Hooked Or Sick

Addictire Behariour~,. Vol. 4. pp. 185 to 191.

0306-4603i7910401-0185S02.00i0

© Pergamon Press Lid 1979. Printed in Great Britain

"HOOKED"

OR OF

"SICK": THEIR

ADDICTS'

PERCEPTIONS

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 acknowledgement 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 treatment, 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 Sex Divorced/ lntraclinic" Male Female Single Married Separated venous Oral Yes No

Preferred drug

N

Mean age

Heroin Physeptone Amphetamines Barbiturates I& other sedativesl Benzodiazepines Codeine/Chlorodyne Multiple Cannabis

14 5 5 2

35.5 22.4 26.2 25.5

I1 3 5 1

3 2 0 I

5 5 5 1

2 0 0 0

7 0 0 1

14 5 3 1

0 0 2 1

13 5 0 0

1 0 5 2

4 4 5 1 40

26.5 26.8 28.8 52.0 30.0

2 2 5 1 30

2 2 0 0 10

1 4 3 1 25

2 0 1 0 5

1 0 1 0 10

0 I 4 0 28

4 3 1 I 12

1 1 2 0 22

3 3 3 1 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 individuals, 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 numerically 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 remembered 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,

J. RICHARDEISERand MICHAELR. GOSSOP

188

Table 2. Overall mean scores for "self" and "others" on the 15 items Item I. I'm terrified of withdrawal. 2. 1 find drugs help me cope with my personal problems. 3. I'm frightened about what drugs may be doing to me. 4. 1 wouldn't have any personal problems if there wasn't so much hassle about getting drugs. 5. l guess l'm really addicted. 6. ! don't think the clinic has anything to offer me except a script. 7. Getting stoned is one of the things that gives me most pleasure in life. 8. If I really wanted to, I could gire up drugs. 9. I've never made a serious effort to give up drugs on my own, 10. 1 don't think I could ever turn down drugs if someone offered them to me. 11. 1 think of my addiction as a sickness. 12. I think other people are to blame for me being addicted today. 13. l'm sure that doctors can help me give up drugs. 14. I've got every right to go on taking drugs if I want to. 15. I don't feel read)' to give up drugs right now.

Mean for "self . . . .

Mean for others"

"Self" vs. t (39)

"'Others" r

61.40

73.40

2.92**

0.663***

55.95

60.95

1.03

0.597***

57.50

57.70

0.03

0.364*

33.80 69.43

52.98 70.18

3.48*** 0.15

0.548*** 0.525***

24.83

56.05

6.01"**

0.509***

47.75

63.13

2.61"

0.375*

55.33

49.03

1.33

0.607***

30.10

38.88

1.46

0.368*

44.50 56.20

57.65 59.50

2.15" 0.60

0.408** 0.494***

21.70

44.10

3.71"**

0.210

41.65

56.35

2.60*

0.489***

55.65

71.83

3.07**

0.494***

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 I. Withdrawal 2. Cope 3. Frightened 4. Hassle 5. Addicted 6. Script 7. Stoned 8. Give up 9. Effort 10. Offered 11. Sickness 12. Blame 13. Doctors 14. Right 15. Ready Personal control Percentages of total variance accounted for

Factor 1

Factor 2

Communality

0.600 0.148 - 0.002 0.409 0.560 0.007 - 0.027 -0.617 -0.181 0.359 0.166 0.422 -0.190 -0.222 0.645 - 0.267

0.024 0.189 0.466 - 0.434 -0.217 -0.413 0.023 -0.095 0.276 0.108 0.382 0.182 0.481 -0.495 - 0.070 0.036

0.361 0.058 0.217 0.356 0.361 0.171 0.001 0.389 0.109 0.141 0.173 0.211 0.267 0.294 0.421 0.072

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

Item 1. Withdrawal 2. Cope 3. Frightened 4. Hassle 5. Addicted 6. Script 7. Stoned 8. Give up 9. Effort 10. Offered 11. Sickness 12. Blame 13. Doctors 14. Right 15. Ready Personal control

Heroin (N = 14)

Preferred drug Other drug (N = 26)

t (38)

71.00 55.43 36.79 37.29 84.43 35.00 27.43 54.71 16.29 32.29 34.93 13.14 27.00 63.57 67.07 5.64

56.23 56.23 68.65 31.92 61.35 19.35 58.69 55.65 37.54 51.08 67.65 26.31 49.54 51.38 57.12 5.08

1.30 0.06 2.44* 0.44 2.09* 1.44 2.74** 0.08 1.73t 1.44 2.85** 1.35 1.86t 0.97 0.86 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 intravenously 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 treatment. 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 negative, 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 characterised 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 cooperate 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. REFERENCES Berzins, J. I. & Ross, W. F. Locus of control among opiate addicts. Journal of Consultiny and Clinical Psycholoyy, 1973. 40, 84~91. Blumberg, H., Cohen, S., Dronfield, E., Mordecai, E., Roberts, J. & Hawks, D. British opiate users 11. Differences between those given an opiate script and those not given one. International Journal oJ'the Addictions, 1974, 9, 205-220. Currie, R. F., Perlman, D. & Walker, L. Marihuana use among Calgary youths as a function of sampling and locus of control. British Journal afAddiction, 1977, 72, 159-165. Edwards, G. The British approach to the treatment of heroin addiction. In G. Edwards, M. Russell, D. Hawks & M. MacCafferty (Eds). Druos and Druy Dependence, Westmead: Saxon House, 1976. Eiser, J. R. Discrepancy, dissonance and the "dissonant" smoker. International Journal of the Addictions, 1978, 13, in press. Eiser, J. R. & Sutton, S. R. Smoking as a subjectively rational choice. Addictive Behaviours, 1977, 2, 129-134. Gossop, M. R. Drug dependence and self-esteem. International Journal of the Addictions, 1976. I I, 741-753. Gossop. M. R. A comparative study of oral and intravenous drug dependent patients on three dimensions of personality. International Journal of the Addictions, 1978a, 13. 135-142. Gossop, M. R. Drug dependence: A study of the relationship between motivational, cognitive, social and historical factors, and treatment variables. Journal of Nervous and Mental Disease, 1978b 166, 44-50. Gossop, M, R. & Roy, A. Hostility in drug dependent individuals: Its relation to specific drugs, and oral or intravenous use. British Journal of Psychiatry, 1976, 128, 188-193. Heller. M. E. & Mordkoff, A. M. Personality attributes of the young nonaddicted drug abuser. International Journal of the Addictions, 1972, 7, 65-72. Jellinek, E. M. The Disease Concept of Alcoholism, Highland Park, N J: Hillhouse Press, 1960. Mirels, H. L. Dimensions of internal versus external control. Journal of Consultinq and Clinical Psycholooy, 1970, 34, 22(~228. Osnos, R. Psychiatric and psychological factors involved in the amenability to treatment of drag dependent individuals. In H. Brill, J. Cole, P. Deniker. H. Hippius & P. Bradley (Eds) Neuropsychopharmacolooy, New York: Excerpta Medica, 1967. Parsons, T. The Social System. Chicago, MI: Free Press, 1951. Robins, L. N., Davis, D. HI & Goodwin, D, W. Drug use by U.S. Army enlisted men in Vietnam: a follow-up on their return home. American Journal of Epidemioloyy, 1974, 99, 235-249. Robinson, D. The alcohologist's addiction: Some implications of having lost control over the disease concept of alcoholism. Quarterly Journal of Studies on Alcohol, 1972, 33, 1028-1042. Rotter, J. B. Generalised expectancies for internal versus external control of reinforcement. Psyeholo,qical Mono9raphs, 1966, 80, (Whole No. 609). Seligman, M. E. Helplessness, San Francisco, CA: Freeman, 1975. Stephens, R, & Levine, S. The "'street addict role": Implications for treatment. Psychiatry, 1971.34, 351-357. Stimson, G. V. Heroin and Behaviour. Shannon: Irish University Press, 1973. Strassberg, D. S. & Robinson, J. S. Relationship between locus of control and other personality measures in drug users. Journal of Consultino and Clinical Psychology, 1974, 42, 744-745. Teasdale, J. The perceived effect of heroin on the interpersonal behaviour of heroin-dependent patients, and a comparison with stimulant-dependent patients. International Journal of the Addictions, 1972, 7, 533-548.