Lived Experiences of Intimate Partner Violence and Help-seeking among Wives of Persons with Alcohol Dependence: A Thematic Analysis

Abstract

Background:

Worldwide, intimate partner violence (IPV) is a significant public health problem. Most of the wives of persons with alcohol dependence (PwAD) experience IPV in their lifetime. The study examined lived experiences of IPV among wives of PwAD.

Methods:

Qualitative research study design was used. Twenty participants were recruited using the consecutive sampling method. The researcher used an in-depth interview guide to collect the data. ATLAS.ti.9 software was used to analyse the qualitative data. Thematic analysis was used for coding and emerging themes. The thematic analysis yielded four themes generated from the in-depth interview: (1) reasons for the IPV, (2) help-seeking, (3) barriers in help-seeking and (4) coping with IPV.

Conclusion:

Survivors of IPV do not seek help due to self-stigma, unavailable resources, and lack of awareness about treatment for alcohol dependence. Clinicians should routinely screen for IPV among female spouses of persons with alcohol-dependent syndrome and provide psychosocial interventions for the survivors of IPV.

Introduction

Globally one-third of women experience physical and sexual violence by their intimate partner.^[1] Intimate partner violence (IPV) includes physical violence, sexual intimidation, emotional abuse, and controlling behaviours.^[2] The co-occurrence of alcohol use and IPV is around 50%.^[3] About 29.3% of married women between 18 and 49 were subjected to IPV in India.^[4] IPV has both short-term and long-term physical and mental health consequences for women.^[5] Alcohol consumption is associated with IPV perpetration.^[6] Women view their husband’s alcohol dependence as a significant causative factor for IPV.^[7] Individuals with alcohol dependence are perpetrators of IPV than those who are not.^[8] An increase in alcohol consumption and the frequency increases the chance of male-to-female interpersonal relationship violence.^[9] Other factors contributing to alcohol-related IPV are strained relationships, financial difficulties, communication problems, and a history of witnessing or experiencing violence in childhood.^[10]

Alcohol consumption is significantly related to IPV perpetration.^[11] Male alcohol dependence is closely associated with physical violence, suggesting that those who experience withdrawal and intoxication are at high risk for perpetration.^[12]

Reasons for IPV

Globally and in India, a well-established correlation exists between husbands’ excessive drinking and wives’ exposure to violence.^[13,14] Most men seeking treatment for alcohol dependence are perpetrators of IPV.^[15,16] Household stressors such as financial constraints, child-rearing challenges, spouse excessive alcohol drinking and infidelity exacerbate IPV risk in women.^[16,17]

Help-seeking Behaviour

Multi-centric IPV survey revealed that 55%–95% of women who had experienced physical or sexual violence had never sought professional help.^[18] The high prevalence of IPV in women and seeking support and disclosure varies significantly by country.^[19] Mostly, women who have experienced physical and sexual violence have told someone about their abuse.^[20] However, in several countries women who subjected to IPV remain silent.^[20] In India, when women seek support for spousal violence, their primary source of support is often their own families. In addition, in-laws and neighbours are the second and third most commonly approached sources of support.^[21] In India, most women prefer seeking help from informal sources, such as family members or neighboring friends, as they believe resolving violence is best handled within the family.^[22] Few survivors seek aid from formal authorities, as many do not consider the police or health care as formal sources of help.^[23]

Barriers in Help-seeking

The South Asian study on IPV highlighted that abused women women show zero tolerance towards violence in marital life.^[24] South Asian women feel responsible for IPV, blaming themselves for violence, which further hinders help-seeking. Survivors of IPV feel ashamed, guilty and stigmatized during the disclosure of abuse.^[25] Perinatal women who experienced spousal violence found three reasons for not disclosing it: fear of social consequences, escalation of IPV further, and divorce. Few women felt trapped and financially dependent on their spouses; hence they did not disclose.^[26] Most Indian studies assessed the frequency, causative factors of IPV. However, few studies examined predictors of help-seeking behavior among IPV survivors.^[27] Therefore it is crucial to understand the factors associated with help-seeking behavior among survivors to address IPV in Indian context.^[27]

Coping with Violence

Worldwide, IPV survivors use coping strategies such as avoidance, marital disengagement, co-dependency on alcohol, and emotions of powerlessness and distress.^[28,29] Survivors used specific relaxation techniques and spirituality to manage their emotions.^[30] Women who experienced violence used coping mechanisms such as seeking support, problem-solving, self-blame, positive evaluation, and avoidance.^[31] About 23.7% of women who had domestic abuse sought aid from someone.^[31] We examined the lived experiences of IPV and help-seeking among women who married to individuals with alcohol dependence syndrome and to develop a group intervention programme for survivors IPV.

Methods

Participants

The study used a qualitative research design. Using consecutive sampling survivors of IPV were selected. The study participants were women who admitted their spouse for treatment of alcohol dependence in Government-run Centre for Addiction Medicine, a tertiary care teaching hospital in Bengaluru. Survivors who were proficient in Tamil, Kannada, and English were included, and those who refused consent were excluded. The first author, a Ph.D. Scholar in Psychiatric Social Work, collected the data. He is certified in qualitative research and underwent one-week online training on the same.

Measure

The Composite Abuse Scale Revised-Short Form was used for screening the participants.^[32] It has 16 items and three domains, namely physical violence, psychological violence, and sexual violence. The researcher prepared the in-depth interview guide and the four mental health experts validated it. The researcher approached 27 survivors who had experienced IPV in the last 12 months. Out of 27 survivors, seven participants did not participate in the study; one refused consent, two did not participate due to time constraints, and four did not meet the inclusion criteria. The researcher stopped recruiting samples after reaching data saturation. Hence, final sample size was 20. The Institutional Ethics Committee granted ethical approval for the study. (Ref No: NIMH/DO/Beh.Sc Div/2020-2021). The data were collected from January 2021 to March 2021 for three months.

Data collection procedure

Informant consent was obtained from all the participants before the data collection. Face-to-face in-depth interview was conducted. The duration of the interview ranged from 20 to 50 minutes. During the interview, field notes were taken. The audio-recorded data were transcribed from vernacular languages into English.

Data analysis

Thematic analysis was done based on the Braun and Clarke method.^[33] The deductive and inductive approaches were used, and software (ATLAS.ti.9) software ATLAS.ti.9 version developed by Scientific software development GmbH. was used for data analysis. Repeated reading and re-reading of the data was carried out and codes were identified then the themes were generated iteratively.

Results

Table 1 shows that the mean age of IPV survivors was 34 years (±5.15). Half of them studied up to higher secondary. Most (65%) were hailing from a nuclear family, 40% were homemakers, and 30% were doing housekeeping job. Most (65%) of respondents had experienced IPV in the last week, and 85% reported that the main reason for IPV was their partner’s alcohol dependence. Most (85%) of them often faced psychological violence, and 60% sought help from other family members.

Table 1:

Socio-demographic and IPV Profile

Socio-demographic and IPV Profile	Categories	Frequency (%) (n=20)
Education	Primary School	02 (10)
	High School	07 (35)
	Pre-University College	10 (50)
	Graduation	01 (05)
Employment	Government	02 (10)
	Private	04 (20)
	Housekeeping	06 (30)
	Homemaker	08 (40)
Family type	Nuclear family	13 (65)
	Joint family	07 (35)
Domicile	Rural	08 (40)
	Urban	12 (60)
Religion	Hindu	18 (90)
	Muslim	01 (05)
	Christian	01 (05)
Last episode of IPV	Within one week	13 (65)
	Within 1 month	05 (25)
	Within 3 months	02 (10)
Reason for IPV	Alcohol	17 (85)
	Couple conflict	03 (15)
Help-seeking behaviour	Family members	12 (60)
	Do not ask help	05 (25)
	Friends	01 (05)
	Doctors	01 (05)
	Police	01 (05)
Most common type of IPV	Psychological violence	17 (85)
	Physical violence	03 (15)

IPV: Intimate Partner Violence

Perpetrators’ profile

Mean age of the perpetrator was 40 years (±4.32). Most of them were employed (65%), hailing from urban area (60%). More than half of them (55%) sought treatment for the first time. (45%) had multiple admission, and the duration of alcohol use was 10.30 years (±7.41).

Thematic analysis results

Table 2 reveals that four major themes emerged and twenty-five subthemes and 164 codes developed from in-depth interviews: (1) Reason for the IPV, (2) help-seeking behavior, (3) barriers in seeking help from others, and (4) coping style.

Table 2:

Thematic analysis

Themes	Sub-themes
Reasons for IPV	1.1: Alcohol intoxication and arguments
	1.2: Not giving money for alcohol use
	1.3: Spent money on alcohol use and not sharing the household expenses
	1.4: Unwilling to continue the treatment
	1.5: Heavy use of alcohol
Help seeking	2.1: Seeking help from the family
	2.2: Seeking police help
Barriers in help seeking	3.1: Self-stigma
	3.2: Concern about family status and dignity
	3.3: Fear of breaching confidentiality
	3.4: Hopelessness and asking help, does not help
	3.5: Fear of revenge
	3.6: Lack of awareness
	3.7: Fear of others behaving inappropriately
	3.8: Concern about parents
	3:9: Poor support from family
Coping	4.1: Being silent
	4.2: Being assertive
	4.3: Safety plans
	4.4: independence gives them confidence
	4.5: Using Religious coping
	4.6: Relaxation
	4.7: Seeking help from others
	4.8: Support for the husband’s treatment
	4.9: Support from self-help group and family

IPV: Intimate partner violence

Theme 1: Reasons for intimate partner violence

Sub-theme 1.1:

Alcohol intoxication and arguments:

Participants reported that violence occurs during the alcohol intoxication discussions related to alcohol use.

“When my husband was under alcohol intoxication a month before, he physically abused me multiple times. I asked him why you drank so much; the arguments went up to 5 min, and then my husband got angry with me and started hitting me for more than ten minutes”

(P 19, 27 years).

Sub-theme 1.2:

Refusing money to buy alcohol.

Violence often occurs when survivors do not give money to their husbands for alcohol use. The survivors often give money to their husband to drink alcohol. When survivors don't have money to give, then the perpetrator becomes violent.

“My husband demanded and threatened me to give him money for alcohol; when I refused, he mauled me and took it. I told him the money needed for essential purposes but was not ready to listen”

(Participant (P) 14, 29 years).

Sub-theme 1.3:

Perpetrators spend money on alcohol use and do not share the household expenses.

When survivors of IPV inquire about their male partners' refusal to contribute to household finances and not paying the loans, it often leads to violence.

“My husband borrowed money from various money lenders and from his friends’ circle; he spent all the money including his salary for drinking alcohol. He never repays his loans and never gives for household expenses, Money lenders, and his friends who gave money to my husband approached me to repay. I asked him about loans and repayment, not giving money for household expenses, he got angry, verbally abused me, and then, at one stage, he beat me very badly; it was not the first time”

(P2, 42 years).

Subtheme 1.4:

Unwilling to continue the treatment.

Participants reported relapse and poor treatment adherence were strongly related to IPV.

“My husband re-started drinking alcohol after a month of stopping alcohol. Later he stopped the medication and unwilling to come for follow -up and treatment. I requested him to take medication and continue treatment for multiple relapses, but he did not listen and continued to drink. Whenever I insisted he takes medicine. He got angry and started abusing me. The similar incidents happened in the past as well”

(P10, 39 years).

Subtheme 1.5:

Heavy use of alcohol.

Violence is more frequent when perpetrators drink heavily.

“Whenever my husband comes drinks heavily, he laughs, talks excessively and scolds everyone. He beats me brutally for no reasons. He scolds neighbours as well who support and protect me during violence”

(P2, 39 years).

Theme 2: Help-seeking

Sub-theme 2.1:

Seeking help from the family members.

Participants who experienced IPV seek help from their maternal family side and confide it to their mothers.

“When my husband beats me, I immediately seek help from my mother-in-law and children”

(P2, 39 years).

“I call my mother and tell her about my problem. She provides me emotional support. I feel a little better after that.”

(P9, 37 years).

Sub-theme 2.2:

Seeking police help.

The participants approach the police when they could no longer tolerate physical abuse; however no cases were filed against them. Most were unaware of the legal remedies available.

“My husband beats me very badly; I got injuries in multiple places in my body, including my head. With bleeding, I went to the police station and filed a written complaint. The police officer asked me to take treatment immediately, and they sent me with a female police officer to the hospital. Police officers went to my home, advised my husband to take treatment for alcohol use and sent him to NIMHANS hospital”

(P17, 26 years).

Theme 3: Barriers in help-seeking

Subtheme 3.1:

Self-Stigma.

Participants mentioned various reasons for not seeking help. Survivors specifically reported that self-stigma is the primary reason which prevents them from seeking help. They expressed concerns that sharing or discussing their problems with others would make them feel being judged or stigmatized, leading them to avoid seeking help. Additionally, they expressed a desire to keep their family issues private and avoid disclosing with others.

“Why do I have to disclose the suffering which I underwent? I am uncomfortable sharing my problems with others”

(P15, 39 years).

“It is not safe to share my problems with others or neighbours about my situation at home, particularly about my husband’s alcohol use and his violent behaviour; they will treat me differently. Whoever studying with my daughter in school will treat her differently” (P15, 39 years).

Subthemes 3.2:

Concern about family status and dignity.

The survivors reported that fear about losing the family’s respect in society, loss of status from the community, and worried about the critical comments from the neighbours.

“If I ask help from someone, neighbours and relatives would come to know about my problems. I do not want to lose my family status and dignity in front of them”

(P2, 39 years).

Subtheme 3.3:

Fear of breaching confidentiality.

Survivors reported that others don't maintain confidentiality.

“I can't trust anyone to share my difficulties and ask for help; somehow, it reaches my husband, and my problems get worse than before”

(P14, 29 years).

Subtheme 3.4:

Hopelessness and asking help, does not help.

The participants reported that after the police complaints, the husband continued the same behaviour; Survivors lost hope that their husband would stop the violence.

“I sought help from police and neighbour multiple times, and they helped me somehow. However, the violence continues at one point, I stopped asking for help. I know that violence will remain the same, so what is the use of asking for help repeatedly”

(P 19, 27 years).

Subtheme 3.5:

Fear of revenge.

Survivors reported that they are afraid of their husband and he might take revenge later, police officers say that giving police complaint will affect his life; due to this reason, they are not ready to take help from the police.

“Whenever I approach the police for my problems, my husband takes revenge on me and abuses me very badly; Many times he did it in the past in the same way”

(P15, 39 years).

“If I seek legal support or file a complaint against my husband, the police would beat him brutally, which he cannot tolerate”

(P15, 39 years).

Subtheme 3.6:

Lack of awareness.

The participants reported they are unaware of the process of the police helplines and women helpline, domestic violence, one stop centre, available in the community.

“I do not know how to ask for help or whom to approach. Is there any provision to seek help”

(P17, 26 years).

Subtheme 3.7:

Fear of others behaving inappropriately.

The participants have a fear that others misbehave with them if they come to know that violence is happening in my family.

“If I ask for help from relatives or others, they may take advantage of me and misbehave with me, especially the opposite gender; if they know my condition. I am already helpless and have no social support, so my problem will be advantageous for them to misbehave with me”

(P1, 35 years).

Subtheme 3.8:

Concern about parents.

The participants reported that they were hesitant to ask help from their parents.

“If I ask for help from my parents, emotionally disturbed and their health would get affected. They are already aged”

(P17, 26 years).

Subtheme 3.9:

Poor support from family.

The participants reported that they don’t have adequate family support to get help from others, and immediate family members are not ready to support them.

“In my husband family, no one bothers about me. I don’t have anyone to support me”

(P 9, 37 years).

Theme 4: Coping

The survivors use different coping techniques to manage violence, such as being silent, problem-focused, emotion-focused, prayers, relaxing, keeping quiet, supporting husband treatment, and attending peer support meetings.

Subthemes 4.1:

Being silent.

The participants often use techniques to manage violence when it occurs. Maintaining silence is a common coping mechanism for survivors to apply control over violent situations.

“Usually, I keep myself calm; if arguments start”

(P19, 27 years).

Theme 4.2:

Being assertive.

The participants reported that if my husband comes under alcohol, that time I will not ask any questions and don't discuss anything. If my husband comes without drinking, at that time he will be in a good mood. We will talk about the remaining problems.

“I usually discuss and share my difficulties with my husband when he is sober”

(P14, 29 years).

Sub-theme 4.3:

Safety Plans.

The participants used to take all precautions to be safe, such as keeping door open, hiding the sharp objectives, staying with other family members, and contacting neighbors. Few survivors reported whatever safety plans used by their friends they have also used.

“Whenever my husband comes under alcohol intoxication, I stay outside, keep the door open, and be around family members”

(P 10, 39 years).

Sub-theme 4.4:

Financial independence gives them confidence.

The participants reported that they always depend on their husbands for everything including maintaining the home and taking decisions. Managing the house is the most stressful situation for them. Once if they start earning money, they feel confident and independently manage the home and get some freedom from their husband and not depending on them for everything.

“I started going to work, focusing entirely on work and my children. Now, I am financially independent and I can take care of myself and my children. Now, I feel more confident”

(P10, 39 years).

Sub-theme 4.5:

Praying to God.

The survivors reported that they manage stress by venting and praying to god.

“Whenever I feel depressed and under stress, I go to the temple and spend time there; I read spiritual books and do prayer”

(P2, 39 years).

Subtheme 4.6:

Relaxation.

The participants used different strategies to cope with stress and violence. They used to go to parks and temples, stay alone and do not interact with others, drink tea, share problems with friends, going to their motherhouse for taking rest.

“I go to a nearby park when I feel more stressed”

(P11, 37 years).

Subtheme 4.7:

Seeking help from others.

The participants reported that most of the time, they used to ask for help from immediate family members like in-laws, parents, siblings and children. Some of the participants used to ask for help from relatives, friends and neighbours. Very few participants reported that if the problems are severe, they will seek help from the police, non-governmental organizations, doctors and other professionals. “I used to share my difficulties and problems with my children and parents; they were very supportive” (P2, 39 years).

Sub-theme 4.8:

Support for the husband’s treatment.

Two respondents reported that they support their husband during relapse.

“I understand that violence is because of alcohol use; I support my husband for treatment, and even if he relapses, I regularly take him to the hospital. Now, I am confident to handle him”

(10, 39 years).

Sub-theme 4.9:

Peer support.

One participant reported that she used to go to an Al-anon (Al-Anon is a peer support group for wives of persons with alcohol use disorders) peer support group to manage herself and help her husband’s recovery and how to handle them.

“I attend Al-Anon meetings regularly; I used to share my problems in the group and sometimes get a possible solution for my problem”

(P 10, 39 years).

“I used to share my difficulties and problems with my children and parents; they are very supportive to me ”

(P2, 39 years).

Discussion

Participants reported that they have experienced multiple forms of IPV when their spouse was under the influence of alcohol and during withdrawal period. Alcohol seems to influence violence.^[7] Our study themes reflect that alcohol is the primary reason for IPV. Several studies have found that consuming alcohol increases the possibility of intimate relationship violence.^[7] The present study revealed that financial difficulties is the primary reason for IPV. This finding was supported by earlier study which highlighted that financial constraints also causes IPV.^[34] We found that unwillingness to take the treatment is another reason for the IPV. Previous study revealed that delay in treatment is one of the reason for IPV.^[35]

Most survivors who sought help from informal sources such as neighbours, family members, or acquaintances, whereas 10% sought formal help. As survivors think that violence is best resolved inside the family, most women in India seek assistance from unofficial sources such as family members or friends.^[22]

We examined the barriers in help-seeking among IPV survivors. Most participants reported self-stigma is the most important barrier in seeking help from others.^[36] Anticipated stigma heightens a sense of shame and secrecy related to IPV.^[37] Another barrier reported by the participants was fear about the husband. Previous study reported that fear about the partner was the barrier in help-seeking.^[38] Another study found that fear of breaching confidentiality,^[39] fear about the consequences of disclosing IPV were the common barriers in seeking help.^[40] Lack of information about available resources makes difficult to seek help.^[41] We found that poor social support system is another reason for not seeking help. This finding is consistent with previous study that revealed lower social support leads to IPV.^[42] The present study found that poor social support systems are also reasons for barriers to help-seeking similar study found that lower social support leads to IPV.^[41]

Handling an individual diagnosed persons with alcohol dependence (PwAD) is difficult for wives to run a family.^[42] They use different strategy to manage alcohol dependent husband during the violence. The wives of individuals with ADS who experienced IPV face numerous stressful life events in their personal life and negative experience.^[43] With coping resources compromised and asking for help from others, they are also less likely to use adaptive coping strategies.^[44] In our study, the survivors used several strategies to cope with the violence situation. These strategies encompassed maintaining silence. Few studies reported similar findings which revealed that silence helps them to know what situations and circumstances to avoid.^[45] employing a problem-focused approach,^[46] engaging in assertive communication,^[47] preparing safety plans,^[48] striving for financial independence,^[49] utilizing emotional-focused techniques,^[31] relying on religious/spiritual strategies,^[50] practising relaxation techniques,^[51] employing social coping mechanisms,^[7] seeking assistance from others,^[52] supporting the husband’s treatment, and accessing peer support groups.^[53]

Implication for Social work practice with survivors of IPV

Identifying and assessing intimate partner violence

Several key steps are involved in the identification and assessment of IPV: Identifying IPV among spouses Individuals seeking treating for ADS in de-addiction setting, assessing the severity of the violence, carrying out psychosocial assessments, and gaining an in-depth understanding of their needs from various perspectives in addiction context.^[54]

Psychosocial interventions

Mental health professionals should focus on the mental health concerns of the survivors. There is a need to develop and assess the effectiveness of different psychosocial interventions/therapy modes for women who have experienced IPV in a setting, including de-addiction services and emergency departments.^[55]

Advocacy, support, and empowerment

The effectiveness of advocacy/support interventions must be tested in preventing violence in this addiction setting. Ensuring the safety of the women is the primary concern. Intergenerational transmission of IPV is standard, and intervention programs to prevent this transmission are needed.^[56]

Home visit and mother-child interventions

Home visits mainly target women experiencing IPV and measure intimate relationship violence as the primary outcome might be advantageous for mother and child intervention. This strategy is based on established child maltreatment practices and tries to support and help these women in their homes.^[57]

Safe shelter

The safe shelter is essential in avoiding violence by offering a safe and supportive environment for at-risk individuals and families. It functions as a haven where victims of violence can seek protection and find physical and emotional safety.

Training health-care workers IPV

Training health-care providers on IPV is critical for preparing them with the knowledge and skills to effectively manage and respond to this issue.^[58]

Need for better methodology

Focus on binge and heavy drinkers and implementing family intervention.^[59] Binge drinking or families having heavy drinkers are at a higher risk of Interpersonal violence.^[60] Addressing partner violence specifically within this group and providing supportthrough family intervention is crucial.^[61] Focusing on intervention for a younger couple: Future studies should prioritize addressing violence within young couples by aiming to identify early signs and providing timely interventions.^[62,63] Focusing on culture-basedintervention programs for intimate partner violence (IPV). India, a multicultural nation, requires interventions tailored to specific cultural contexts.^[64] Such culture-based interventions provide valuable insights for professionals and survivors, improving studyoutcomes.^[65]

Recommended intervention

IPV and addiction integrated programs address both IPV and addiction concurrently, recognizing their interplay and co-occurrence. IPV and addiction treatment programs aim to break the cycle of violence and substance abuse, offering individuals a pathway to healing, recovery, and a healthier future. Batterers intervention programs designed to address and treat individuals who engage in domestic violence.^[66] These programs aim to hold individuals accountable for their abusive behavior and help them to develop non-violent and respectful ways of interacting within relationships.^[67] Younger couples with less hazardous drinking- low-intensity intervention: Low-intensity interventions for younger couples with less hazardous drinking focus on providing targeted support and resources to address their drinking behaviors. These interventions are designed to be accessible, brief, and tailored to the couple’s specific needs.^[68]

Conclusion

This study provides valuable insights into why survivors of IPV may not seek help. By examining the factors associated with help-seeking behavior, barriers to seeking assistance, and coping styles, the study helps us better understand the underlying reasons that prevent survivors from seeking help. This study would be useful for developing effective psychosocial interventions and strengthening social support systems that can address these barriers and encourage survivors to seek the help needed for recovery.