal 0.600 0.024 0.361

2. Cope 0.148 0.189 0.058
3. Frightened - 0.002 0.466 0.217
4. Hassle 0.409 - 0.434 0.356
5. Addicted 0.560 -0.217 0.361
6. Script 0.007 -0.413 0.171
7. Stoned - 0.027 0.023 0.001
8. Give up -0.617 -0.095 0.389
9. Effort -0.181 0.276 0.109
10. Offered 0.359 0.108 0.141
11. Sickness 0.166 0.382 0.173
12. Blame 0.422 0.182 0.211
13. Doctors -0.190 0.481 0.267
14. Right -0.222 -0.495 0.294
15. Ready 0.645 - 0.070 0.421
Personal control - 0.267 0.036 0.072

Percentages of total
variance accounted for 19.0 12.5

o b t a i n e d s c o r e s b e l o w t h e m e d i a n (Chi2 = 7.03, d . f . - - 1 , P < 0.01), s u g g e s t i n g t h a t

h e r o i n users, r e l a t i v e l y s p e a k i n g , d i d not t e n d t o see t h e m s e l v e s as p a r t i c u l a r l y " s i c k "
o r in n e e d o f p s y c h i a t r i c t r e a t m e n t . T h i s is b o r n e o u t by t h e s c o r e s o n t h e s e p a r a t e
i t e m s (see T a b l e 4) w i t h h e r o i n users b e i n g far less i n c l i n e d t o say t h a t t h e y t h o u g h t
o f t h e i r a d d i c t i o n as a sickness, r e p o r t i n g r e l a t i v e l y little p l e a s u r e f r o m g e t t i n g s t o n e d
o r fear o f t h e c o n s e q u e n c e o f t h e i r d r u g use; t h e y w e r e r a t h e r m o r e p r e p a r e d t o l a b e l
t h e m s e l v e s as a d d i c t e d a n d also ( m a r g i n a l l y ) less c o n v i n c e d t h a t d o c t o r s c o u l d h e l p
t h e m g i v e u p d r u g s , a n d m o r e i n s i s t e n t t h a t t h e y h a d m a d e s e r i o u s efforts to give
u p d r u g s o n t h e i r o w n (Sickness, S t o n e d , F r i g h t e n e d , A d d i c t e d , D o c t o r s a n d Effort
items respectively).
W h e n s u b j e c t s w e r e classified a c c o r d i n g t o o t h e r criteria, t h e r e w e r e few s y s t e m a t i c
differences in t e r m s o f t h e i r q u e s t i o n n a i r e r e s p o n s e s . T h e 10 f e m a l e s w e r e m u c h less
c o n f i d e n t t h a n t h e 30 m a l e s in t h e i r o w n a b i l i t y t o t u r n d o w n d r u g s if t h e y w e r e offered

Table 4. Comparisons between heroin users and users of other drugs: mean scores
on the 15 items (ratings for "self") and the Personal Control scale

Preferred drug
Heroin Other drug t
Item (N = 14) (N = 26) (38)

1. Withdrawal 71.00 56.23 1.30

2. Cope 55.43 56.23 0.06
3. Frightened 36.79 68.65 2.44*
4. Hassle 37.29 31.92 0.44
5. Addicted 84.43 61.35 2.09*
6. Script 35.00 19.35 1.44
7. Stoned 27.43 58.69 2.74**
8. Give up 54.71 55.65 0.08
9. Effort 16.29 37.54 1.73t
10. Offered 32.29 51.08 1.44
11. Sickness 34.93 67.65 2.85**
12. Blame 13.14 26.31 1.35
13. Doctors 27.00 49.54 1.86t
14. Right 63.57 51.38 0.97
15. Ready 67.07 57.12 0.86
Personal control 5.64 5.08 0.69

f P < 0.1, *P < 0.05, **P < 0.01, 2-tailed probabilities.

Note: Maximum score on items 1 to 15 = 100 ("Very much the way I feel");
on Personal Control Scale = 10 (Internal).
190 J. RICHAgDEISERand MICHAELR. GossoP

any (Offered: means = 74.20 and 34.60 respectively, t = 2.98, d.f. = 38, P < 0.005), but
no other sex effects approach significance. The 28 subjects who took their drugs intra-
venously also showed no significant differences from the 12 oral drug users in their
ratings for "Self" apart from a stronger denial that others were to blame for their
own addiction (Blame: means = 14.21 and 39.17 respectively, t = 2.61, d f = 38,
P < 0.02). The Personal Control Scale was also not reliably related to any of the ratings
for "Self", although a marginal correlation with Offered (r = -0.265, P < 0.1) implied
that more "external" subjects saw themselves as having rather more difficulty turning
down drugs. The weak negative loading on factor 1 is also in a plausible direction,
with more "external" subjects seeing themselves as rather more "hooked".

DISCUSSION
Our findings point to important differences among addicts in their perceptions of
their own dependence and their expectations of change. The positive correlations
between "self" and "other" attitudes may be seen in the context of the drug subculture.
Stephens & Levine (1971) have pointed out how the "street addict" role provides a
set of norms, values and behavioural prescriptions for certain drug-takers. Our results
show that the subjects tended to present themselves as relatively co-operative, but
expected other addicts at the clinic to be more drug-orientated and resistant to treat-
ment. This may be a reflection of the subcultural expectations which are shared by
many addicts, and may interfere with attempts to help the addicts to function without
drugs and to cope with their problems in other ways (cf. Osnos, 1967).
A number of studies have looked at aspects of drug use in relation to locus of control
(e.g. Berzins & Ross, 1973; Strassberg & Robinson, 1974), although their findings are
not unambiguously predicted by Rotter's (1966) theory. Our results are generally nega-
tive, although there was a weak relationship between externality and the perception
of oneself as "Hooked". It should be borne in mind, however, that we used a shortened
version of Rotter's (1966) scale, with those items reflecting more socio-political attitudes
(cf. Mirels, 1970) having been excluded.
Two independent factors describe the ways in which the subjects perceived their own
addiction. These we have called " H o o k e d " and "Sick". The " H o o k e d " factor is charac-
terised by a feeling of being "really addicted", fear of withdrawal, a belief in the addict's
own inability to give up drugs and unwillingness to attempt to give up at the present.
The "Sick" factor, on the other hand, picks out the addict's feelings that he does have
problems apart from these related to drugs, that he has no right to go on using drugs,
and that his addiction is a sickness. At the same time the addict believes that the
clinic has more to offer than simply a prescription and that doctors can help him
to give up drugs.
It is worth noting that aspects of both these factors seem to be included in the
conventional concept of the sick role (Parsons, 1951). There is a lack of confidence
in one's own ability to "get better" through one's own efforts, reminiscent of Seligman's
(1975) concept of learned helplessness, which implies that one cannot be held personally
responsible for one's continued addiction. At the same time, there is the expectation
that any 'cure' depends on medical intervention. Our results suggest that it may be
important empirically to discriminate between these two aspects of the concept.
It is interesting that the heroin group differ from the other drug users in terms of
the second factor only. Compared with the other drug users, they do not seem to
see their addiction as a sickness, and they do not feel that doctors can help then to
give up drugs. However, their assertion that they are "really addicted", together with
their admission that they have failed to give up drugs by their own efforts, suggests
that they have adopted a general attitude of resistance to change in this context.
Currently, there is debate over whether the aim of drug dependence clinics should
be "drug-free functioning" at all costs, or whether stable long-term maintenance of
patients on drugs is a legitimate goal (Edwards, 1976). A direct implication of our
results is that patients who regard themselves as " H o o k e d " would be more attracted
 Addicts' perceptions of their addiction 191

to a programme of treatment directed towards long-term maintenance. Addicts who

regard themselves as more "Sick" might be more likely to give up drugs, and to co-
operate with treatment programmes that aimed to withdraw them from drugs, whilst
at the same time dealing with their other personal problems. Since the two factors
are orthogonal, and not opposing poles of a single dimension, some addicts will regard
themselves as both "Hooked" and "Sick". For these, the prognosis for adequate social
functioning would seem to be more complex and less encouraging. The feelings that
one would have personal problems even without drugs suggests that a maintenance
programme could represent no more than a partial solution for such patients. At the
same time, such patients' feelings of inability to give up drugs and of unwillingness
to do so, may make it more difficult for the therapist to establish the kind of relationship
with them in which positive change could be achieved.

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