RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS. JOSELINE C GEORGE1st Year M.Sc Nursing
Rajiv Gandhi College of Nursing
IIT Campus
Near Meenakshi Temple
Bannerghatta Road
Bangalore – 76
2 / Name of the Instituition / RAJIV GANDHI COLLEGE OF NURSING
3 / Course of study and subject / ist year Msc nursing
psychiatric nursing
4 / Date of Admission to course / 21-05-2009
5 / Title of the Topic / A COMPARITIVE STUDY TO ASSESS THE MARITAL RELATIONSHIP,PSYCHOLOGICAL DISTRESS AND PERCEIVED SOCIAL SUPPORT AMONG SPOUSES OF ALCOHOLICs and non alcholics ATTENDING SELECTED DEADDICTION CENTRE and urban community in BANGALORE.
BRIEF RESUME OF INTENTED WORK:-
6.1 INTRODUCTION:-
…O thou invisible spirit of wine,
If thou hast no name to be known by,
Let us call thee devil!...
O God, hat men should put an enemy
In their mouths to steal away their brains!
That we should, with joy, pleasance, revel
And applause transform ourselves into beasts!
(William Shakespeare,Othello Act 11,scene3)
Alcohol dependence has been showing a rising trend all over the world. Alcohol dependence is a complex behavior with far reaching harmful effects on the family, work, society as well as the physical and mental health of the individual. Alcoholism is one of the major health and social problems seen allover the world.Globally there are 140 million alcohol dependents and 78% of them are not treated1. It is the third leading psychiatric problems in the world today2.
Alcoholism is a disease of the family. The impact of substance abuse goes beyond the individual abuser.Consequences of alcoholism often results in chaotic, disorganized and dysfunctional family units. Alcoholism is linked to disrupted family role, violence, and impaired family communication physical and psychological illness1.
A study showed that members also suffer from a disease called Co-dependency or co-alcoholism.Separate treatment for family members with out the alcoholic presence includes education about alcoholism and co-dependency
referred to Al-Anon,Al-Ateen or ACOA(Adult children of alcoholics) groups, and individual or group therapy to increase the individual wellbeing of distressed family members3.
The families of alcoholics experience guilt,shame,resentment, insecurity,delinquency,financial troubles, isolation,fear and violence. Families of alcoholics are more disturbed in all areas of their family environment and family burden when compared to non-alcoholic families4.
Alcohol consumption is a contributing cause of marital aggression and that successful resolution of heavy drinking will often lead to a reduction and in some cases a cessation of domestic violence5.
The commonest stressors faced by the spouses were financial problems,physical abuse. Abuse of children and social stigma.Co-morbid conditions like depression, generalized anxiety, somatisation, phobia and dissociative disorders were found among them6.
Dyadic and family function is typically associated with a family member’s alcohol or drug abuse.One area of research interest based on clinical conception of these families is that of partner support or coping in response to the addiction.Female partners of male alcoholics have received much of these clinical and research attention, and have alternatively labeled as codependents, co-alcoholics or enablers. Broadening the therapeutic emphasis beyond the impaired individual underscores the
systematic notion that a loved one’s addiction necessarily affects spouses and partners, and tat partner responses mayin turn affect drinking or drug behavior.7
An amazing rise of 14% from the 1988 levels that roughly translates by the average alcohol user has jumped from the equivalent of 9 bottles (750ml) of whisky per year in 1988-89 to 20 bottles in 1998-99 and 35 bottles in 2008-2009.8
Several studies have reported hepatic dysfunction, cognitive impairment, head injuries, serious psycho social problems including family disruption, marital discord, problems in childrenand wives, financial difficulties,domestic violence,employment problems consequent to alcoholism9
The WHO Global status reported on alcohol a study on spouses and family members of people with alcohol dependence. In interviews with 45 Al-Anon members in Mexico (82% of them, the wife of a husband who was alcohol depended) 73% reported feelings of anxiety, fear and depression. 62% reported physical or verbal aggression by the spouse towards the family and 31% reported family disintegration with serious problems involving money and the children10.
Alcohol use and the problems associatedwith it are on the increase in India which has the second largest population in the world with 33% of the population consuming alcohol11.
6.2 NEED FOR THE STUDY:-
“More men are drowned in glass than in sea.”
(Freedman, Kaplan)
Family is a more or less durable association of husband and wife with or without children, or of a man or women alone with children. The striking problem that confronts modern family is its instability. Alcohol abuse is one of the major factor contributing to the instability. There is lack of mutual trust. The marriage bonds have weakened. The ancient ideals of fidelity and sex relationship have been adversely affected.
There is sexual disharmony between husband and wife. Marital happiness is largely the result of mental adjustments between partners. Hence family as a unit would have to be assessed to delineate its strength weakness in orders to promote its wellbeing. Consequences of alcoholism often result in chaotic disorganized and dysfunctional family units.
The National family health survey (NFHS) findings released at the end of the year 2007 reveals the extend to which woman lack autonomy; more than 50% justify or even accept, violence with in the home as normal. About 3 out of 5 women considered wife-beating justified wife-beating justified at least on one of the six grocends-neglecting the house or care of children, going out with permission of her
husband, showing dis-respect to in-laws, not cooking food properly, infidelity and failure to being money or goods.
Alcohol provokes the desire, but takes away the performance. Alcoholism is one of the major health and social problems seen all over the world. Globally there are 140 million alcohol dependents and 787 of them are not treated. Alcohol use has been indentified for 1.5% of all deaths in the world and 3.5% of disability adjusted life years and 4% of global burden of diseases.12
Physically abused women lived under constant fear , threat and humiliation.They are potential candidates for personality disorders and psychosomatic problems.The Indian female feels the entire responsibility of preserving the family as her duty; hence she endeavors to adjust herself to the atmosphere and the mores of her husband’s home.Women subjected even to extreme physical and psychological violence does not ordinarily seek divorce and suffer the onslaughts in silence as they
feel that their trauma and that of the children is the price they have to pay for the sake of the family.1
The family of the chemically abused person is a set of hurt, confused, people. They are the victims of addiction who do not use chemicals, but are victimized by the drug. They are victims struggling desperately to solve their problems.13
Alcoholism forms a diseased family with disrupted family roles, violence, physical and psychological stress. Therefore the study was aimed to compare the marital relationship, psychological distress and perceived social support among the spouses of alcohol dependents and wives of non-alcoholics.
Alcohol is the primary cause of violence and described five mechanisms were that. 14
1) Alcohol causes disinhibition that can lead to violence.
2) Alcohol misuse destroys the normal growth and development of the individual and of the family system.
3) The drinker’s ability to accurately judge social cues is diminished which leads to violent behavior.
4) Alcohol serves as a rationalization for family violence.
5)Alcohol alters brain functioning.
At present health professionals attention is mainly focused towards the alcohol dependents when the actual suffers are family members, especially the wives. The wives of alcoholics used various adaptive and maladaptive coping behaviors to restore the equilibrium and to relieve stress. This can lead to increased stress perception and crisis.
The investigator has observed the suffering of wives of alcoholics attending NIMHANS de-addiction centre, Bangalore with empathy .But all the health care professionals are focusing only on alcoholic and the actual sufferers are family members, especially wives who is accessible to alcohol husband. As an investigator I felt the need to asses how extent they are suffering, than non alcoholic .So investigator planned to compare the marital relationship, psychological distress and perceived social support among spouses of alcoholics and non alcoholics.
6.3 REVIEW OF LITERATURE
The review of literature presented here will cover the following areas,marital relations, psychological distress, and perceived social support among spouses of alcohol dependents.Studies carried out in various setting will be covered
MARITAL RELATION
A study conducted to examine the association between partner alcohol problems and selected physical and mental health outcomes among married cohabiting women, before and after adjusting for potential confoundetus. Results showed that women whose partner’s had alcohol problems were more likely to experience victimization, injury, mood disorders and anxiety disorders and were in poorer health than women whose partners did not have alcohol problems. They also experienced more life stressors and had lower mental/psychological quality of life scores. This study showed that partner alcohol problems pose diverse health threats for women that go beyond their well-documented association with domestic violence and those psychological issues and quality of-life-problems need to be addressed among wives of alcoholics.15
A study was conducted to examine partner violence before and after behavioral cognitive therapy(BCT) for 303 married or cohabiting male alcoholic patients and used a demographically matched non alcoholic comparison sample. In the year before BCT, 60% of alcoholic patients has been violent towards their female partner, 5 times the comparison sample rate of 12%.In the 1st and 2nd year after BCT, violence decreased significantly from the year before BCT and clinically significant
violence reduction occurred for patients whose alcoholism was remitted after BCT. Structural equation modeling indicated that greater treatment involvement (attending BCT sessions and using BCT-targeted behaviors) was related to lower violence after BCT and that this association was mediated by reduced problem-drinking and enhanced relationship functioning16.
A study was conducted a survey of 2027 adults in UK using both oral and computer-assisted question format. They were asked questions related to their own drinking pattern and the most severe incident of physical aggression experienced by and to a spouse/romantic partner during the previous two years. Approximately 20% of respondents reported partner aggression, with drinking by one or both partner occurring in 35-40%of incident. Alcohol use at the time of aggression was associated with increased severity of aggression, anger and a fear, especially for aggression by a male towards a female respondent. Drinking patterns of the respondent is the partner predicted alcohol involvement in aggression that did not involve alcohol17.
A study examined the relationship of husband violence, marital conflict and couples alcohol use in the first year of marriage. Husband-to-wife marital violence occurs in the 2nd year and 3rd year of marriage. Newly wed couples(Husband were on average 24.2 years of age and wives were on average 23.3 years of age at the time of marriage) were recruited and were interviewed regarding alcohol use and experience with violence 1 year after marriage and 3 year after marriage.It was found that violence in year 1st was predictive of subsequent marital violence.Husband and wife drinking patterns in the 1st year of marriage interacted to predict violence in later years.The most violence is subsequent years occurred in coupleswhere the husband was a heavy drinker and the wife was not. Husband who were in year 1st were more likely to be violent in later years.When no violence occurred in the first year, frequent use of verbal aggression in year 1st was predictive of violence in subsequent years18.
The frequency and correlates of intimate partner violence by type(physical,sexual,battering and emotional abuse) was estimated among women seeking primary health.Women aged 18-65 years who attended family practice clinics.Participation included a brief in-clinics survey assessing intimate partner violence.Multiple polytomous logistic regression was used to assess correlates of partner violence by type .Results indicated that of 1401 eligible women surveyed 772 (55.1%) had experienced some type of intimate partner violence. 77.3% experienced physical or sexual violence and 22.7% experienced non physical abuse. Alcohol and/or drug abuse by the male partner was the strongest correlate of violence19.
PSYCHOLOGICAL DISTRESS
A study examined how one spouse’s alcohol involvement and alcohol related problems affect his/her spouses depressive symptamatology .634 couples from a community sample were assessed for past year alcohol involvement and alcohol related problems(marital and non-marital) and depressive symptomatology when they applied for a marriage license. They were reassessed at their first and second anniversaries, alcohol related problems were assessed in the past year, for husband and wives, using item that were modified from the National Alcohol survey, the drinker inventory of consequences, and the work of Polish and Orvis (1979).the measure was made with two subscales alcohol related marital problems and alcohol related other problems. Depressive symptomatology was assessed at each interview using the centre for epidemiologic studies depression scale. The results showed both husband’s and wives marital alcohol problems were associated with wives depressive symptoms. Husband marriage-related alcohol problems and frequency of heavy drinking were related to wives depressive symptoms20.
A retrospective analysis was conducted using data from a Querber community health survey .The study of the study was to ascertain the mental health of female spouses living with a male life-time at risk drinkers(aged 30-54years) and the psychological distress of their nondrinking female spouses. The statistical technique used to analyze the data was t test, chi square test and bivariete correlations. This study confirmed higher levels of psychological distress in female spouses of male life time at risk drinkers in the general population. Implications of the study was that life time at-risk drinking is a risk factor for the spouses psychological distress.21
. The study was examined sources of psychological and relationship distress among 90 nonalcoholic women with alcoholic male partners seeking outpatient, conjoint alcohol treatment. Results indicated that greater psychological distress among these women was most strongly associated with lower perceived social support from family, and more frequent with attempts to cope with the partner’s drinking. Controlling for psychological distress, greater marital satisfaction was associated most strongly with greater attempts to reinforce positively the partner’s abstinence and with less effort to detach from the partner’s drinking. Severity of partner’s alcohol problems was unexpectedly associated with greater marital satisfaction in multiple regression analysis, though not in bivariate analyses. Results highlight the close connection between psychological and relationship distress and potential relations between alcohol-related coping behaviors and both psychological and relationship distress22.
Marital estrangement, positive feeling towards partner and locus of control was examined in 323 female counselors married to alcohol abusing or non abusing husbands according to DSM-1V-TR criteria. The instruments used were problem drinking scale, marital disaffection scale, positive feelings questionnaire and Nowickistrikeland locus of control scale. The results showed that wives of alcohol abusers experienced a great detachment from the husbands and there was a decline of caring about them with less desire for emotional intimacy leads to psychological distress23.
A study was conducted to evaluate the effectivenessof three approaches to assisting the female partners of problem drinkers with the stress imposed by the male’s drinking. Participants were assigned randomly via random number tables to one of three treatment conditions: supportive counseling, stress management and alcohol-focused couple’s theraphy.61 married women whose husbands drank heavily, participants reported protracted alcohol problems, severe impact of alcohol on social functioning and severe marital distress. The women’s stress, alcohol consumption by the male and relationship functioning were assessed at pre and post treatment and at 6 months follow-up. All 3 treatments involved 151 hour sessions with the woman. In the alcohol-focused couple therapy, attempts were made to engage the man in these sessions. Results indicated that contrary to the author’s predictions, there were few differences between the treatments. All 3 treatments were associated with reduction in thewomen’s reported stress, with trends fore some what greater reduction in the women’s stress in the stress management and alcohol-focused couple’s therapy conditions than for supportive counseling. None of the treatment produced clinically