The Development and Application of a Questionnaireto Assess the Changing Personalities of SubstanceAddicts During the First Year of Recovery

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Ian SutherlandUniversity of Plymouth

The Addiction Recovery Index, a 60 item questionnaire, was developedand administered to 889 recovering substance addicts with a view tomeasuring levels of the primary trait of Neuroticism as well as six accom-panying subtraits during the first 12 months of recovery. Good reliabilityand validity scores were achieved for the ARI and results indicated thatrecovering addict’s overall Neuroticism scores reduced as a function ofSubstance Free Time (F (11, 877) 5 338.37, p , .0001). It was alsonoted that the individual sub-trait scores decreased, but various anoma-lies, particularly with Anxiety, were recorded. © 1997 John Wiley & Sons,Inc.

In addition to general personality research, there has been much discussion in the literature overthe question of the existence or otherwise of an addictive personality (see for example: Hoff-man & Slade, 1993; Platt, 1975; Sutker & Allain; 1988). Some researchers appear to considerits presence to be a foregone conclusion (see for example: Begun, 1977; Sleisenger, 1985),while others regard the concept with a substantial degree of scepticism, calling into questionthe direction of causality and claiming that any specific traits identified are consequent uponthe addictive behavior, with psychopathology or aberrant personality findings resulting directlyfrom the dependent state rather than contributing to it (Nathan, 1988; Sutker & Allain, 1988).

The question of causality is particularly important if the subject population is made up ofaddicts or recovering addicts and researchers have to attempt to conclude if the trait is ante-cedent, concurrent, or consequent to the addictive behavior.

Costa and McCrae (1985) have indicated that personality traits tend to remain stable overtime; therefore, if the addictive personality does exist, it should be assumed that the traits ofthat personality would remain relatively, but not necessarily totally, stable throughout the addic-tive process. However, Brown et al. (1991), in a study of 91 recovering addicts, found that 40%of recently detoxified male alcoholics reported significantly elevated levels of Anxiety andDepression one week after they had ceased drinking, with levels steadily decreasing after that

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until levels comparable with non-addicts were achieved. It is understandable that recently detox-ified individuals should have raised personality indicators, especially in the areas of Anxietyand Depression, but, if the addictive personality construct is to be accepted, it seems surprisingthat those indicators should so readily fall back to within the normal limits for a non-addictedpopulation.

These findings are supported by Christo and Sutton’s (1994) work with 200 recoveringaddicts using Spielberger’s (1983) State-Trait Anxiety Inventory and Rosenberg’s (1965) Self-Esteem Scale. This work has indicated that although Anxiety and Self-Esteem are initiallyraised in addicts during early recovery, there appears to be an almost linear relationship betweentheir decreasing scores and the length of an individual’s recovery. As with Brown’s work,assuming that Anxiety and Self-Esteem make up part of an addictive personality construct, thisfinding would appear to contradict the concept as continuing raised levels of the traits could beexpected even post active addiction.

In a review article of the Minnesota Multiphasic Personality Index (MMPI) and its use-fulness in identifying the characteristics of alcoholics, Graham and Strenger (1988) concludedthat no single personality type is characteristic of all alcoholics and, as such, the concept of anaddictive personality could not be promulgated.

In light of this evidence, it may well be reasonable to assume that although addicts of alltypes may be linked by an addictive process, they are not necessarily united by a common,addictive, personality.

However, in spite of this continuing controversy over the addictive personality, it doesappear possible to say that addicts may differ in some way from non-addicts, but the level andtypes of these differences remains unclear. In a review article, Retka and Chatam (1974, p. 15)said that the personality of drug addicts has been variously described as “. . . alienated, frus-trated, aggressive, emotionally unstable, nomadic, narcissistic, dependent, sociopathic, hedo-nistic, childlike, paranoid, rebellious, hostile, infantile, retreatist, cyclothymic, constitutionallyimmoral, hysterical, neuroesthenic, self-indulgent, introspective, essentially normal. . . .”

Although Retka and Chatam’s comments indicate that researchers have found addicts withnumerous divergent facets to their personalities, there have also been many instances wherestriking commonalities have been found too, particularly within the concept of Costa andMcCrae’s Neuroticism, and it is these commonalities that has prompted researchers to examinethis particular area of personality in detail. (See for example, Gossop & Eysenck, 1980; Lodhi& Thakur, 1993; Sutker & Allain, 1988; Tarter, 1988).

Barnes (1983) has indicated that the consensus of opinion among researchers is that addicts,relative to non-addict controls, exhibit raised levels of Neuroticism, either before, during, orafter active addiction. Additionally, Bergman (1979), examined data obtained from an MMPIanalysis of 60 alcoholics and 60 clinically diagnosed neurotic patients and found no differencesbetween the two groups’ sources, thereby indicating that the alcoholics had raised levels ofNeuroticism.

In addition to numerous other instruments, the Eysenck Personality Questionnaire (EPQ)(Eysenck & Eysenck, 1975) has been used extensively in this area and addicts have invariablybeen found to score significantly higher than non-addicts on the Neuroticism–Stability dimen-sion (Barnes, 1983). For example, Sahasi, et al. (1990) found that heroin addicts in India scoredvery highly on the Neuroticism sub-scale which replicated and supported similar work byEysenck in Britain (Eysenck & Eysenck, 1975).

However, although the trait of Neuroticism can be seen to be raised in an addict population,it is possible that Neuroticism is, in itself, too broad a concept to be particularly useful.

Various attempts have been made to break down the Neuroticism trait. For instance,Falkowski, Hatcher, Sondhi, Fong, and Young (1986), in a study of drinking patterns amongmedical students, found that there was a positive correlation between the amount of alcohol

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taken and scores achieved on the Crown Crisp Experiential Index (CCEI) (Crown & Crisp,1966). They concluded that the more a person drank, the more deviant were his or her scores ofthe sub-traits of Free Floating Anxiety, Somatic Disorder, Depression, and Hysteria. However,the validity of the sub-scales of the CCEI is poor and heavy drinking medical students areprobably not a representative sample of addicts as a whole.

An extensive literature review by the author suggested that the sub-traits most often citedas being abnormal in an addict population are Self-Esteem (or feelings of Worthlessness),Depression, Anxiety, Hypochondria, Hostility (or Anger), and Fantasy and it is these traits thathave been utilized in the construction of the Addiction Recovery Index (ARI).

Following extensive consultation with drug workers from various disciplines, the ARI wasconstructed and applied to a group of recovering addicts and alcoholics, the expectation beingthat recovering addicts would have high levels of Neuroticism and the accompanying sub-traits, which would gradually decrease as a function of Substance Free Time. (SFT)

METHOD

Design

The study was carried out using a cross-sectional questionnaire design and was constructed tomeasure Neuroticism and the sub-traits of Anxiety, Depression, Fantasy, Hostility, Hypochon-dria, and Worthlessness.

Subjects

Participants were 889 recovering drug and alcohol addicts who were attending various treat-ment centres around Great Britain. There were 677 males and 211 females with a mean age of33 years 6 months. (Maximum5 67 years, Minimum5 17 years,SD5 11.6)

Participants had a mean Addiction Time of 16 years and 9 months (Maximum5 45 years,Minimum 5 1 year,SD5 110.7) and a mean Substance Free Time of 5.9 months which wasverified by the treatment centre they attended. (Maximum5 12 months, Minimum, .5 months,SD5 3.4)

On average, participants had spent 48% of their lives addicted to various substances. (Max-imum 5 80%, Minimum5 3.4%,SD5 14.2)

Materials

An item pool of 150 statements were initially gathered. A number of sources were used for thisand although no items were taken directly, the NEO-PI, CCEI and the Eysenck PersonalityQuestionnaire (EPQ) were consulted. Additionally, various personal consultations with clinicalpsychologists and workers at drug rehabilitation centres took place. Following this phase, thenumber of statements was reduced to 120.

Pilot work was carried out at a rehabilitation clinic, Narcotics Anonymous meetings, andAlcoholic Anonymous meetings in the south-west of England. One hundred and twenty fiverecovering drug addicts and recovering alcoholics took part in this pilot phase of the develop-ment of the ARI.

Item Analysis then reduced the total number of items to 60, 10 for each of the sub-traits.The final version of the Addiction Recovery Index was constructed with the 60 items being

randomized so that participants would not be able to determine a pattern to the statements.All statements were Rating Scale Items with the possible responses being: Strongly Dis-

agree, Disagree, Neutral, Agree, and Strongly Agree. These five responses were chosen as it

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was felt they were non-ambiguous and would give respondents enough scope in which toexpress themselves adequately.

In order to avoid any subject’s possible tendency towards acquiescence, half of the itemswere reversed so that an equal number were scored in each direction.

Social Desirability was also considered in the construction of the ARI, however, due to thenature of the target population and the areas in which it was intended the ARI should explore,designing statements that would avoid social desirability bias was considered to be impossible.Alternatively, five items from the Crowne–Marlowe Social Desirability Scale (1960) wereutilizedas “test” questions at the beginning of the ARI in order to avoid response distortion.

The manner in which participants could respond to the Crowne–Marlowe scale was adjustedso that responses were made in the same format as for the ARI. In this way, participants couldachieve a maximum score of 20 and a minimum score of zero with a higher figure indicatingthat the participants’ scores were possibly liable to response bias. An arbitrary figure of 15 waschosen and any potential participant who scored this figure or more was discarded.

Background information was included so that items such as the participants’ age, sex,length of addiction, and drug of choice could be recorded.

Instructions were designed to be clear and unambiguous and participants were asked torespond to each item as quickly as possible. This last instruction was given as another measureto avoid Response and Social Desirability bias.

The final form of the ARI was reliability tested and was calculated using Cronbach’sAlpha.

An alpha coefficient ofa 5 .93 was achieved for the overall ARI scale. Reliability for theAnxiety sub-scale was calculated asa 5 .76, for Depressiona 5 .69, for Worthlessnessa 5.77, for Fantasya 5 .67, for Hostilitya 5 .74, and for Hypochondriaa 5 .71.

The ARI was validated against the NEO-PI and the CCEI using Pearson’s Product MomentCorrelation. Seventy-eight subjects completed the ARI, the Neuroticism section of the NEO-PIand the CCEI. None of the three questionnaires were labeled and the participants were merelytold they were part of a validation study.

When the results were calculated, the ARI achieved a correlation of .881 when validatedagainst the Neuroticism section of the NEO and a correlation of .778 against the CCEI with anon-addict population.

Procedure

Contact was made, by letter, with 351 treatment centers. Both National Health Service andcenters from the private sector were contacted and asked if they would care to participate in astudy of “altering personality in recovering addicts.”

There was a 42% response rate from the centers, 84% of whom agreed to take part, makinga total of 123 participating centers.

Two thousand one hundred fifty four copies of the ARI were sent out with a return deadlineof October 14, 1994. By that date 1,071 had been received.

The returned ARI forms were subjected to scrutiny based on the Crowne–Marlowe socialdesirability scale and 180 were rejected on these grounds and a further two were excludedbecause they were soiled.

RESULTS

The results were considered in two different sections. First, the recovering addict’s overall ARIscores, making up the gross trait of Neuroticism, was examined and, second, their sub-traitresults were considered.

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Overall ARI Scores

A Oneway Analysis of Various (ANOVA) revealed that there was a highly significant differ-ence in overall ARI scores for the recovering addicts as a function of Substance Free Time(F (11, 877)5 338.37,p , .0001). This provides very strong evidence that levels of Neuroti-cism reduce with increased Substance Free Time and allows the null hypothesis that there willbe no change in the personalities of recovering substance addicts to be rejected.

Sub-Trait Addiction Recovery Index Scores

There were differences in the reduction profiles of the various sub-traits, however, a significantreduction was noted in each separate sub-trait over the experimental period. As can be seen inFigure 2, the Anxiety sub-trait reduced by 31.58%, Depression by 35.97%, Worthlessness by45.38%. Fantasy by 33.1%, Hostility by 36.45%, and the Hypochondria sub-trait by 39.9%.

DISCUSSION

The results indicate that the Addiction Recovery Index may be a useful tool in the measurementof Neuroticism within a population of recovering substance addicts. The data presented showsthat the instrument has adequate reliability characteristics and correlates favorably with otherinstruments commonly used to measure similar personality constructs.

Figure 1. Recovering Addict’s Overall ARI Scores During the First Year of Substance Free Time.

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The results obtained indicate support for the hypothesis that the personality characteristicsof recovering substance addicts will show a tendency towards normalization as a function ofSubstance Free Time.

Additionally, the results indicate that the Neuroticism sub-traits of Depression, Fantasy,Hostility, Hypochondria, and Worthlessness all appear to fall in accordance with the centralreduction. It should, however, be noted that the sub-trait of Anxiety does not reduce with thesame profile as the other sub-traits.

The Addiction Recovery Index

The instrument yielded adequate Cronbach’s Alpha scores both overall and across the sub-traitsand its sensitivity was shown by the changes found in recovering addict’s overall and sub-traitscores. Additionally, the ARI achieved good concurrent validity correlations when measuredagainst the Neuroticism section of the NEO-PI and the CCEI both of which have been used tomeasure similar personality constructs.

The validity correlations obtained for the ARI were impressive and while there is goodevidence of concurrent validity, the crucial test for the ARI’s usefulness will come from anexamination of its predictive validity. In order to achieve this, several of the treatment centersthat took part in the study have agreed to supply data in the future on the relapse rates of theirclients.

Given the validity and reliability of the ARI, it might well be appropriate to obtain stan-dardization figures for both the overall Neuroticism measure and the sub-traits. If this is achieved,it might then be possible to look at an individual’s scores and predict their chances of a suc-cessful outcome to their treatment.

The results obtained supports researchers such as Barnes (1983), who indicated that althoughan addictive personality might not exist, addicts do have significantly elevated levels ofNeuroticism.

Figure 2. The Reduction Profiles of the Sub-Traits.

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Overall Neuroticism

The overall ARI scores indicated that there is a relationship between Substance Free Time andlevels of the primary trait of Neuroticism in that the initially elevated overall scores decreasedby 37.25% over the observed period of 12 months.

This finding appears to support Christo and Sutton’s (1994) conclusions that althoughpersonality indicators are initially grossly abnormal in addicts during early recovery, thereappears to be an almost linear relationship between their improvement and the length of anindividual’s recovery.

However, it should be noted that the findings in this study indicate that although addict’sscores decreased dramatically during the first nine months of SFT, they plateaued for the lastthree months of the study period.

This plateau effect may be interpreted as the addicts having “normalized” fully, whichwould be contrary to Christo and Sutton’s findings who suggested that it could take up to 42months for an addict’s personality to normalize. It could also be seen as a temporary halt in therecovery process.

Addicts’ Individual Sub-Traits

In Figure 2, it can be seen that the six sub-traits show a tendency to lower over the 12 monthperiod of the study. However, there are noticeable exceptions to the reduction pattern followedby the sub-traits.

Although Anxiety was raised throughout the study period, specifically, at SFT month eightthere is a resurgence of Anxiety with scores returning to the levels of five and a half monthsSFT. This Anxiety spike directly precedes the nine to 12 month plateau effect and may possiblyindicate that a crisis point has been reached in the addict’s recovery.

This may not be totally surprising as raised levels of Anxiety would support the findings ofWells and Stacey (1976) who found that addicts had consistently higher levels of Anxiety thannon-addicts.

If the integrated stance of personality theory is accepted, (see for example, Carson, 1989;Costa & McCrae, 1989; Deary & Matthews, 1993) it does appear likely that the personalityconstructs measured with the ARI are interrelated with each sub-trait interacting with all theothers. In this way, it may be reasonable to assume that if Anxiety stopped falling at a particularpoint, or indeed became raised again as it did in this study, then, for example, the linkedsub-traits of Hypochondria and Worthlessness may also stop improving.

It is also possible that Anxiety levels were adversely affected by the other five markers. AtSFT month seven the sub-traits of Fantasy, Worthlessness, and Hostility were all higher thanAnxiety. Up until that month Anxiety had shown the highest score of the sub-traits and it maytherefore be possible to speculate that as the participants became less conscious of their Anx-iety feelings they became more aware of feelings of Worthlessness and Hostility. This thencaused a rebound effect and Anxiety returned to the high levels found at SFT month five.

Following this, once Anxiety had risen again the addict participants may have focused onthat particular sub-trait to the detriment of the other five whose progress was effectively stalledat SFT month nine.

In addition to Anxiety, the profile for Depression was found to be outside of the generalreduction pattern.

Levels of Depression fell only gradually during the first five months of SFT, but once thattime point had been reached the Depression scores decreased at a quicker rate than the others.

Keeler et al. (1979) found that 98% of active addicts complained of depressive episodesand continuing high levels were expected in this study. However, the sudden reduction in

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Depression levels during SFT months five to eight, followed by the plateau effect may notindicate a true reduction of underlying Depression, but instead may be an indicator of a gen-eralized, but temporary, euphoria at being substance free. Additionally the reduction profilemay be a pointer to the underlying instability of the recovering addict’s personality.

The reduction profiles of Worthlessness, Fantasy, Hostility, and Hypochondria did notdiffer significantly from the overall pattern of reduction found, however, they all reduced sig-nificantly over the experimental period.

One of the central beliefs of all of the self-help groups that use the Minnesota Model(Alcoholic Anonymous, Narcotics Anonymous, etc.) is that total recovery is not a practicalgoal, but an ideal (Peyrot, 1985). However, if Neuroticism can be taken as an indicator ofoverall psychological health, the decreasing scores in this study lend support to the idea that atleast partial recovery at the end of a year of abstinence is possible.

A particular problem associated with this work was that the participants may not have beenrepresentative of the addict population as a whole. Participants in the addict group were eitherundergoing, or had undergone, voluntary (and sometimes expensive) therapy in treatment cen-ters which might indicate that they were more highly motivated than addicts who had notundergone some form of treatment. It is therefore possible that the study was limited to adistinct sub-culture within the general addict population, a sub-culture that was highly moti-vated and, importantly, outside of its normal addictive environment.

No figures are available on what percentage of the general addict population actually seekshelp in treatment centers and that being the case, it may not be possible to extrapolate thefindings of this study to the whole of the addict population which would lead one to questionthe external validity of the work.

Additionally, no figures were available on drop out rates from the treatment centers. It ispossible that addicts with, for instance, very high Anxiety or Depression scores left the treat-ment centers before the completion of their program.

In addition, the study did not exclude self-selection. It is again possible that only addictswho were feeling the benefit of treatment completed the questionnaire, addicts who were toounwell or who had very high personality indicators might well have refused to take part in thestudy giving the results a skew.

If that is the case then the levels of the sub-traits may be distorted, measuring the levelsonly of those addicts who were highly motivated and who had managed to reduce their sub-traits.

Importantly, treatment centers were not asked for their theoretical orientations and nomeasure was taken of the type of treatment, or absence of it, that was being received by indi-vidual addicts. It is therefore possible that subjects were, for example, taking part in confron-tational group therapy or, alternatively, had been taking tri-cyclic antidepressants or coming tothe end of a course of Methadone, all of which could artificially affect personality indices(Kleber, 1989). These treatment orientations should, in any future studies, be looked upon aspossibly confounding variables and taken into account accordingly.

Many of the participants had only a few weeks SFT and as such, were probably underenormous psychological strain. If they had only recently undergone detoxification then it isentirely possible that the ARI was only measuring their perception of their personality at thatparticular moment in time, the underlying trends may have been too inhibited beneath the acutesymptoms to have been recorded.

It is acknowledged that addicts seem to be particularly troubled by affective disorders(Gossop & Eysenck, 1980) and the results achieved here seem to bear that out. However, giventhat recovering addicts do have higher Neuroticism indices than their non-addict counterparts,where does that lead the researcher? It is possible that this path could lead back to the conceptof an addictive personality with all the controversy that would entail. More likely, and probably

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of better theoretical value, would be to accept that the trait of Neuroticism is elevated and torefine addict specific instruments, such as the ARI, to delve more deeply into this construct.While it is felt that the six sub-traits examined here are worthwhile elements of Neuroticism, itmay be appropriate in future to generate sub-trait specific instruments that would be capable ofassessing each sub-trait individually and more subtly.

Additionally, greater precision may have been achieved if instead of having an all encom-passing group of “addicts” the study had divided up the participants by addiction and hadlooked at the different types of substance addiction. In that way it might have been possible toshow that former users of heroin had a different Neuroticism profile compared to amphetamineaddicts or alcohol addicts.

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