Stories of courage in a group of adults with Substance Use Disorder.

The treatment for drug addiction is considered a difficult path for the most of patients. As matter of fact, individuals with Substance Use Disorder (SUD) experience numerous challenges before, during and after the treatment (e.g. tackling an unpredictable, uncertain and paradoxically negative future, tackling the anxiety and anticipatory fear of physical pain associated with abstinence; decide to go beyond self-justification and self-deception). Courage could be considered a positive and functional resource to help people with SUD to face challenges and difficulties related to treatment. In connection therewith, the aim of this study was to examine, using an embedded mix method analysis, the personal stories of courage of 80 individuals with SUD in order to identify the themes and types of courage used in their life. The analysis carried out showed that individuals with SUD reported more frequently stories of courage related to their SUD condition respect to other life situation. Moreover, the quantitative analysis showed that participants used more frequently psychological courage respect to moral and physical courage when these stories were referred to their SUD condition then other life situations.

Introduction

Substance Use Disorder (SUD) is a condition in which the use of one or more substances leads to a clinically significant impairment or distress. Specifically, it is characterized by a pattern of continued pathological use of the drug, with effects on the individual's physical, mental health, and welfare (American Psychiatric Association, 2013). For this reason, the interventions for SUD are heterogeneous and multidimensional and the recovering drug users is a constant, lifelong process (Flynn, Joe, Broome, Simpson, & Brown, 2003; Margolis, Kilpatrick, & Mooney, 2000). Moreover, the treatment can be considered a difficult path for most of the patients since it is featured by setbacks, voluntary suspension and continuous relapses in the use of the substance (American Psychiatric Association, 2013; Dennis, Scott, Funk, & Foss, 2005).

An estimated 5% of the global adult population has used drugs. Even more worrisome is the fact that about 29.5 million of those drug users, or 0.6% of the global adult population, suffer from SUD (UNODC, 2017). These data have also been confirmed in Europe and in Italy. The latter seems to be at the top places for drug use among European Countries (EMCDDA, 2018a) and it is estimated that around 0.7% of the Italian population suffers from SUD (EMCDDA, 2018b). In Italy, approximately 1 in 10 clients entering treatment is female (EMCDDA, 2018b). As reported by Presta (2009), the mean age of Italian clients in treatment for SUD is about 38 years. Moreover, Presta (2009) showed that Italian clients in treatment for SUD are characterized by low schooling, 7% of patients are homeless, the unemployment rate is 40%, an additional 12% of patients only have occasional jobs and about 31% of them have a civil disability allowance.

As regard the treatment of people with SUD, Laudet, Morgen, and White (2006) reported the two main problematic themes frequently cited by persons with SUD during the treatment process: “future” and “past” with the main purpose of a better life. Specifically as regards the future, people with SUD generally report being afraid of the future as they have to overcome many barriers to be able to live a satisfactory future life of quality (Laudet et al., 2006; Richardson, Wood, Montaner, & Kerr, 2012). The future is hindered by many obstacles and challenges that can be linked to the treatment, for example managing to control craving (American Psychiatric Association, 2013; Putman, 2010), which can lead patients to relapses in drug use or to stop the treatment itself; to the client, for example in the case of low levels of instruction, little working experience, poor planning abilities (Richardson et al., 2012); to the context, for example, low employability rates, high levels of prejudice against drug users found in different contests (health, work, family) (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013; Graham, 2006).

As regards the past, drug users' life prior to beginning treatment is typically limited to the need for and the use of the substance, which lead them to behave illegally, lose their jobs, continually live interpersonal conflicts (American Psychiatric Association, 2013). Moreover, drug users' past may be also marked by traumas tied to difficult family environments, violence and neglect (Boroughs et al., 2015; Daigre et al., 2015; Handley, Rogosch, Guild, & Cicchetti, 2015).

In this regard, Putman, 2004, Putman, 2010 with his theoretical assumptions maintains that people with SUD need courage to be able to face, and in some respects accept, their own past and then go on to deal with the challenges connected with their future. By taking Putman's theorizations into account and using a mixed method embedded design, the aim of this study was to explore the issues and the different forms of courage in the stories told by a group of people with addiction being treated for substance abuse.

Courage and substance use disorder

Putman (2010), defined courage as the first human virtue meanwhile it makes all of the other virtues possible. In line of this, courage is considered by Peterson and Seligman (2004) a combination of strengths that include bravery, persistence, integrity, and vitality that promotes “the exercise of will to accomplish goals in the face of opposition, either external or internal” (Peterson & Seligman, 2004, p. 199). Specifically, courage represents the ability to act for a meaningful (noble, good, or practical) cause, despite experiencing the fear associated with perceived threat exceeding the available resources (Woodard, 2004).

Pury, Britt, Zinzow, and Raymond (2014) suggest differentiating between different types of courage considering the dangerous situations in which courage is used and the goals that it allows to pursue and achieve. Based on this, it is possible identified three different types of courage: physical courage, moral courage and psychological courage.

Physical courage involves incoming voluntarily in physically dangerous situation, characterized by high physical risks/difficulties to achieve noble goals related to protecting others.

Moral courage involves standing up to the powerful of others for what is believed in, with the risk that the others will treat you poorly and it is characterized by high risks in the social context. In others words, moral courage involves entering voluntarily in moral and social dangerous situation to noble goals related to personal moral and ethical values.

Psychological courage involves facing unpleasant truths or unpleasant treatment experiences in order to reach wellness. Psychological courage is characterized by high emotional and psychological risks and high internal benefits. Specifically, risks in psychological courage are related to loss of psychological stability for personal growth (Putman, 2004, Putman, 2010). In others words, psychological courage involves entering voluntarily in emotional and psychological dangerous situation in order to achieve wellness and personal growth.

Therefore, Rate's (Rate, 2010; Rate, Clarke, Lindsay, & Sternberg, 2007) conception of courage, which involves both personal risks and noble goals, provides a framework for understanding different types of courage in terms of risk – goal pairs. In other words, courageous acts that involve a particular type risk may be more likely to involve one type of goal than another (Pury et al., 2014).

The few studies that have addressed courage in individuals with addiction show that courage can be considered an important resource in substance use disorder treatment. For instance, Sgaramella, Di Maggio, and Santilli (2015) involved 12 people in treatment for SUD and analyzed their stories of courage. Using only quantitative measures, the authors showed that these people considered courage a necessary resource to cope with change (e.g., beginning treatment, finding a job, resuming social relationships, etc.) and to face the future (e.g., avoiding risky settings, persisting in their commitments). Moreover, Ehrmin (2001) in an ethnographic study, interviewed several African-American women resident in a community for substance abuse, indicated that the key concepts identified in the participants' narration referred to the courage to face treatment-related to cope fear associated with physical pain and to forgive oneself for the past mistakes.

These results support the importance of courage in helping people with SUD begin and continue with treatment, but also in facing a difficult past and an uncertain future, as theorized by Putman, 2004, Putman, 2010. Specifically, Putman, 2004, Putman, 2010 stated that psychological courage, more than the other types, has an essential role in managing the barriers, challenges and difficulties that these individuals have to face. It is mostly their internal challenges and barriers that put their own psychological stability at risk. Putman, 2004, Putman, 2010 proposed that people with addiction need psychological courage for: tackling an unpredictable, uncertain and negative future, tackling the anxiety and anticipatory fear of physical pain associated with abstinence; go beyond self-justification and self-deception. Specifically, admit an addiction and facing a therapeutic path means to restructure one's own attitudes, accept negative past choices and confront one another with a more negative image of oneself.

Research aims

Considering the relevance of courage in the treatment of people with the limited scholarly focus on this topic, the aim of this study was to provide empirical results to the theorizations of Putman, 2004, Putman, 2010. Specifically, based on Putman, 2004, Putman, 2010 theoretical assumptions, that emphasizes the role of psychological courage in respect to other types of courage (physical and moral) to help individual to face challenges related to substance use rehabilitation, the stories of courage reported by adults with SUD were analyzed in order to identify the themes and types of courage performed considering risk – goal pairs. It was expected that individuals with SUD should more frequently stories related to their drug addiction life experience (e.g. facing an uncertain and potentially negative future; facing abstinence, and a difficult past) compared to stories of courage related to other life experience. Moreover, it was expected that individuals with SUD reported to use more frequently psychological courageous than physical and moral courage especially when their stories were referred to the addiction rather than to other life situations.

Method

Participants

The sample included 80 Italian persons in treatment for SUD, of which 57 (71.3%) men and 23 (28.8%) women. One average, participants were 41.19 years old (SD = 9.63). Primary substance of use was multi-drug/or combined drug and alcohol among 45% (36 participants) and only alcohol among 55% (44 participants). In this regard, the participants reported to have a problem in substance use on average by 12.32 years (DS = 9.49). In terms of education, the participant reported to have on average 9.22 years of education.

Measures

Courage interview

A semi-structured format interview was developed for this study considering the study of Pury, Kowalski, and Spearman (2007). The interview was introduced to participants as follows: “The purpose of the present interview is to better understand the experience of courage that the persons live in your life. Life is often complex and difficult and for this, life requires patience, perseverance and courage. In your experience, have you been courageous? If yes, try to describe a situation during which you were a courageous person?” Next, participants were invited to describe a life situation that they have faced courageously, and describe where the event occurred, which other persons were involved, how they felt and what they thought, what the consequences were, and how the other people behaved in that situation.

The responses to the interview were audio recordings and professionally transcribed. The researchers reviewed the transcripts to develop coding categories using a hybrid approach of qualitative methods of thematic analysis (Fereday and Muir-Cochrane, 2006a, Fereday and Muir-Cochrane, 2006b; Miller & Shifflet, 2016). Following this approach, deductive and inductive codes were generated. The deductive codes based on Putman, 2004, Putman, 2010 theorization were used to understanding the themes of courage stories related to drug addiction life experience. Instead, the inductive codes were generated to understanding the themes of courage stories related to other life experience. Only, deductive codes based on Pury et al. (2014) and Rate et al. (2007) suggestion were generated to understanding the type of courage related to stories of courage reported by participants. Specifically, we classified the stories as requiring physical courage when the participants reported having had courage to face physical danger situation to achieve noble goals related to protecting others; as requiring moral courage when the participants reported having had courage to face a moral and/or social danger situation to achieve noble goals related to personal moral and ethical values; as requiring psychological courage when the participants reported having had courage to face emotional and/or psychological danger situation to achieve noble goals related wellness and personal growth.

Procedure

Individuals with SUD were identified by contacting rehabilitation centers for a project aimed to stimulate individuals with SUD to reflect on their courage experiences. Once selected, participants were contacted by a career counselor, who explained that the project aim was to foster reflection courage experiences, and informed them that collected information would be protected by professional confidentiality, following ethical procedures ruled out by the Italian Ethical Principles of Psychologists. The assessment phase lasted approximately 40 min and at the end of activities all participants received a personalized report.

Data analysis

A mixed methods design was used in order to combine qualitative and quantitative procedures within a single study. Particularly, a mixed method embedded design that consisting in the embedding of quantitative analyses within qualitative data (Creswell, Clark, & Garrett, 2008) was used. Qualitative procedures were used to categorize the stories of courage in term of themes and types of courage performed; quantitative procedures were used to test main and interaction effect between themes and types of courage.

Qualitative procedure

In order to search themes and type of courage a qualitative analysis based on the thematic analysis procedure (Daly, Kellehear, & Gliksman, 1997; Fereday and Muir-Cochrane, 2006a, Fereday and Muir-Cochrane, 2006b) was used. Thematic analysis is a search for themes that emerge as being important to the description of the phenomenon (Daly et al., 1997). The process involves the identification of themes through “careful reading and re-reading of the data”. It is a form of pattern recognition within the data, where emerging themes become the categories for analysis (Daly et al., 1997; Fereday and Muir-Cochrane, 2006a, Fereday and Muir-Cochrane, 2006b).

The method of analysis chosen for this study was a hybrid approach of qualitative methods of thematic analysis (Fereday and Muir-Cochrane, 2006a, Fereday and Muir-Cochrane, 2006b; Miller & Shifflet, 2016). Following this approach, deductive and inductive codes were generated by two independent researchers.

After this, the codes generated were applied to several writing samples to determine the applicability and reliability of the codes (Boyatzis, 1998). The range of Cohen's Kappa inter-rater reliability index obtained was 0.75–0.88. In case of divergence in the classification, researchers met and tried to reach consensus. Once the codes were revised to reflect the data set, the codes were applied to the full sample of data (Miller & Shifflet, 2016).

Quantitative procedure

Quantitative analyses were carried out using R software. Specifically, in order to test main and interaction effect between themes of courage stories (addiction related vs. not addiction related) and types of courage (moral vs. psychological vs. physical) General Lineal Modeling with Poisson distribution analysis was used (Agresti & Kateri, 2011). Two model with and without interaction effect was compared using Akaike information criterion (AIC; Akaike, 1973) and Bayesian information criterion (BIC; see Wagenmakers, 2007). AIC and BIC allows to compare non-nested and nested models. Given a set of models that share the same null model, the model with the smallest AIC and BIC represents the best fitting model (Snipes & Taylor, 2014; Wagenmakers, 2007). Moreover, to quantify the evidence of the best fitting model against the competing models, the differences between model BICs were evaluated. Difference in BIC between 0 and 2 indicates weak evidence, a difference between 2 and 6 indicates positive evidence, a difference between 6 and 10 indicates strong evidence, and a difference larger than 10 indicates very strong evidence for the best fitting model (Raftery, 1995; Wagenmakers, 2007).

Results

First, the themes underlying the stories of courage were examined. After this, the types of courage (physical, moral and psychological courage) have been divided, considering only, unlike what was planned, the danger situation to face with courage reported in the stories because in the narration of participants the goals related to courage acts were not explicitly described. Specifically, we classified the stories as requiring physical courage when the participants reported having had courage to face physical danger situation; as requiring moral courage when the participants reported having had courage to face a moral and/or social danger situation; as requiring psychological courage when the participants reported having had courage to face emotional and/or psychological danger situation. Finally, main and interaction effects between themes and types of courage were reported.

Themes underlying stories of courage

Stories of courage are addressed with a description of the emerged themes (classification units) and with quotes of categories. Table 2 presents an overview of all themes and categories. More specifically, as regards the themes, two classification units were identified: stories related to addiction and stories not related to addiction (stories related to other life situations).

Table 2

Frequencies and percentages of courage stories categories.

Themes of courage stories	Categories	F	%
Addiction related (63.8%)	Courage to start treatments and to face the therapeutic pathway	19	23
	Courage to accept difficult past behaviors	27	33.8
	Courage to face new challenges for the benefit of their future despite the fear of failure	5	6.3
No addiction related (36.3%)	Courage to help other persons	10	12.5
	Courage in work context	15	18.8
	Courage in other situation	4	5

Stories related to addiction

More than half of the participants (63.8%) reported courage stories related to their addiction. More specifically, as reported in Table 1, 23% of participants reported to have been courageous at the time when they decided to start the treatment and to face the therapeutic pathway (e.g. to start treatment and face once and for all my problems with substances… to accept what I am now … the fact of facing every day that passes by with many difficulties). 33.8% of participants reported to have been courageous at the time when they begin to accept difficult past behaviors (e.g. to give her daughter a trust; to steal cars; to do robberies; to present at work under the effect of substances; to have suffered a rape; to have suffered violence from his father). 6.3% of participants reported to have been courageous at the time when they have decided to face new challenges for the benefit of their future despite the fear of failure (e.g. to start a course of study; to go back to work).

Table 1

Frequencies and percentages danger situation characterizing the different stories of courage.

Stories of courage		To face moral and social danger situation		To face physical danger situation		To face emotional and psychological danger situation
f	%	f	%	f	%	f	%
11	13.7	0	0	11	100	0	0
8	10.0	8	100	0	0	0	0
61	76.3	0	0	0	0	61	100

Stories not related to addiction

36.3% of participants reported stories of courage not related to their addiction. More specifically, as reported in Table 1, 12.5% of participants reported to have been courageous at the time when they saved or helped a person in difficulty (e.g. to save a boyfriend at sea while he was drowning). 18.8% of participants reported to have been courageous in a work context (e.g. to have faced a difficult task; to have taken a great responsibility) and 5% of participants reported to have been courageous in other situations (e.g. to roll from a considerable height).

Types of courage

The stories of courage are addressed with a description of the type of risks situation in Table 1. Risks of physical courage are reported in the 13.7% of the stories. In these stories the participants used courage mainly to face physical danger situations [e.g., “(…) While I was doing a gardening job I had to climb a 15-meter high ladder, I thought that if I was to fall, I would die (…)”; “(…) I rescued a person who was in a serious car accident and I risked being hit by the explosion of the car (…)”].Risks of moral courage is mentioned in 10% of the stories. In these stories, the participants used courage mainly to face moral and social danger situations, in particular related to fear of losing the consensus of others [e.g., “(…) Because of my past, I gave evidence against dangerous individuals, even though all my friends and relations had advised me against it (…)”; “Some years ago when I was in prison I started to work in the kitchen and, because I was HIV-positive, the inmates wanted to send me away. I thought it was unfair and so I hung on even if I knew that by doing that I wasn't going to be a favorite with the other prisoners (...)”]. Most of the stories (76.3%) referred to risks of psychological courage. In these stories the participants used courage mainly to face emotional and psychological danger situations [e.g. “(…) admitting I was not able to look after my son. Leaving him in the care of others for his good and mine (…)”; “When I stopped running away from all that, I had to put my pride on one side and accept myself and what I had become (…)”; “I feel brave in being able to overcome the trauma I experienced, I was sexually abused when I was 14 years old (…)”].

Main and interaction effects between types of courage and themes

General Lineal Model with Poisson distribution analysis showed a significant main effect for types of courage (related to type of risks situations) [χ2(2) = 62.21; p < .001] and themes [χ2(1) = 6.13; p = .01; see Table 2] and a significant interaction effect between types of courage (related to type of risks situations) and themes [χ2(2) = 27.97; p < .001]. Moreover, based on ΔBIC and ΔAIC test (ΔBIC = 24.38; ΔAIC = 23.97) the model with main and indirection effects (BIC = 31.71; AIC = 32.96) represented the best fitting model respect to the model with only main effect (BIC = 56.10; AIC = 56.93). After, in order to explore more in detail the significant main and interaction effects obtained different Chi-squared test with Bonferroni correction were carried out. The analysis showed that participants reported more frequently risks of psychological courage than risks of physical [χ2(2) = 40.95; p < .001] and risks of moral courage [χ2(2) = 28.54; p < .001; see Table 1]. Moreover, the post-hoc analysis with Bonferroni correction showed that participants reported more frequently risk of psychological courage when these stories were referred to the addiction then other life situations [χ2(2) = 40.95; p < .001; see Table 3].

Table 3

Frequencies and percentages of risks of different types of courage for different themes (Addiction related and no addiction related).

Risks of different types of courage	Themes of courage stories
	Addiction related		No addiction related
	f	%	F	%
Risks of physical courage	0	0	11	100
Risks of moral courage	4	50	4	50
Risks of psychological courage	47	77	14	23

Discussion

The aim of this study was to analyze courage resources in adults with SUD. More specifically, using mixed method embedded design, the stories of courage of individuals with SUD in order to identify the themes and type of courage (related to type of risks situations) performed were examined. Based on Putman, 2004, Putman, 2010, we was expected that individuals with SUD described more frequently stories related to their experience of drug addiction resect to other life situation. Moreover, we expected that individuals with SUD reported to face risks of psychological courage than physical and moral risks, especially when these stories were referred to the addiction rather than to other life situations.

As hypothesized, the analysis carried out showed that individuals with SUD reported more frequently stories of courage related to their SUD condition respect to stories of courage related to other life situations. This results is in line with Putman, 2004, Putman, 2010, that emphasizes the role of courage to help individual to face challenges related to substance use rehabilitation. As matter of fact, the qualitative analysis carried out showed in line with different studies (Ehrmin, 2001; Sgaramella et al., 2015) that courage has been an important resource to start treatments and to face the therapeutic pathway, to accept difficult past behaviors and to face new challenges for the benefit of their future despite the fear of failure. The qualitative analyses carried out underlined that the stories of courage related to past experiences refer not only to the acceptance of addiction behaviors, as Putman, 2004, Putman, 2010 reported, but also to the acceptance of some past violent behaviors and/or ill-treatment suffered. This last data is confirmed, in fact, by several studies that show as stories of sexual, emotional or physical abuse (it is in interact with numerous other nested contextual levels such as live in disadvantaged neighborhoods) represents an individual-level risk factor can to effect on risk to develop substance use disorder (Boroughs et al., 2015; Daigre et al., 2015; Handley et al., 2015).

The analysis carried out have also showed, as hypothesized, that individuals with SUD to face more frequently risks of psychological courage than physical and moral risks, especially when these stories were referred to the addiction than other life situations. This mechanism can be explained by the theorizing of Putman, 2004, Putman, 2010. More specifically, for Putman, taking on an addiction requires more psychological courage in respect to moral and physical courage, because the challenges associated with treatment and achieving drug-free status (face challenges related to their past experiences and choices but also to face challenges related to personal and professional future planning) involve a number of dangerous situations associated with maintaining psychological stability.

Therefore, the results obtained in this study can be considered relevant because it provides empirical support to Putman, 2004, Putman, 2010 theoretical assumptions showing how psychological courage can be considered a relevant resource in people in treatment for SUD. Moreover, the results obtained can be also considered relevant because allow a better understanding the different life situations linked and not linked to drug addiction that may require a certain amount of courage in people with SUD.

As regards the applicative implication, the results obtained suggest the importance to help individuals with SUD to increases their courage. In this regard following Pury et al. (2014) suggestions, we can use in counseling sections direct or vicarious models of individuals with SUD who have succeeded in facing their fears and in persisting to reach their goals. Moreover, for Pury et al. (2014) can be useful to stimulate the clients to examine the purpose of the courageous behavior by using the principles of utility of their future goals, and identify with them resources and strategies to overcome their fears. Moreover, in particular, based on the results obtained in our study it could be useful to propose in counseling sessions stories of psychological courage, in order to support people with SUD to identify, and recognize situations in which they have been used (or others have used) psychological courage. All this could motivate people with SUD to face, as happened in the past or to others, risks related to treatment for substance abuse.

Finally, as regard the use in counseling sections of personal narration of courage stories related and not related to drug addiction we believe, in line with Toporek and Cohen (2017), that the analysis of this positive and personal stories could be very useful in the counseling sections to help people build a positive image of themselves and increase their levels of self-esteem.

Limitations and directions for future studies

The limitations of this research project indicate several avenues for future research. More specifically, the current study is limited from different methodological aspects. First, it was not possible to analyze the stories of courage considering the risk – goal pairs as suggestion by Rate et al. (2007), because the goals related to courage acts were not clearly explained by our participants. In this regard, Pury et al. (2014) affirm that the universe of risk – goal pairs is lumpy. Specifically, for this authors the risks and goals not always seem to come in natural pairs in the environment for this reason their suggestion for future research is to use measures to study goals and risks of the courageous in specific and separated way. Additional, the analyzes were conducted on a small group of participants and predominantly men. Future studies should involve a larger number of participants (at least one hundred subjects) and should consider and analyze the role of gender variables on stories of courage in people with SUD. Finally, in the future, researchers should also test the predictive role of psychological courage in different outcomes related to success in therapy, in work and social inclusion in people with SUD.

Declaration of Competing Interest

The authors whose names are listed above certify that they have NO affiliations, financial interest, involvement or direct or indirect connection, with the tobacco, alcohol, cannabis, pharmaceutical or gaming industries or anybody substantially funded by one of these organizations or entity with any financial interest. Moreover, the authors declare that they have NO any financial conflict of interest arising from involvement with organizations that seek to provide help with or promote recovery from addiction. Finally, the authors declare that they have NO any contractual constraints on publishing.