دو روی یک سکه: عاملین و بازماندگان دیدگاه سه گانه از الکل، خشونت خانگی و بهداشت روانی در جنوب هند

The present study explored the intersection among alcohol consumption, gender roles, intimate partner violence (IPV) and mental health from the perspective of heavy drinking men who also perpetrate IPV (perpetrators) and their spouses (survivors). Interpretive phenomenological approach was used, and in-depth interviews was conducted with adult married heavy drinking men who reported to have perpetrated IPV (N = 10) and their spouses (N = 10). These interviews were audio-recorded, and salient themes were generated using the NVivo software. Findings indicated a deeply embedded association among alcohol consumption, IPV, and mental health, with culturally sanctioned gender norms strongly contributing to this association. There was evidence for anxiety and depression in the survivors and emotional-behavioral and academic difficulties in their children. The study provides valuable insight into the intersecting problems of alcohol and IPV, which independently and together signify an emergent public health problem that can have immense ramifications on mental health of individuals and families.

Alcohol use is a growing public health problem with immense ramifications on the individual and the society. Alcohol related problems are on the rise in developing countries, including India and significantly impacts finances and health outcomes, particularly among the poor (Saxena et al., 2003). The National Survey of Drug Use in India, which by far is the only systematic effort to document the nation-wide prevalence of substance use including alcohol, recorded alcohol use in the past year in 21% of adult males; the current use of alcohol ranges from 7% to 75% (Ray et al., 2004). Although India was once regarded as a ‘dry’ or ‘abstaining’ country, the impact of globalization appears to have resulted in a widespread attitudinal shift to greater normalization of alcohol use (Benegal, 2005 and Bennett et al., 1993) with a significant lowering of age of initiation of drinking from 28 years to 20 years (Benegal, 2005). In addition among men who drink, the prevalence of heavy drinking episodes are high and is associated with various high risk behaviors such as drunken driving, violence, and unprotected sexual encounters (Chandra et al., 2003 and Poulose and Srinivasan, 2009). Pillai et al. (2013) in a population based study in Goa found that heavy drinking patterns in men were associated with psychiatric morbidity, risky sexual behaviour and partner violence. Studies examining the antecedents of IPV have indicated the role of a lower socioeconomic status (Bangdiwala et al., 2004), lower levels of education and problem drinking in the spouse (Bonomi et al., 2006, Kumar et al., 2005, Jewkes et al., 2002, Jeyaseelan et al., 2004, Jeyaseelan et al., 2007, Verma et al., 2007 and White and Chen, 2002). Murphy et al. (2005) in their study on intimate partner violence showed that the number of standard drinks consumed by the husband in the previous 12 hrs was significantly higher prior to violent versus non-violent conflicts. Spouses of abused women had a higher prevalence of alcohol use (82%) compared to spouses of non-abused women (18%). A study from Goa observed that among 29 harmful drinkers who admitted to violent acts, 21 were drinking alcohol at the time of perpetrating violence (D’Costa et al., 2007). Further, gender role related factors shaped by prevailing cultural norms may also be associated with IPV(Krishnan, 2005). A recent Indian study showed that women employed in vocational training centers were at an increased risk of IPV as they were likely to defy prevailing gender norms (Krishnan et al., 2010). In another prospective study conducted in Bangalore, women who were unemployed at baseline and began employment by the first follow-up had 80% higher odds of violence compared to those who maintained their unemployed status (Rocca et al., 2009). Thus, while alcohol use among men has been consistently linked to IPV, gender roles could be an important mediator in the link between heavy drinking and high risk behaviors such as IPV. Mental health consequences of IPV among women mainly include depression, post-traumatic stress disorder (PTSD) and completed or attempted suicides (Ellsberg et al., 2008 and Pico-Alfonso, 2005, 2007; Scheffer-Lindgren and Renck, 2008 and Vizcarra et al., 2004). Studies in India have also demonstrated a high prevalence of psychiatric disorders, such as, depression and PTSD among women reporting IPV (Chandra et al., 2009 and Verma et al., 2007). A population based survey in Goa reported that it was critical to address women's violence related attitudes in addition to partner alcohol use and violence in order to prevent and treat mental health psychiatric disorders in women (Nayak et al., 2010). The effects of IPV on behavioural outcomes in children have been inadequately researched. Western studies have shown a strong association between maternal IPV and emotional/behavioral problems in the child (Kernic et al., 2003, McFarlane et al., 2003 and Paterson et al., 2008). In India, while several studies have found an association between maternal IPV and infant death (Ahmed et al., 2006; Jejeebhoy et al., 1998, Ackerson and Subramanian, 2009), there are no published studies in India, to the best of our knowledge that have examined the impact of IPV on cognitive, emotional and behavioral problems in the child. In addition, there is a high prevalence of emotional and behavioral problems in children whose parents abuse alcohol (Christensen and Bilenberg, 2000). Various studies report that children of alcohol dependent parents exhibit elevated symptom levels for both internalizing (sadness, worrying) and externalizing (aggression) syndromes compared with children of non-dependent parents (Carbonneau et al., 1998). Previous studies have shown parental conflict and violence as important mediators in the association between alcohol use and childhood behavioral problems (Wall et al., 2000). Furthermore, identifying children who grow up witnessing IPV is important to avoid the perpetuation of the cycle violence as adults (Narang et al., 1997). The above review highlights that problem drinking and IPV together pose significant health burden on men and their families. IPV has been studied extensively from the survivors perspective and no known studies have documented perceptions of perpetrators and survivors on the same. Very few studies have examined gender norms and their contribution to the relationship between alcohol and IPV, particularly in India where patriarchy is prevalent. Finally, although the consequences of problem drinking and IPV on survivors mental health has been researched, its impact on children is has not been studied. The aim of the present study was to explore perpetrators and survivors perspective on the embedded relationship between alcohol consumption and intimate partner violence. This study constituted the formative phase of a larger intervention study to examine the effectiveness of an integrated treatment for alcohol use and Intimate Partner Violence in men with problem drinking in south India. Therefore, findings from the proposed study will not only fill gaps in current literature, but will also have broad implications for both preventive and treatment programs for perpetrators and survivors, and may eventually safeguard at risk and vulnerable populations such as women and children.

The study provides valuable insight for understanding the intersecting problems of alcohol and violence, which independently and together signify an emergent public health problem that can have immense ramifications on mental health of individuals and families. This is of particular relevance to developing countries where socio-cultural factors complicate this intersection manifold and result in adverse mental health outcomes for the individual and his family. The study also adopts an inclusive approach and integrates the perpetrators’ and survivors’ perspectives on the intersection of alcohol, violence, mental health and the role of gender and culture. The findings throw light on salient issues and strategies that may be incorporated in the development of interventions for high risk individuals and their families.