Research Article

Psychopathology Received: February 9, 2022

Accepted: August 31, 2022
DOI: 10.1159/000527084 Published online: October 25, 2022

Toward a Phenomenological Assessment

of Values in Alcohol Misuse
Maria Julia Francischetto Ribeiro Soares a, b Guilherme Messas a, b
aDepartment
of Mental Health, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil;
bCollaborating
Centre for Values-based Practice in Health and Social Care, St Catherine’s College, Oxford, UK

Keywords willpower. Conclusions: The results of this study contribute

Values · Alcohol abuse · Alcohol use disorders · Alcoholism to developing strategies for bringing care closer to the pa-
treatment · Value-based practice · Decision-making · tient’s perspective of the disease and encourage their active
Motivational strategies participation in the formulation of care.
© 2022 S. Karger AG, Basel

Abstract
Introduction: Alcohol misuse emerges from a complex Introduction
range of psychopathological experiences and personal and
cultural values. For this reason, understanding the reasons The World Health Organization (WHO) considers al-
why a person seeks treatment is crucial to effective care. This cohol consumption as an important factor for increased
study aimed to identify the values which guide the decision- morbidity and mortality in the world [1]. It is associated
making process of persons seeking voluntary hospitalization with over 200 diseases as defined by the International
for treatment for alcohol misuse, as well as the values of sig- Classification of Diseases [2], and individuals diagnosed
nificant others. Methods: A phenomenological investigation with alcohol use disorder (AUD) account for approxi-
was conducted through interviews with 25 individuals (and mately half of the problems reported with the use and
family members) who had voluntarily admitted themselves misuse of alcohol [3]. The misuse of substances, such as
to a hospital in São Paulo, Brazil, with the objective of main- alcohol, emerges from a complex set of psychopathologi-
taining abstinence from alcohol dependence. Results: The cal experiences, personal choices, specific psychological
main factors that determined the treatment-seeking deci- vulnerabilities, personality traits, and cultural values [4];
sion were damage to social relationships and fear of illness consequently, it is not easy to find a consensus about the
and deterioration of the physical condition; the factors re- core elements that make substance use pathological or
lated to treatment expectations were restoring personality problematic [4], making it difficult to recognize these in-
and awareness of morbidity; and the single factor consid- dividuals and propose appropriate treatment.
ered most important to the success of the treatment was
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[email protected] © 2022 S. Karger AG, Basel Correspondence to:

www.karger.com/psp Maria Julia Francischetto Ribeiro Soares, majufrs @ gmail.com
 Understanding the reasons for substance use and mis- schizophrenia [9] or substance misuse [15], offering new
use as belonging to their context of personal values could tools for clinical decision-making [16]. In this study, we
be a fundamental step in increasing the effectiveness of would like to extend this new scientific trend to AUD,
treatments, especially in users who refuse to engage in through a dialectical phenomenological method (DPh)
treatment [5]. There is evidence that taking into account [14, 15, 17]. The DPh enables the researcher to describe
the preferences of individuals with AUD when imple- some ideal types of experiences – in our case, of value ex-
menting therapeutic strategies leads to higher rates of ad- periences. The description of ideal types of experiences is
herence [5], with potential increase of the effectiveness of one of the most classical and fertile strategies for a pre-
decision-making in medical care [6, 7]. liminary evaluation of a topic [18]. The exploration by
To implement a treatment strategy guided by personal ideal types favors a preliminary view of the essential char-
values, they first need to be identified. Values are “[…] are acteristics of psychological experiences, to be further in-
attitudes or dispositions that are the guide of actions sub- vestigated in more detailed quantitative and qualitative
ject to praise or guilt” [8, 9]. Values are expressed in a research.
person’s preferences, desires, and everything one evalu-
ates positively or negatively in terms of having merit or
not [9]. However, values are not purely preferences or Methods
fixed entities; rather, they result from the perceptions and
The trial was conducted at the Hospital do Servidor Público
relationships of the person with their community and so- Estadual de São Paulo (HSPE), São Paulo, Brazil, from October
cial environment, that is, they are qualities that arise from 2019 to February 2020 among (self-diagnosed or diagnosed by a
subject-environment interaction [10]. relevant person) alcohol-dependent persons who voluntarily
For a better understanding of a person’s set of values, sought treatment and agreed to participate in the research, by sign-
it is fundamental to understand as well the values of the ing a free and informed consent form. The sample contained 25
patients and 25 important others. The first day of psychiatric hos-
subculture and the society to which the person belongs. pitalization in the emergency room was the initial contact with the
This enriched understanding of the cultural values of sub- users. None of the volunteers were intoxicated nor showed at the
stance misuse patients can help to both better understand moment of the interviews any symptom of withdrawal syndrome
their psychopathology and reduce the barriers between or oscillation of the consciousness level. After careful reading and
users and service providers [11, 12]. This enriched under- signing the consent form, the volunteers were submitted to a semi-
structured interview. The semi-structured interview was conduct-
standing might qualify health professionals to work in ed based on the trigger question: why did you request hospitaliza-
partnership with users, making the decision-making pro- tion for treatment of alcohol misuse? All the subsequent questions
cess more effective [4]. from the interviewer followed the principle of asking for more de-
The effort of assessing the users’ personal values raises tails of the experience of the subject related to the trigger question.
a number of questions as follows: does a group of users, The interviews were applied by the first author (M.J.F.R.S.) and
were conducted on a single occasion. The interviews were audio-
from the same subcultural background, and in the same recorded and later transcribed. No notes were taken during or after
health care service, have similar individual values regard- the interviews. The interviews lasted between 7 and 34 min. Data
ing their treatment? Do the same values determine the saturation was discussed between the two authors of the study. The
choice of whether or not to seek voluntary hospitalization participants did not have access to the transcripts.
to stop alcohol misuse? If this is the case, a better under- We only included individuals in the study who specifically
said that they sought hospitalization for gaining alcohol absti-
standing of these values should produce better treatment nence. Additionally, an individual from the user’s social support
outcomes in these individuals. network was also interviewed, indicated by the user. A total of 30
The aim of this study was to contribute, through a phe- users were initially approached to take part in the survey, but
nomenological perspective, to the assessment of personal three could not provide a contact and two refused to participate.
values that influence alcohol misusers’ decision to under- All the patient contacts agreed to be interviewed. The study was
approved by the Ethics Committee of HSPE (No. 3.566.883;
go hospitalization. We follow recent trends in the scien- CAAE: 17608619.5.0000.5463).
tific literature that have been demanding the incorpora- The data analysis was based on the DPh, steps of which are de-
tion of the subjects’ lived experiences into the scientific tailed in Messas et al. [17]. This method is based on a hermeneutic
endeavor, particularly in psychotic disorders [13]. Phe- elaboration developed by the researcher (second-person perspec-
nomenology has been considered one of the most rele- tive) over the subjective first-person account offered by the inter-
viewee in a semi-structured interview, constituting a synthesis be-
vant methods for carrying out this kind of study, both as tween first- and second-person perspectives. The values identified
a general investigation of altered experiences [14] and as by the method are therefore initially determined from the report
a form of assessment of personal values in disorders like of the user him/herself and/or his/her significant other about the
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2 Psychopathology Soares/Messas
DOI: 10.1159/000527084
reasons they considered central to the search for hospitalization. to be harmful: “(the misuse of alcohol) can ruin a person’s
In a second step, the examiner’s own experience at the time of the life, you fight with your wife, fight with your mother, with
interview was analyzed and dialectically included in the conclu-
sions so that each value defined by the study is a result of an inter- your sisters …” And in response to a question on why he
pretation of the first-person accounts, validated by the direct ex- was becoming abstinent now was the answer: “because I
perience of the first examiner M.J.F.R.S. Finally, the identification divorced my wife,” which becomes a driving force to seek
of the values interpreted in this study were confirmed, rejected, or treatment. In response to the question “why are you seek-
transformed by both authors, in specific meetings, adding validity ing hospitalization?,” one user responded “So that I can
to the findings [19].
return home, to my family, which is my wife, my daugh-
ter, the people who love me, I would stay out of the house
for 2 or 3 days, my wife said she doesn’t want that any-
Results more.” This value also appears in the responses of family
members, such as: “He’s killing himself, he’s lost his life,
The interviews identified values related to three di- he’s lost his family, he’s lost everything, he only has the
mensions of the clinical care: (i) treatment-seeking deci- clothes on his body,” and when asked why the user sought
sion, (ii) success of the treatment, and (iii) treatment ex- hospitalization, the response was follows: “his separation
pectations. The values that determined treatment-seek- from my mother and his divorce, he freaks out and then
ing decision were: “damage to social relationships” and he regrets it.”
“fear of illness and deterioration of the physical condition”; The damage also includes the user’s professional
the value that the users and families believed most deter- sphere. This value emerges in users, for example, when
minant for treatment success was “willpower”; and the the alcohol misuse threatens their retirement, as in: “Be-
values related to treatment expectations were “restoring cause of alcoholism I can lose my work rights …I’m hav-
personality” and “awareness of morbidity.” In the follow- ing to fight to get my pension.” The same user also said “I
ing, we will explore them in more detail. was a great teacher; I was losing the chance to be the
teacher I always wanted to be.” This awareness makes the
Values That Determined Treatment-Seeking Decision user start to consider alcohol use as a negative behavior:
Damage to Social Relationships “because my life was all messed up, because I can’t work,
This value is related to a central dimension in the us- I can’t really do the things I do.” Another user expressed
ers’ lives, the family sphere. For example, one family similar feelings in respect of both the professional and fa-
member gave an example of the user’s damaged social miliar spheres: “I’m losing my family; I’m practically los-
relations: “Her mother is in constant need of her … her ing my job.” The importance of professional life as a rea-
mother has Alzheimer’s disease … and her brothers threw son for the treatment-seeking choice is also highlighted
her out (from home) because she (while intoxicated) had in a family member’s comment: “he was already about to
threatened to kill her mother.” A user said that her seek- lose his job, (it was important) for him to become aware
ing for hospitalization was related to avoiding fights in that he had no other way out other than treatment.”
her family environment “(I sought treatment) to avoid
conflict.” This value is also related to the need to cope Fear of Illness and Deterioration of Physical
with the social damage that alcohol abuse has already Condition
caused, as exemplified by the statement of a user, who Fear of illness and deterioration of physical condition
said: “I actually want to rebuild my family, to tell you the are the result of symptoms that emerge from intoxication
truth, if I were alone, I wouldn’t be so worried.” This val- and are visible in responses such as: “the lapses in mem-
ue was also demonstrated by another family member who ory that I had were not normal” or “because I was drink-
said: “(…) because he realized that it affected his health, ing a lot, and I had an outbreak of talking to myself, psy-
and had an impact on his relationship with his wife and chotic I think … after this outbreak I was even more
his children.” afraid of getting a mental problem.” They also emerge
Social damage is most evident in relation to conjugal from abstinence syndrome: “(why did you seek hospital-
relationships, as demonstrated by responses expressing ization?) because I had a tremor.” They can be related to
regret about intoxicated behavior: “When we were going the appearance of comorbidities, such as those reported
out (the user and the ex-girlfriend), I was under the influ- by one user: “I’m physically tired, I have leg problems, I
ence of alcohol, and many times, I didn’t enjoy the mo- have problems with peripheral neuritis, I had sciatic
ment with her” and the misuse of alcohol starts to be seen nerve problems and I believe that all these problems are
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Assessing Values in Alcohol Misuse Psychopathology 3

DOI: 10.1159/000527084
caused by alcohol… it destroyed my nervous system,” ful” or in “(a treatment) that helps him to understand the
and a family member commented: “Alcohol is ruining disease.” This relates to one of the main treatment chal-
his health, he already has a heart condition.” Users also lenges because many users, even if voluntarily seeking
commented on the relationship between comorbidities hospitalization, do not fully accept that their alcohol con-
and intoxication, as in: “It’s been 2 days I can’t sleep, I sumption is a serious problem, as demonstrated in state-
can’t sleep anymore, then, when I drink (he makes vom- ments such as: “Why do I drink? The only fun I have is
it noise), I pass 5 days without eating, (he makes vomit this, and… for nothing, I’m not an addict, I drink because
noise) … I have three esophageal varicose veins, if I burst I have no shame” or in the lack of awareness about the
one, I die.” condition, which often makes treatment seem like a waste
of time, as in “I can’t believe I am because I could be work-
Value That Determines Treatment Success ing, so now it’s hurting me.”
Willpower
The main value highlighted in the interviews as being
fundamental in respect of the expected treatment success, Discussion
both by users and their family members, was the user’s
desire to start treatment, the so-called readiness to change. The identification of the personal values that led per-
This value expresses the users’ engagement in the treat- sons with alcohol misuse to spontaneously seek treat-
ment, by performing the actions proposed by the health ment, more specifically the hospital admission, contrib-
professionals to maintain the health care. It appeared in utes to the understanding of the high dropout rate and, as
several comments similar to: “I believe it is up to oneself such, may help improving the motivational strategies ap-
to stop (drinking)” or “He has already been in many treat- propriated for clinical care. It suggests that other behav-
ments, the last one lasted 9 months, if he doesn’t want to ioral and psychosocial therapies, besides hospitalization,
…” or “you can only do it if you really want to,” and some should be encouraged to this population. Understanding
family members thought that a lack of willpower might misuse as a chronic condition and demonstrating the im-
make the treatment ineffective: “I don’t think he has the portance of the intervention of other forms of support
willpower to stop (drinking)” or “I don’t know if he will appear to be central elements for the enhancement of
have enough willpower.” therapeutic effectiveness.
The scientific literature clearly shows that the percent-
Values Related to Treatment Expectation age of dropouts in the treatment of drug dependence, in-
Restoring Personality cluding alcohol [20], is so high that it compromises the
The value of personality restitution emerges from us- effective public health management of the problem. There
ers’ belief that under the influence of alcohol, they “trans- are several factors that explain the high dropout rates
form themselves,” as in: “(with the use of alcohol) it seems among alcohol-dependent patients. These include sys-
that you’re no longer you, you take on another personal- temic factors related to limitations in the health system
ity” and can become a driving force for treatment. One – such as a lack of professionals or a general lack of infor-
user said that their objective was “to return to normality, mation in society about the problems related to alcohol;
what is called in Latin restitutio ad integrum,” and an- sociocultural and individual factors, such as lack of fam-
other said it was “to get back in touch with people without ily support, lack of motivation, or the presence of preju-
the use of alcohol.” This was also reflected in the respons- dice and social stigma related to the recognition of the
es from family members, such as: “I hope he go back to need for treatment [20, 21]; and structural factors, for ex-
the way he was, today it’s as if he is stopped in time,” or ample, the difficulty in establishing an empathic relation-
“because without booze he’s a great person and I wanted ship between therapists and patients or the cost of treat-
him to be more like that with his family,” or “(I hope) he ment [22].
can go back to being the person he was a few years ago.” One strategy to reduce the number of dropouts and
increase therapeutic effectiveness is to bring the treat-
Awareness of Morbidity ment offer closer to the core values of the users and their
This response came from the group of significant oth- families so that they can experience the health system as
ers, who wanted the treatment to make the users more a relevant actor concerning their health needs. Our study
aware of their problem, as in: “I see (the treatment) as a identified two main reasons that prompted users and
reality check so that he sees the losses, but I’m not hope- their close stakeholders to seek hospital treatment – dam-
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4 Psychopathology Soares/Messas
DOI: 10.1159/000527084
age to social relationships and fear of illness and deterio- management of the condition must be continuous and
ration of physical condition. The identification and ex- with multidisciplinary assistance [25].
ploration of this value can help to bring the treatment The third group of values that this study identified re-
goals of the service providers more in line with those of fers to expectations regarding treatment. The interviews
the users and their families. showed that users and their families understand treat-
One of the most common strategies used to engage ment to result in a complete restitution of personality, as
people with substance misuse in clinical care are motiva- if there had never been alcohol dependence in their lives.
tional strategies, such as motivational interviewing, This expectation can prove extremely frustrating for us-
which focuses on behavioral and cognitive changes [23]. ers since there is abundant evidence that alcohol depen-
The goal of motivational interviewing is to identify users’ dence can be controlled but not definitively overcome
values and life goals in order to stimulate these changes [27], and even abstinent alcoholics who have abstained
[24]. Our results corroborate the results of other studies from drinking for more than a year continue to be nega-
that have shown this to be an effective intervention for tively impacted in many areas of cognitive function [28].
reducing alcohol consumption [23]. Therefore, explor- Based on our results, it could be suggested that it is vital
ing these personal values during motivational interview- to provide users and their families with information about
ing might be crucial for a successful treatment [24]. For the limitations of life after abstinence and, above all, re-
the population investigated in this study, an important construct behaviors in which the meaning of life is not
motivation strategy for treatment could be the continued based on alcohol.
discussion of the physical and social losses related to the Another important factor for effectiveness is the
pattern of alcohol use. The prominence of concern for awareness of the problem by users and their families. Al-
physical illness indicates that users and their families though it is expected that awareness of a problem is the
seem to underestimate the risks of alcohol dependence first step to solving it, the psychopathological nature of
itself, giving greater value to its somatic consequences alcohol dependence itself often constitutes as an obstacle
than on the consequences related to behavioral and psy- to this awareness. A recent study shows that the central
chopathological changes imposed by alcohol misuse, psychopathological phenomenon of substance misuse is
thus producing a preference for seeking inpatient treat- the incapacity, by the users, to experience the complexity
ment. As a result, services specialized for monitoring the of reality [4]; for users, the psychological first-person ex-
behavioral changes necessary for the good evolution of perience is transformed into a unique set of experiences
the case tend to be neglected. Our results indicate that of plenitude, generally pleasurable; they begin to live
initiatives are needed to reinforce to the population the uniquely in the present, and, consequently, have difficul-
importance of interventions and follow-up of patients ties in living the future and supporting their own experi-
regarding behavioral and psychopathological changes so ences in the past, which often make it practically impos-
that more effective treatments for alcohol dependence sible – or technically impracticable – for the user to be-
can be designed. come aware of the substance misuse. These altered
The second set of values we identified was related to experiences end up impacting not only the lives of the
the patients’ concepts regarding the success of their own users but also as with any type of drug dependence, in-
treatment. In the group studied, the participants consid- cluding alcohol dependence, can have a significant im-
ered their willpower to be the determining factor for ther- pact on the family of the user [29, 30]. Our findings sug-
apeutic success. However, the literature shows that will- gest that it is vitally important that family members try to
power plays a modest role in treatment [25]. Thus, our convince users to seek treatment even when they do not
results suggest that users and their families need to be have a clear awareness of the existence of a problem. Us-
made more aware of the factors that are actually linked to ers often have an ambiguous attitude toward treatment as
therapeutic success. The introduction, during hospital it ultimately constitutes the abandonment of what they
treatment, of mechanisms to raise the awareness of users consider to be a pleasurable activity. Every hospitalization
and their families about the therapeutic limitations of is accompanied by some degree of coercion [30], either
willpower may be a decisive element in the user’s ability self-imposed or imposed by the family members. More-
to get, and remain, involved in the treatment for long over, studies show that involuntary hospitalizations have
enough to produce positive outcomes. It is known that approximately the same therapeutic efficiency as volun-
AUD must be treated as a chronic disease for better treat- tary treatments [30]. The presence of an authority figure
ment effectiveness [26], and from this point of view, the who has the respect of the patient is an important part of
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Assessing Values in Alcohol Misuse Psychopathology 5

DOI: 10.1159/000527084
any strategy for successful therapy [12]. Thus, the search may not represent their most genuine values since they
for a compromise solution between the psychopathologi- might still be influenced by the psychological state of the
cal particularities of substance misuse and the values of period of heavy substance use.
users and their family and relevant persons might be con-
sidered a one of the fronts in which clinical care of alcohol
dependence might explore [15, 31]. Statement of Ethics

The study was approved by the Ethics Committee of HSPE (No.

3.566.883; CAAE: 17608619.5.0000.5463). The participants agreed
Conclusion to participate in the research by signing a free and informed con-
sent form, and all the procedures were conducted ethically in ac-
Given the growing trend of health service delivery cordance with the Declaration of Helsinki.
models that take into account the perspective of users re-
garding their own sense of well-being [32–35], identify-
ing the values that lead them to treatment is a crucial step Conflict of Interest Statement
toward the optimization of mental health provision. We
The authors have no conflicts of interest to declare.
identified the following values in patients voluntarily ad-
mitted to hospital because of alcohol misuse: concerns
about damage to social relationships, fear of illness and
Funding Sources
deterioration of physical condition, willpower, personal-
ity restitution, and consciousness of morbidity as deter- None.
mining factors for seeking and following treatment. This
knowledge constitutes an important step toward bringing
treatment closer to the perspective of the user, thus en- Author Contributions
couraging their co-participation in the formulation of
therapeutic strategies, with the purpose of positively in- All of the authors participated in the conception of this study,
in the analysis and interpretation of the results, and in the elabora-
fluencing their prognosis. tion and critical review of the final manuscript. The author Maria
Julia Francischetto Ribeiro Soares participated in the project con-
Limitations ception, data collection, data analysis, and manuscript construc-
The principal limitation of any study that explores psy- tion. The author Guilherme Messas participated in the project
chological experiences by means of ideal types is the gen- conception, analysis, and manuscript construction.
eralizability of their results. The types described here
should be explored in larger populations before anything
can be said about their epidemiological relevance. An- Data Availability Statement
other limitation comes from the fact that the users’ period All data generated or analyzed during this study are included
of abstinence at the time of the interviews was not clearly in this article. Further inquiries can be directed to the correspond-
established, which may favor statements on their part that ing author.

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Assessing Values in Alcohol Misuse Psychopathology 7

DOI: 10.1159/000527084