|Year : 2021 | Volume
| Issue : 3 | Page : 312-318
Resilience in wives of persons with alcohol use disorder and their marital quality: A cross sectional study from a tertiary care center
Derrick Johnson, Sheena Varughese, Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
|Date of Submission||07-Jun-2020|
|Date of Decision||11-Jun-2020|
|Date of Acceptance||28-Jun-2020|
|Date of Web Publication||08-Sep-2021|
Dr. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla - 689 101, Kerala
Source of Support: None, Conflict of Interest: None
Context: Alcohol use disorder (AUD) in men has a profound impact on the mental health of wives of persons with alcohol use disorder (WoPA). Quality of their marital life is an overlooked aspect which affects both the mental health of the partners and their children. Resilience in WoPA acts as a protective element in maintaining their marital quality and, in turn, their mental health. Aims: The aim of this study was to assess the resilience in the WoPA and to find its association with marital quality. Subjects and Methods: Data was collected through an interview using a sociodemographic questionnaire and standardized tools and from current case records. The resilience of WoPA was assessed using the Connor-Davidson Resilience Scale. The Marital Quality Scale was used to assess their marital quality. The severity of alcohol consumption of patients with AUD was evaluated using the Severity of Alcohol Dependence Questionnaire. The differences between the scores were analyzed using ANOVA or Student t-test, whichever was applicable. Results: The mean score of resilience was 50.98 (26–77), and 52% of the wives reported their marital quality as severely affected. Low resilience was found to be associated with poor marital quality. Resilience was found to be poor in wives who experienced physical abuse from their husbands. Conclusions: The resilience of WoPA has a significant association with their marital quality. Hence, improving the resilience of WoPA would improve their marital quality, which, in turn, would positively impact the treatment of their husbands' alcohol use and their children's mental health.
Keywords: Alcohol use disorder, marital quality, physical abuse, resilience, wives
|How to cite this article:|
Johnson D, Varughese S, Kallivayalil RA. Resilience in wives of persons with alcohol use disorder and their marital quality: A cross sectional study from a tertiary care center. Indian J Soc Psychiatry 2021;37:312-8
|How to cite this URL:|
Johnson D, Varughese S, Kallivayalil RA. Resilience in wives of persons with alcohol use disorder and their marital quality: A cross sectional study from a tertiary care center. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Jan 26];37:312-8. Available from: https://www.indjsp.org/text.asp?2021/37/3/312/325753
| Introduction|| |
Alcohol use disorders (AUD) are common among substance use disorders in all developed and developing countries. In India, the use of alcohol is substantially higher in men (27.3%) compared to women (1.6%). The magnitude of the problem of alcohol consumption in India is apparent by the fact that 4.9% of its population has AUD with an annual rise in consumption. Apart from causing acute and chronic physical impairment, it is also related with wider social, mental, and emotional bearing on persons with AUDs as well as their family members, especially on their spouses. These impacts are mostly reflected as partner violence which may be physical, verbal, sexual, and emotional. Wives of persons with alcohol dependence (WoPA) often need to play different roles in the family and are exposed to problems such as emotional distress and financial crisis. This may cause psychological, biological, and behavioral responses leading to high rates of psychiatric morbidity, especially mood and anxiety disorders in spouses along with poor marital satisfaction. Marital quality refers to the overall quality of the marital relationship, which is influenced by the way one may be thinking and/or feeling or interacting with their spouse. An enormous body of research has demonstrated a strong relationship between the husband's AUD and divorce rate, which is high in patients with AUD compared to the general population.
Despite the evidence of increased psychological distress and marital dissatisfaction in WoPA, most of them are able to adapt remarkably well in their family life. There are certain protective factors that minimize or neutralize the effects of adversity and help them to cope effectively. In order to understand the protective factors within the family, researchers in the field of substance use disorders have set forward to explore the effect of resilience. Various researchers have identified resilience as a type of cognitive strength to overcome the risks or a type of problem-solving ability in order to meet future challenges in a practical and confident manner., Resilience is defined as the ability of an individual to withstand stressors and not to manifest psychological dysfunction while coping with extreme stress and trauma or in simple terms “ability to bounce back during the phase of adversity.” A study from South India attempted to explore the factors associated with resilience in WoPA, and good resilience was associated with a less severe and shorter duration of alcohol dependence, absence of domestic violence, and good social support. Poor resilience was associated with depression. Another study from South India on resilience and marital quality in WoPA concluded that people with low resilience had significantly poorer marital quality.
However, there are not enough researches examining resilience and marital quality in WoPA. Few studies have attempted to explore the factors of resilience and association of resilience and marital quality. We need further research to improve our understanding about the association of resilience and marital quality. Hence, in this study, we attempted to assess the resilience and marital quality in the WoPA and to find its association.
| Subjects and Methods|| |
After obtaining the institutional review board and ethical clearance, patients diagnosed with AUD, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) attending the de-addiction clinic along with their wives who met the inclusion and exclusion criteria were recruited. After describing the nature of the study, written informed consent was obtained from the patients and their wives.
Wives of persons with alcohol use disorders (WoPA) who were in the age group of 25–60 years and residing with husband for a minimum period of the past 5 years were included in the study. The Mini-International Neuropsychiatric Interview (MINI) v7.0.2 was used to screen for any psychiatric morbidities and was excluded if found any except for nicotine dependence. A semi-structured proforma comprising past medical, psychiatry, family, and personal history was used to exclude intellectual disability, substance use, neurological deficits, cognitive impairments in wife, and psychiatric illness in their first-degree relatives. WoPA with any chronic or debilitating illnesses such as diabetes mellitus, hypertension, and physical disability were also excluded from the study. A total of 58 WoPA were interviewed initially of which the final sample consisted of 50 patients and their wives (WoPA), as five of the WoPA were married for <5 years and three screened positive on the MINI for psychiatric disorders and thus were excluded from the study and were referred to the consultant psychiatrist. Sociodemographic details of both the patients and WoPA were collected using a semi-structured proforma prepared for the study, and available medical records were used to obtain the clinical details of the patients.
Modified Kuppuswamy Socioeconomic Status Scale 2018
It takes account of education, occupation, and income of the family to classify study groups into high-, middle-, and low-socioeconomic status.
Mini-International Neuropsychiatric Interview 7.0.2
The MINI was designed as a brief structured diagnostic interview for the major psychiatric disorders in DSM-III-R, DSM-IV, and DSM-5 and International Classification of Diseases, tenth revision. Validation and reliability studies have been done comparing the MINI to the Structured Clinical Interview for DSM-III-R and the Composite International Diagnostic Interview. The results show that the MINI has a similar reliability and validity properties but can be administered in a much shorter duration of time. This was used in WoPA to screen for any psychiatric morbidities.
The current version used in the study was developed for DSM-5, version 7.0.2 which was purchased from www.harmresearch.org.
Severity of Alcohol Dependence Questionnaire
The Severity of Alcohol Dependence Questionnaire (SADQ) was formulated by Edwards and Gross in 1976. It is a self-administered, 20-item questionnaire designed to measure the severity of alcohol dependence. There are five subscales with four items in each, and each item is scored on a four-point scale from a score of 0–3. The scale was used in patients to assess the severity of alcohol consumption.
Connor-Davidson Resilience Scale 25
It is a self-report measure comprising 25 items, with each rated on a five-point scale. The Connor-Davidson Resilience Scale (CD-RISC) yields a total resilience score from 0 to 100, with a high score reflecting greater resilience. The CD-RISC has good internal consistency and test–retest reliability. This was used in WoPA to assess the resilience.
The scale was purchased from the author for the purpose of this study.
The Marital Quality Scale (Female Form) by Anisha Shah
The Marital Quality Scale (MQS-1995) is a multidimensional self-report scale which assesses the marital quality of spouse (male/female) developed by Shah in 1995. The scale yields a total score on marital quality and 12 factor scores. The 12 dimensions of marital quality assessed are understanding, rejection, satisfaction, affection, despair, decision-making, discontent, dissolution potential, dominance, self-disclosure, trust, and role functioning. Total scores range from 50 to 200. Higher scores indicate poorer quality of marital life. The scale was used in WoPA to assess the marital quality.
Permission from the author through E-mail was sought for the purpose of this study.
Descriptive analysis was carried out using frequency and percentages for the categorical variables and using mean and standard deviation with range for the continuous variables. For evaluating association in continuous variable ANOVA and Student's t-test were used. For categorical variables, Fisher's exact and Chi-square tests were used. P < 0.05 was considered as statistically significant. Statistical analysis was done using Statistical Product and Service Solutions (SPSS) IBM SPSS version 25 (IBM, New York, USA. the version we used for our study was version 25).
| Results|| |
The initial sample included 58 WoPA and their husbands; five of them were married for <5 years and three screened positive on the MINI for psychiatric disorders and thus were excluded from the study and were referred to the consultant psychiatrist. The final sample consisted of 50 WoPA and their husbands.
The sociodemographic and clinical details are recorded in [Table 1] and [Table 2]. The majority of the wives were educated up to secondary school (74%) and were homemakers (72%) from nuclear family (60%). Among the men, 52% of the men had dependence of 5-year duration, majority of them have had uncomplicated withdrawal (64%), but 42% of the men had medical complications such as fatty liver or any other forms of chronic liver disease as evidenced by their medical history. Fifty-four percent of the men scored for moderate dependence in SADQ. Among the WoPA, 28% reported physical abuse. The resilience scores ranged from 26 to 77 in our study population, with a mean value of 50.98. The scores of MQS ranged from 68 to 150 with a mean of 110.22 of which majority of the population (52%) reported their marital quality as severely affected. Resilience was found to be affected by grades of marital quality such that poor the marital quality, lower was the mean resilience and both were statistically significant (P = 0.041). As per CD-RISC scoring, as scores increase, resilience would increase too, whereas in MQS, as the scores increase, the marital quality decreases. Of the 12 subfactors of marital quaity scale, “satisfaction” and “affection” were found to have negative correlation with resilience [Table 3].
Resilience was seen to increase with the increasing age of wives, age of husband, and the duration of their marriage but was interesting to note that mean resilience was lower in wives with higher education. We also found that higher mean resilience was observed in wives whose husbands had a longer duration of alcohol use. Along with it, another interesting find was that resilience was higher in wives of men who had moderate and severe alcohol dependence scores on SADQ than mild [Table 4]. Although only 28% of the WoPA reported a history of physical abuse, it was found to have a significant association with their marital quality, and 8 of the 12 subfactors had a significant association with physical abuse [Table 5].
| Discussion|| |
The studies on resilience in WoPA are very limited, and none have been reported from Kerala which describes the association of resilience of WoPA and their marital quality specifically. Our study was aimed at bridging this gap in the literature. In our study, the mean score of resilience in WoPA was 50.98 ± 13.44 ranging from 26 to 77. Resilience was associated with a longer duration of marriage, increasing age of wife as well as that of husband. Resilience in our study was also seen to be higher in wives of men who used alcohol for a greater number of years. Interestingly, resilience was higher in wives whose husbands scored moderate and severe dependence in SADQ than who scored mild. These variables do show that resilience has a direct association with clinical variables of alcohol use which was not in accordance with the study by Johnson et al. where no significant association was found. At the same time, this does show that there are other factors in play in the development of resilience and simultaneously raises the question of what makes them resilient even while being in the midst of continuing stress. This could be due to the fact that our sample population had patients who have been on follow-up from our de-addiction clinic for some time, and as a routine, we provide psychotherapy services to the wives which itself could act as a positive social support making them resilient.
In a study by Sreekumar et al., resilience was associated with a shorter duration and lower severity of alcohol dependence in SADQ. Again, it points to the same question as to why would a similar study produce opposite results than ours. In order to answer this dilemma, a basic knowledge of resilience is warranted. Resilience is a dynamic mental process that exists on a continuum and would be scientifically wrong to view it as a dual variable as in stating if it is present or absent. Resilience in a person may change over time through intervention from the environment or people around him/her. There are many factors responsible in formation of resilience such as social support, early life experiences with stress, genetics, certain developmental protective and risk factors, and parental care. Among all these, psychosocial factors play a major role which includes positive emotions, optimism, loving caretakers, firm role models, practice of mastering challenges, social support and religion, and spirituality. Moreover, as described by Block et al., resilience takes its initial form through the personality constructs of ego-resiliency. Ego-resiliency refers to the individual's adaptive reserve, a dynamic ability to temporarily change the reactions and perceptions to meet the situational demands of life.
In our study, we found that a group of wives who had a lower educational background were more resilient than others. This too raises the question of whether education matters in the formation of resilience. The answer would be that it is not just the education, but also as stated above, it is an interplay between various factors such as genetics, social, developmental, experiences including education, and personality factors. In the book Resilience and Mental Health: Challenges across the Lifespan, Southwick et al. describes that older adults tend to be more resilient than younger people. Various factors such as their life experiences with adversaries, acquired coping skills, able to accept and tolerate the mishaps in life, their social or other forms of support system, and the wisdom acquired along with spirituality play an important role in making them resilient.
Although there have been studies on marital quality and resilience, the literature discussing these two factors is limited. Even though resilience is better with age, severity and duration of alcohol use, and duration of marriage in our study, we found a significant positive correlation between marital quality and resilience which reveals that poorer marital quality was associated with lower resilience. Furthermore, there were two subfactors of marital quality that had a significant association with resilience, namely satisfaction and affection. Our study was in par with a study from the southern state of India by Satheesan and Satyaranayana which too found a positive correlation between marital quality and resilience. Another study from South India by Kishor et al. also found a positive correlation between marital satisfaction and severity of alcohol dependence. Keeping in line with the literature, our study too found a significant relationship with physical abuse with marital quality. However, it was worthwhile to note that 28% of our sample reported a history of physical abuse which was close to the National Family Health Survey 2015–2016 of 30%. Although the results from our study cannot be generalized, it is still alarming even in the background of being one of the most literate states in the country. It brings our attention to the association of resilience and marital quality which not only depends on the sociodemographic and illness related factors but also on overlooked factors such as physical abuse.
One more thought-provoking scenario we came across was that of the initial 58 wives screened, only 3 qualified for a diagnosis of depressive disorder and, as per our selection criteria, were excluded. Even though 52% of our study population scored as being severely affected in MQS, they did not have any depressive symptoms. This was not in accordance with the study by Sreekumar et al. where their participants had depressive symptoms. This again points to the factors in and around a person contributing to their resilience.
In our culture where wives play a major role as the primary caretaker in the majority of the cases, it is our responsibility as mental health professionals to ensure they are resilient enough so as to play the multiple roles an Indian woman caters to. This should be formally brought into the treatment guidelines, especially in conditions such as AUD where the wives suffer the major brunt of it. Although the resilience training program is common to the Western countries with a standardized structure in place such as the Penn Resiliency Program and Comprehensive Soldier Fitness Program, it is yet to be made a formal training program in India. Although there have been researches on the need for resiliency training in children and in armed forces, the idea seems to have been a halt. From a clinical standpoint, resilience training can be imparted to the wives by teaching them certain aspects such as improving their social competence, maintaining and supporting their existing social network, training in cognitive control, mindfulness, and increasing their coping mechanism.
Thus, resilience is a dynamic process and the capacity of a human being to adapt in the context of adversity which is directly associated with their quality of marriage. Taking these into accounts, it would be safe to say that resilience should be evaluated more on a dynamic level rather than as a single-point intervention. A multifaceted treatment approach is to be put forward with a special focus on the WoPA's resilience and ways in which their marital quality can be improved. As stated in a study from North India by Sharma et al., importance must be given to improve their coping mechanisms which would, in the long run, decrease their burden and avoid psychological disturbances which they are prone to.
The major limitation of the study is that the sample was selected from patients who sought help at a tertiary care teaching hospital. Hence, the findings may not be generalized to patients with similar problems in the community or who may seek help in other kinds of settings. A comparative group of wives residing with husband without AUD could not be studied. A longitudinal study could have helped in ascertaining the dynamic variations of resilience in a person.
| Conclusions|| |
WoPA who had poorer marital quality also scored low in resilience, particularly in satisfaction and affection – subfactors of marital quality. Marital quality was also low in WoPA who had physical abuse. Addressing these issues by specifically targeting the factors involved in their marital quality and low resilience should be incorporated during psychotherapy sessions. As in the Indian culture where the family fulfills an important role as a caretaker, it should become part of a treatment guideline to ensure the WoPA be more resilient which will, in turn, help in increasing their marital quality and in treating the patients with AUD.
We would like to thank Dr. Anisha Shah for permitting us to use their scale. We would also like to thank Dr. Pradyumna Rao for his support in the statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]