|Year : 2022 | Volume
| Issue : 2 | Page : 188-194
The silent survivor: A cross-sectional study of domestic violence, perceived stress, coping strategies, and suicidal risk in the wives of patients with alcohol use disorder
Kranti S Kadam, Sampada Anvekar, Amey Y Angane, Vishnu B Unnithan
Department of Psychiatry, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
|Date of Submission||03-May-2020|
|Date of Decision||29-Jun-2020|
|Date of Acceptance||18-Jul-2020|
|Date of Web Publication||08-Sep-2021|
Dr. Amey Y Angane
Department of Psychiatry, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Alcohol use disorder has many negative effects on the wives of patients including domestic violence. The wives are in a position where their mental state can be severely compromised, leading to suicidal behavior. The purpose of the study is to assess the prevalence and types of domestic violence in the wives of patients with alcohol use disorder. The study examined the extent of perceived stress, nature of coping strategies used, suicidal risk, and their relationship with domestic violence. Methodology: A cross-sectional study of 100 wives of patients diagnosed with alcohol use disorder as per the Diagnostic and Statistical Manual, Fifth Edition, recruited using purposive sampling technique was conducted over 6 months. The wives were administered a semi-structured pro forma along with Severity of Violence against Women Scale, Perceived stress scale-14, Columbia Suicide Severity Rating Scale (C-SSRS), and Coping Questionnaire-30. Contingency tables and linear regression analysis helped examine the associations and correlations. Results and Discussion: Domestic violence was highly prevalent (87%) in the wives of patients with alcohol use disorder. A statistically significant correlation was seen between domestic violence and perceived stress. It was seen that those who experienced domestic violence used predominantly tolerant inactive coping mechanism. The wives facing domestic violence had a four-fold greater prevalence of suicidal behavior. Statistically significant relationships were seen between domestic violence and intensity as well as severity of suicidal ideation. Conclusions: The study highlights the importance of screening for domestic violence in the wives of alcohol use disorder patients as it is highly prevalent. Psychoeducation to effectively deal with the stress and adopting healthy coping ways to improve psychological health is essential. Spreading awareness about both, domestic violence in the community and the need for treating patients with alcohol use disorder, may prove to be helpful.
Keywords: Alcohol use disorder, coping strategies, domestic violence, perceived stress, suicidal risk
|How to cite this article:|
Kadam KS, Anvekar S, Angane AY, Unnithan VB. The silent survivor: A cross-sectional study of domestic violence, perceived stress, coping strategies, and suicidal risk in the wives of patients with alcohol use disorder. Indian J Soc Psychiatry 2022;38:188-94
|How to cite this URL:|
Kadam KS, Anvekar S, Angane AY, Unnithan VB. The silent survivor: A cross-sectional study of domestic violence, perceived stress, coping strategies, and suicidal risk in the wives of patients with alcohol use disorder. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:188-94. Available from: https://www.indjsp.org/text.asp?2022/38/2/188/325757
| Introduction|| |
Alcohol use disorder is a major public health problem in India. By 2050, it is estimated that in India alone, alcohol would cause the loss of 552 million quality-adjusted life years due to consumption, 258 million life years by deaths, and a net economic loss of INR 97.9 lakh crore (1.45% of India's GDP). Alcohol is the most common psychoactive substance used by Indians with country liquor and Indian-made foreign liquor being among the predominantly consumed beverages. Nationally, about 16 crore people (14.6% of the population), aged between 10 and 75 years, consume alcohol with the prevalence being 17 times more in men.
Alcohol use disorder has a plethora of negative effects on the wife causing increased responsibility, financial burden, and social stigma. This may lead to constant feelings of hatred, self-pity, and avoidance of social contacts. They may suffer exhaustion and eventually become physically or mentally ill. Very often, they are also subjected to moderate-to-severe forms of harassment, conflict, and a tense atmosphere.
One of the frequently occurring, but not adequately recognized, effects of alcohol use disorder is domestic violence. Domestic violence is the use of intentional verbal, psychological, or physical force by one family member (including an intimate partner) to control another. While reliable statistics are hard to come by, studies estimate that, from country to country, between 20 and 50 per cent of women have experienced physical violence at the hands of an intimate partner or family member.
This not only causes physical injury but also undermines the social, economic, psychological, spiritual, and emotional well-being of the victim and the society as a whole. Nayak et al. found that excessive alcohol use by the partner increased the risk of disorders such as depression and anxiety by two- to three-fold.
Thus, the wives of patients of alcohol use disorder experience high levels of stress due to dual problems of alcohol use disorder of the patient and domestic violence., Under these circumstances, the married woman's position is severely compromised, making her vulnerable to psychiatric morbidity and suicidal behavior.,,
Various types of coping strategies are used to deal with this stress. Coping refers to both cognitive and behavioral strategies that can be used to deal with a stressful event. A progressive rise in all types of coping behavior is reported by wives depending on the severity and frequency of alcohol consumption by their husbands. Although coping has been studied in relation to how women learn to live with husbands having alcohol use disorder, there is a dearth of literature regarding the same.,
Domestic violence, although identified as a public health priority, has been widely ignored. Early identification and intervention can help in the prevention of psychological morbidity and eventually suicide. The purpose of the study is to assess prevalence and types of domestic violence in the wives of patients with alcohol use disorder. The study examined the levels of perceived stress among these wives, their suicidal risk, and coping strategies used by them. It further uncovered the relation of domestic violence with perceived stress, suicidal risk, and coping strategies.
| Methodology|| |
Taking into consideration previous studies, which had shown prevalence from 65% to 68% and Cochran's formula (n = Z2PQ/e2) (where n = sample size, P = prevalence of the disease, Q = 1 − P, Z = Z value at confidence levels and e = precision/margin of error), sample size was calculated to 10% margin of error and 95% confidence levels. Hence, the sample size was taken as 100.
Ethical clearance from the Institutional Ethics Committee was sought for and obtained before beginning the study. Written informed consent was taken from all participants for consent to participate in the study and for publication of the results obtained after completion of the study. The consent was obtained in the language they best understood (English, Hindi, or Marathi).
The cross-sectional study was conducted over 6 months by the Department of Psychiatry and the subjects were recruited from the patients attending the Deaddiction OPD of the tertiary care hospital. Using purposive sampling technique, 100 wives of patients diagnosed with alcohol use disorder as per the Diagnostic and Statistical Manual, Fifth Edition were recruited into the study. Patients of alcohol use disorder currently on treatment for any comorbid psychiatric disorder like “schizophrenia spectrum and other psychotic disorders” as per DSM 5 criteria as well as those having any other substance use disorder except tobacco use were ineligible for our study and their wives were excluded to minimize the confounding factor.
A semi-structured pro forma was used to document sociodemographic data including age, occupation, education, and income. Further details regarding the alcohol use disorder of the patient were also noted. They were subsequently administered.
Severity of violence against women scale
Severity of Violence against Women Scale was created by Linda Marshall to assess the frequency, type, and severity of physical aggression committed by women's partner. The 46 items consist of three subscales that differ in level of severity (i.e., threats of violence, acts of violence, and sexual aggression).
Items were ordered based on the perceived severity of the acts. When completing the measure, women indicate how often their partner has inflicted each of the acts in a given period of time with a four-point scale. The Cronbach's alpha reliability coefficient for the scale is 0.94 for threats of violence, 0.95 for acts of violence, and 0.97 for sexual aggression.
Perceived Stress Scale-14
It is one of the most popular tools for measuring psychological stress. It is a self-reported questionnaire that was designed to measure the degree to which individuals believe their life has been unpredictable, uncontrollable, and overloaded during the previous month. The Cronbach's alpha reliability coefficient for the scale is 0.82.
Columbia Suicide Severity Rating Scale
The Columbia Suicide Severity Rating Scale (C-SSRS), created by the United States Food and Drug Administration, is a semi-structured interview that measures four constructs to assess the risk of suicide: the severity of suicidal ideation, the intensity of ideation, behavior, and lethality. Cronbach's alpha for the C-SSRS intensity scale was 0.94 and 0.95 for “since last visit” and “past week” assessment intervals, respectively.
| Coping questionnaire|| |
Created by Orford, especially to assess the coping strategies in family members of patients of alcohol use disorder, the aim of the Coping Questionnaire (CQ) is to obtain responses to a number of standard questions about the ways in which they have coped with their relatives' problem drinking or drug taking. Three subscales are present scored on a four-point Likert scale:
- Engaged coping – Confronting his drinking patterns, asking to bring a change, try to limit his drinking
- Tolerant-inactive coping – Putting oneself out for him, lending money for drinking, hopeless or frightened to do anything
- Withdrawal coping – Withdrawing and gaining independence, putting one's own interest before spouses.
The Cronbach's alpha for CQ-30 is 0.83 for engaged coping, 0.75 for tolerant-inactive coping, and 0.59 for withdrawal coping.
All the scales were translated into regional languages (Hindi and Marathi). These scales were translated and back-translated by consultant psychiatrists. They were then submitted to the institutional ethics committee which examined the scales in comparison to the original and approved their use.
The wives were given the option to select the language which they best understood and the approved scales were used. For illiterate wives, the scale was read out to them in the language they best understood and responses were noted.
GraphPad Prism 8.0 (San Diego, California) was used for statistical analysis. Descriptive analysis in terms of mean and standard deviation for continuous variables and frequency with percentage for nominal and ordinal variables was done. Association between domestic violence, coping strategies, and suicide was done using Fisher's exact and Mann–Whitney U test. Correlation was found using Spearman's coefficient of correlation. Prevalence risk ratio was used to find suicidal risk.
| Results|| |
100 eligible couples meeting our inclusion criteria were examined in the deaddiction OPD during the duration of the study. The wives were recruited into the study after taking written informed consent. The response rate was 100%.
The husbands had a mean age of 43.60 years. Among the 100 husbands, 4% were graduates, 20% who had studied up to higher secondary (12th stdandard), 61% till secondary, 11% up to primary, and 4% illiterates. The husbands sampled included 34% unskilled laborers, 24% semiskilled, 19% clerical, and 6% semi-professional workers as per Kuppuswamy's classification. 17% of patients were employed. 70% of the husbands had been consuming alcohol for >15 years. The mean year of alcohol consumption by the husbands was 22.39 years [Table 1].
The mean age of wives was 41.64 years. The wives comprised 4% graduates, 23% who had studied up to higher secondary college, 59% till secondary, 10% up to primary, and 4% illiterates. 7% of wives worked as unskilled laborers, 6% as semiskilled laborers, 35% earned their living doing clerical jobs, and 1% worked as a semi-professional. The remaining 51% were housewives, which was slightly more than half.
72% of wives belonged to nuclear families while the remaining 28% lived in joint families. They had been married for an average of 17.96 years.
Domestic violence was experienced by 87% of wives. 82% of wives had threats of violence and 79% of wives had experienced acts of violence. Sexual aggression was experienced by 58% of wives [Figure 1]. Domestic violence had no significant association with the number of years of alcohol use, education of the patient, the employment status of the patient, and their wives' or with the type of family they lived in [Table 2].
|Figure 1: Horizontal clustered bar chart showing the most prevalent types of domestic violence experienced|
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|Table 2: Association of domestic violence with sociodemographic variables|
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The wives had an average score of 29.38 on the perceived stress scale. There was a significant positive correlation (r = 0.3483) seen [Figure 2] between domestic violence and perceived stress (P = 0.0005) [Table 3].
|Figure 2: Linear regression graph showing correlation between domestic violence and perceived stress|
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|Table 3: Correlation of domestic violence with perceived stress and suicidal intensity|
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The coping mechanisms predominantly used were both tolerant-inactive (99%) and engaged coping (100%). A statistically significant relationship of domestic violence with tolerant inactive coping was seen (P = 0.0003) [Table 4].
|Table 4: Comparison between domestic violence in different types of coping|
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The mean suicide intensity was found to be 5.95. Statistically significant relationships were found of domestic violence with suicidal ideation (P = 0.0004) and suicidal behavior (P = 0.002) [Table 5]. The wives facing domestic violence have a four-fold higher prevalence of suicidal behavior [Table 6]. The study also uncovered a statistically significant positive [Figure 3] correlation (r = 0.3294) between levels of domestic violence and intensity of suicidal ideation (P = 0.0008).
|Figure 3: Linear regression graph showing correlation between domestic violence and suicidal intensity|
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|Table 6: Prevalence risk ratio of suicidal behavior with domestic violence|
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| Discussion|| |
There were patients and wives from all educational and professional classes, indicating that alcohol use disorder is not restricted to a select few but affects people across all boundaries, thus highlighting the need for spreading awareness about alcohol use disorder and seeking professional psychiatric treatment for the same. A similar sociodemographic sample was obtained in a study conducted in Kerala.
The study noted that domestic violence was highly prevalent in the wives of patients with alcohol use disorder as 87% experienced domestic violence. This finding was consistent with the study done by Nanjundaswamy et al. Fear of being left alone and factors such as homelessness, security concerns, religious, societal, social, personal, and emotional beliefs linked with marriages and lack of economic independence possibly makes women tolerate domestic violence.,,,,,
It was seen that 82% had threats of violence and 79% of wives had experienced acts of violence. Sexual aggression was experienced by 58% of wives. Wives faced violence in the form of threats (like threats to destroy property and threats to kill) or acts of violence (like pushing or shoving, pulling hair, and choking) or in the form of sexual aggression (physically forced to have sex). Similar findings were also implied in other studies in which men found to have drinking problem seemed to “torture” their wives mentally, physically and sexually., Alcohol operates as a situational factor, enhancing the likelihood of violence by decreasing inhibitions and clouding judgment.
Domestic violence had no significant association with the number of years of alcohol use, education of the patient, patients and their wives' employment status, and with type of family they lived in. This contradicts findings from a study conducted in Goa which showed that intimate partner violence was associated with longer duration of drinking. Previous studies,, have also documented that alcohol use is a risk factor for domestic violence. However, as already stated, alcohol use being a situational factor, the consumption of alcohol increased the likelihood of violence and this likelihood was not altered merely by the duration of alcohol consumption. Thus, our study yielded a non-significant result.
There was a significant weak positive correlation seen between domestic violence and perceived stress. These findings were in concordance other studies.,, This shows that wives of patients with alcohol use disorder faced additive stresses of both the alcohol use disorder as well as the domestic violence which was secondarily inflicted. This increased stress becomes a future predictor for depressive, anxiety states, as well as suicide.
The study demonstrated that wives of patients of alcohol use disorder are often subjected to various forms of physical, psychological, and emotional problems. Thus, they used various types of coping mechanism to deal with the problems posed by husband's alcohol use disorder and domestic violence. Coping mechanisms predominantly used were tolerant-inactive and engaged coping. India being a socially close knit country, withdrawal coping was hardly used as everyone in the family including all well-wishers get involved in the drinking problem of the patient.
It was found that the domestic violence had significant association with tolerant inactive coping indicating that wives accepted and kept experiencing acts of violence and sexual aggression possibly because they considered the situation to be hopeless. Tolerant coping mechanism includes self-sacrifice by accepting the situation as an unchangeable part of life. The survivor feels hopeless, frightened and indecisive. She covers up for the repercussions of alcohol-induced behavior and gives the patient money in spite of knowing that it will be used for alcohol consumption. In this kind of coping mechanism, the wife, especially in an Indian context, where she is expected to adjust herself to prevent marital disharmony, pretends that things are normal or lessens the impact and extent of drinking. However, this behavior actually causes a paradoxical increase in alcohol consumption which inevitably leads to a further increase in violence.
Engaged coping was the second most commonly used coping mechanism, suggesting a welcome transition in social structure leaving behind the dependent, submissive stereotype of the weaker sex and progressing toward filling the niche of an independent, autonomous individual who is capable of and instrumental in bringing about positive change for her family and herself.
In a study conducted by Orford et al., partners have been found to use significantly more of both tolerant-inactive and withdrawal coping. Similar to our study, Ahuja et al. also found that English Sikh wives would show higher level of tolerant-inactive coping than White English wives suggesting higher withdrawal coping skills are used in the west. In Indian society, marital separation owing to drinking problem is still considered more stigmatic than staying in a conflicting discordant relationship. Thus, wives tend to go out of their way to change their partner's drinking problem for the sake of maintaining their marriage. While, in the initial few years of the problem, they begin with tolerant styles; a hope that things will eventually improve if they take matter into their own hands leads to more of engaged coping. Such styles when employed over years, without any positive outcome, ultimately compel the wives to engage in withdrawal coping. Hence, coping mechanisms can be understood as dynamic.
The current study also showed a statistically significant positive correlation between levels of domestic violence and intensity of suicidal ideation concluding that domestic violence significantly increases the intensity of suicidal ideation in the wives. On comparing the domestic violence faced by women with suicidal behavior, we found that the wives facing domestic violence are at significant suicidal risk. The prevalence of suicidal behavior increases by four-fold. Higher severity of suicidal ideation was also found in those facing elevated levels of domestic violence. Though studies done by Parkar et al., Sheikh et al., Dufort et al. and Carmen et al. strongly associate suicide with domestic violence, prevalence assessment was not done as is brought to light in this study. Increased stress and financial burden due to alcohol use disorder eventually causes emotional turmoil and unbearable feelings of hostility that leads to wives taking such drastic steps.
Our study had some limitations. The study being a cross-sectional study, the causal relationship could not be established. This study was done in a single tertiary care center and from a metropolitan city and thus the result obtained cannot be generalized nationally. Individual factors such as support from the in-laws and the wives' own personality would result in a variation between perceived stress scores even in otherwise similar situations. Longitudinal interventional national level studies with behavior assessment and prognosis assessed through multiple follow-ups are future recommendations.
| Summary and Clinical Implications|| |
Domestic violence was highly prevalent (87%) in the wives of patients with alcohol use disorder. It was seen that 82% wives had faced threats of violence, 79% had experienced acts of violence, and 58% had faced sexual aggression. Domestic violence was present irrespective of number of years of education of the patient, employment status of the patient and his wife, duration of alcohol consumption by the patient, and the type of family they lived in.
A statistically significant correlation was seen between domestic violence and perceived stress. The wives used various coping mechanisms to overcome the situation. It was seen that those who experienced domestic violence used predominantly tolerant inactive coping mechanism. The wives facing domestic violence had a greater risk of suicide, the prevalence increasing by four-fold. Statistically significant relationships were also seen between domestic violence and intensity as well as severity of suicidal ideation.
The study enshrined that the effects of alcohol use disorder extend well beyond its diagnostic significance. Domestic violence is an all-pervasive, serious social malady with major public health implications. The study highlights the importance of screening for domestic violence in the wives of patients of alcohol use disorder, as it is highly prevalent among them. Sensitization of health care professionals about domestic violence in this population during routine history taking is the need of the hour as most of the times it is overlooked. The study also emphasizes the importance of screening these wives for suicidal risk thereby helping in early detection and treatment, if needed.
Psychoeducation of the wives to deal with stress effectively and adopting healthy coping ways can be effective ways to improve psychological health. This can be done using referral to support groups and self-help groups for the wives dealing with issue of domestic violence. The study sheds light on the fact that it is only by spreading awareness about both, the domestic violence prevalent in this community and the simultaneous need for treatment of patients with alcohol use disorder, can the spirit of these silent survivors be bolstered and negative effects mitigated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]