Health Challenges to Community Psychology

The Mental Itineraries of the Everyday Lives of Indigenous Women Linked to their Partners Excessive Alcohol Consumption

The Mental Itineraries of the Everyday Lives of Indigenous Women Linked
to their Partners Excessive Alcohol Consumption

Guillermina Natera
Instituto Nacional de Psiquiatría, México

Abstract

Some time ago, a psychosocial research project was launched (1999) in an Otomí community in the state of Hidalgo to determine the dynamics of alcohol consumption. It was found, as in many places in Mexico, that alcohol consumption is deeply rooted in culture and that it is a tradition, but also the cause of many social problems, which involve various spheres of everyday life. One of these is women’s everyday lives due to the violence and economic negligence inflicted on them, which produces emotional states of anguish, anxiety, physical and psychological malaise, which increases when they see how their partners’ health is affected as a result of alcohol consumption. Can anything be done for them? Do they want help? Although women are not the only ones to suffer from this, since some children and parents are also affected, they are the main ones to feel the effects. As a means of supporting the family group, a brief intervention model was adapted as an alternative for providing support for the family. The results of the participation in the intervention program and the analysis of the narrations of this process expressed by women are presented in this paper. By mental itineraries, we understand the processes of psychological and cognitive changes undergone by these women in the search for an answer to a situation they could no longer tolerate, which plunged them into a state of crisis. This is analyzed from the theory of experience (Turner, 1994; Mier, 2001) and the Ritual Process (Turner, 1969) understood as, a process of awareness different from previous ones, which makes it different from other similar events. It also drives them to seek help, even though this may involve dealing with cultural norms and patriarchal dominance. What changes an everyday experience for a woman who has tolerated a situation for a long time, suddenly turning it into a social drama that drives her to seek help? The anthropology of experience is based on how individuals experience their culture, in other words, how events are perceived by awareness. To document this experience, we not only recorded data but also cognition, feelings and expectations.  Studying this long-established, everyday situation that suddenly becomes a social drama requires examining all the stages in order to be able to reconstruct it. The social drama comprises four stages: rupture, crisis, readjustment and reintegration. Lastly, the study proved the usefulness of the intervention for indigenous communities, despite the fact that the model is counter-cultural, since it runs counter to the cultural habits of alcohol consumption and obedience in a highly patriarchal society that looks for victims and culprits as a means of dealing with situations that cannot be solved or understood.

Keywords: Alcohol consumption, indigenous women, patriarchal culture, mental itineraries, symptoms reduction.

Los itinerarios mentales de las vidas cotidianas de mujeres indígenas ligadas al consumo excesivo de alcohol por sus parejas

Resumen

Hace tiempo se inició un trabajo de investigación en una comunidad otomí (1999), del estado de Hidalgo, con el objetivo de conocer la dinámica del consumo de alcohol. Se encontró como en muchos lugares de México, que el consumo está arraigado en la cultura, es una tradición, pero también es causa de muchos problemas sociales, que implican varias esferas de la vida cotidiana. Una de ellas es la vida de las mujeres por la violencia y la negligencia económica que se ejerce hacia ellas, que les produce estados emocionales de angustia, ansiedad, malestares físicos y psicológicos, que se incrementan de ver cómo se va deteriorando la salud de sus parejas por el exceso en la ingesta de alcohol ¿Se puede hacer algo por ellas? ¿Desean ayuda? Aunque no es privativo de las mujeres este padecer, pues hay hijos y padres que también lo sufren, lo más común es que sean las mujeres. Como una forma de apoyar al grupo familiar se adaptó un modelo de intervención breve, para ofrecerlo como alternativa para dar apoyo a la familia. Resultado de la participación  en el programa de intervención y el análisis de las narraciones de este proceso que expresaron las mujeres,  es lo que se presentará en este trabajo. Entendemos como itinerarios mentales, los procesos de cambios psicológicos y cognitivos,  por los que transitaron estas mujeres en la búsqueda de una respuesta a una situación que ya no podían tolerar, que hizo crisis. Se analiza esta desde la teoría de la experiencia (Turner, 1994; Mier, 2001) y del Proceso del  Ritual (Turner, 1969), entendida como un proceso de conciencia diferente a los anteriores, que la hace distinta a otros eventos semejantes, que les hace acudir a buscar ayuda aunque para ello tengan que enfrentarse a las normas culturales y la dominancia patriarcal. ¿Qué hace diferente una experiencia cotidiana para una mujer que ha tolerado por mucho tiempo una situación y, de repente se convierta en un drama social que acuda a solicitar ayuda? La antropología de la experiencia lidia en saber  cómo los individuos experimentan su cultura, es decir cómo los eventos son recibidos por la conciencia. Por la experiencia nosotros no sólo registramos los datos, sino también la cognición, sentimientos y expectativas.  Este proceso es cotidiano y ancestral, en un momento se vuelve un drama social que exige, a manera de un proceso ritual, pasar a la persona por todas las fases para poder reconstruirse. Cuatro son las fases del drama social: la ruptura, la crisis, el reajuste y la reintegración. Finalmente, se demostró la utilidad de la intervención para comunidades indígenas, a pesar de ser un modelo que podría considerarse contracultural por el quebrantamiento de los hábitos culturales del consumo de alcohol, y de obediencia a  una sociedad altamente patriarcal, que suele buscar víctimas y culpables ante situaciones que no se pueden resolver  o comprender.

Palabras clave: Consumo de alcohol, mujeres indígenas, cultura patriarcal, itinerarios mentales, reducción de síntomas.

Introduction

The purpose of this study is to show the impact of a program designed for the relatives of alcohol consumers implemented in Hñähñü indigenous communities in the Mezquital Valley in the state of Hidalgo. It examines the various phases of adaptation of the model: the feasibility study, the adaptation of the instruments, the application of the model and lastly a preliminary qualitative and quantitative evaluation of the process followed by these women to make decisions and find new ways of coping with a relative’s problem of alcoholism.

The Valle del Mezquital zone in Hidalgo State (150 km from the capital of Mexico) was chosen because various researchers at the National Institute of Psychiatry have undertaken several studies on alcohol consumption for the past ten years (García-Andrade, et al., 2005), to understand and explain the high mortality rate from hepatic cirrhosis in the region –40 out of every 100,000 inhabitants, when the national rate is 21.7 (Narro, 1994).

Alcohol consumption in indigenous communities is linked to cultural norms that form part of a historically constructed pattern of behavior, in a symbolic space used to mediate conflicts, political relations and friendship and reaffirm gender roles (Corcuera, 1996; Oechemin, 2004). The purpose of this study is therefore to examine alcohol consumption and its consequences in communities. Inhabitants may feel that this practice is being threatened by a possible intervention that will lead them to reduce their consumption, as a result of which they may object to participating in the study.

One should also recall that any health intervention is usually an extrinsic event, outside the autonomous development of the collectivity, which in turn disturbs a stable system. The intervention demands “the implementation of a framework of unusual norms in a universe that is already governed by rules, which necessarily creates an atmosphere of confrontation” (Mier, 2002: 23-35).

Among the consequences due to alcohol abuse that have been reported, Orford (1998, 2005), Holmila (1994), Natera (2007) and Tiburcio (2007) have consistently documented those that affect family members, for whom no care is provided in Hñähñü indigenous communities. The suffering of families that coexist with a situation of alcohol consumption is not dealt with, even though it is extremely common.

The intervention model developed is a brief intervention model, designed to support the families who experience the consequences of alcohol consumption. It focuses on the coping styles used by relatives to deal with consumption and comprises the following five steps: 1) listening to and understanding the relative's particular problem, 2) providing relevant information, 3) identifying and analyzing coping styles, 4) analyzing support networks and 5) referring individuals to sources of specialized assistance, if required, Natera et al., (2009); Tiburcio et al. (2009). The purpose of this model is to help the relative cope with the situation in different ways in order to encourage his well-being (Orford, 2010).

In order to implement this intervention model in the community, first of all, a feasibility study was carried out in the communities. The principal results of this study made it possible to clearly identify the challenges to be dealt with in the implementation of the intervention.  Among the difficulties identified were the predominantly patriarchal lifestyle into which power relations and the control of women are inserted through one of the main channels: gossip. Women from these communities are not easily allowed to seek access to psychological care in which they will discuss a primarily male problem such as alcohol consumption. Working in such small communities (with 300 to 900 inhabitants), the counselor must earn the trust of the persons he deals with and guarantee that he will not tell others about their problem. This is common among health workers who, with good intentions but fatal consequences, may utter phrases to the husband, such as “I’ve heard you're not behaving well at home,” or “I’ve heard you’re drinking a lot,” triggering acts of violence in men. Another challenge, which is no small matter, is that alcohol consumption is perceived as a socially accepted and even desirable form of behavior among men that is inserted into everyday life as well as extraordinary events.  At the same time, the culture of poverty and having a subsistence economy is a challenge to any intervention, since their scarce financial resources, time and physical energy are used primarily to satisfy their subsistence needs. These include food preparation, which often entails sowing, harvesting and preparing foods as in the case of making several kilos of tortillas a day, the main foodstuff, made from maize. Taking children to school and bringing them back, dealing with community tasks, fulfilling the social programs assigned to them, for which they are paid, are all priorities, as opposed to investing money to go to an appointment to deal with their mental health. This often involves walking long distances or paying a lot for transport to get there, as a result of which mental health becomes an extremely secondary matter. There are also aspects related to the difficulties of expressing their needs for care, since if there is a lack of services oriented towards their physical health, the situation is even worse for mental health. However, there was a consensus regarding the need for psychological support that would help them learn how to deal with their partners' excess alcohol consumption.

Since the original model was developed for the urban population (Natera, Mora, Tiburcio, 2008), it was necessary to adapt both the language and the psychological instruments used to evaluate psychological malaise and the community’s representation of how to deal with a relative’s problem of alcoholism. The cognitive laboratories technique was used for this purpose (Tiburcio, Natera and García, 2009). The result was a manual designed for this population, which contains suggestions on how to cope with potential obstacles to its implementation that may arise (Tiburcio, Natera and Medina Mora, 2009).

Method

Participants
A total of 60 women between the ages of 18 and 60 participated, all of whom are residents of the municipalities of Cardonal and Ixmiquilpan, in Valle del Mezquital, Hidalgo. Participants were divided into two groups of 30 each. The first group received the sessions and the second did not. All the participants were invited to take part in the intervention. Those who agreed formed part of the intervention group while those who did not were assigned to the non-intervention group.

Materials and instruments
Three questionnaires previously adapted and validated for this zone by Tiburcio (2007) were used. The Scale of Symptoms (SRT), which reports the presence of physical and psychological symptoms associated with stress, the Coping Questionnaire (CG) to describe the coping styles used for dealing with consumption and the Center for Epidemiological Studies Depression Scale (CES-D) to classify possible cases of depression.

Procedure
A quasi-experimental design was used, with an evaluation before the intervention and an evaluation 3 months later. The three instruments were used in both groups. Intervention sessions were held in the respective community health centers although some sessions were conducted in the family's home. The confidentiality and anonymity of all the participants was guaranteed through informed consent.

Each person attended between 4 and 6 sessions, with an approximate duration of ninety minutes. The intervention ended once the patient said she was confident enough to use new coping styles and her support networks.

Results
Below are some of the preliminary quantitative and qualitative results. The former correspond to the application of the instruments before and after and a preliminary anthropological analysis showing part of the processes experienced by the women.
The results of the group that did not receive the intervention were compared with those that did. A significant reduction in depressive features and in the number of physical and psychological symptoms was found in participants after the treatment. (Figures 1, 2 and 3).

Figure 1 (availabe in PDF version). Percentage of depressive features experienced by group before and after the intervention.

Figure 2 (available in PDF version). Percentage of depressive features by group before and after intervention.

Figure 3 (available in PDF version). Psychological symptoms identified in groups of participants.

Ways of coping with the problem of alcoholism were found to be universal (Orford, 2005). In other words, although these forms are very similar in the urban and rural zone, there are cultural, material and affective elements that make them have different expressions and alter the way they are understood. Individuals nearly always request help to know “how to stop the other person from drinking,” when the purpose of the intervention is to orient the intervention towards the relative’s concerns.

An increase in independent coping, related to lower stress, was found. Conversely, the group that did not receive the intervention not only remained the same but four months later, its situation had deteriorated, as regards both depressive features and physical and psychological symptoms (Natera et al., 2010).

What are the mental itineraries followed by those who suffer from having an alcoholic relative?
 
Initial stage: By mental itineraries, we understand the processes of psychological and cognitive changes undergone by these women in the search for a response to a situation they could no longer tolerate, which had plunged them into a state of crisis and expressed in phrases such as the following: I am condemned to live like this! I won't be happy until he stops drinking! I am worried…I have a lot of problems with my husband because he is an alcoholic!  He arrives drunk and hits me! If only he stopped drinking! I want to die! No-one needs me! “He insults me, shouts at me, swears at me and my mother, which really annoys me."

These were some of the most common phrases heard at the beginning of the interviews with relatives of alcohol consumers. They include stories with a great deal of violence and infidelity, as Estela said, “Now I know it’s the alcohol, he always used to come home drunk.”

Given that the perception of alcohol consumption is a behavior that is fully accepted by the community, relatives do not feel that they can complain, since consumers are the ones that must decide whether or not they stop drinking. Thus, what triggers the process of seeking help is an associated problem. The only thing that explains why women seek and accept help now is because they are going through an experience (Turner, 1994) understood as a process of awareness different from previous ones, which makes it different from other similar events. What makes this experience different is its scope and impact. The feeling of dizziness is what makes this event unique and different from others. This experience is shot through by the perception of pain, which has become the maximum offense, which is why they seek help.

Following the intervention model, the first interview is a continuous narration of the itineraries of a multitude of scenes of suffering they have experienced, which form part of their everyday lives, where men’s alcohol consumption is a form of behavior that is totally accepted by the community. Relatives do not feel they can complain since consumers are the only ones that have the power to decide whether or not stop drinking alcohol, even though the rest of the family suffers the consequences, such as violence and financial negligence. The possibility of a solution is focused on the consumer.  These feelings and emotions may last between 10 and 20 years. Women are not warned about the constant suffering they will experience from the time they marry. Other community members do not take into account the fact that they will have to deal with this problem. As Clementina says, “They knew he drank a lot but they did not tell me.” Afterwards, she will have to bring up her children alone. “You know what you have to do with your daughters, I don’t know anything about that.” The husband is obviously not giving his wife power, but rather, avoiding responsibility. But she also suffers on his behalf, in the path of loyalties she has been taught to feel towards men. It hurts her to see her husband suffer and look down on himself, as when she says, "He only wants to drink, I don’t care what they do to him, they can throw him down a ravine."
The lack of clear information about alcoholism still focuses on the fact that deciding to stop drinking is a sign of will. The drinker probably does not want to stop drinking, which he may use as an excuse for his behavior, but he may also be unable to stop drinking.

Second Stage. As a result of the break, the crack and the crisis expand. In this itinerary, there is increased awareness, although this does not happen in the same way among all the interviewees, since it varies in intensity, space and time. The respondent continues a process of intervention focusing on cognitive and affective aspects and begins to see things differently. Responsibilities are clarified and guilt is reduced. The respondent acknowledges the fact that the problem of alcohol consumption is the other person’s and that she has a responsibility to herself. Asked whether she had refused to give her husband money, Josefina replies: “To tell you the truth, I have refused to give him money because he’ll spend it on drinking.” This internal discourse, which women have never shared with other people and which confuses them about what they should do, combines with a series of feelings, such as anger, sadness and resignation, where guilt is present on an everyday basis. The woman feels guilty about having lied to a man, her man! She begins a process of understanding and recognition of herself, and of realizing that refusing to give him money was not the wrong response.

It is worth analyzing what would have happened if she had given him the money. What would the advantages and disadvantages have been? Then, in the presence of the counselor who does not judge her but understands her, she realizes that this was the best decision. There is catharsis, relief and a self-evaluation that she did not make the wrong decision, that she was entitled to do so and that she made the right decision. She realizes that lying does not make her disloyal. Instead, it allows her to reaffirm herself and strengthens her way of coping. She knows that she is doing the right thing and feels less guilty.

Part of this process involves recognizing her Part of this process involves acknowledging her discomfort and relating it to alcohol consumption, having lived in suffering and isolation, in an attempt to conceal her problems. Physical pain, intense headaches, concern, anger and nerves in the face of the uncertainty of what her relatives are going to say, relatives who no longer visit her because her husband is always drunk. She does not sleep because she is worried about not knowing where he is, because he has not come home. She gets frightened and becomes paralyzed and feels she cannot do anything. He threatens to leave but she knows he won't. Once again, she takes stock of her health as a result of a problem for which she is not responsible.

Is violence a separate problem? As mentioned earlier, the women in the study now realize that, “Now I know it was because of the alcohol.” A woman does not denounce her husband’s violence, because that would mean talking about alcoholism. It would make the problem visible because the process means that the whole family and community would find out. Although paradoxically, she has threatened to denounce him because she knows that it is a crime to hit their daughters, “Without doing anything, or in revenge for anything, just because he is drunk.” This is a problem that is associated more with justice than health.

They realize that they have experienced loyalty that should no longer continue and that they have suffered a great deal. For example, Clementina said: “There is a person who made me angry because he criticized him and I defended him,” but she does not care any more.

Third Stage.- Reconstructive or delimiting action. There is no going back at this stage, because the woman is now aware of herself. This is when the intervention can achieve a transformation that runs counter to the prevailing culture. And so she restructures her thoughts by analyzing what she can choose. By reflecting on the advantages and disadvantages, she can choose something new. “After the talks with the lady (the counselor) I calmed down and it was then that I thought about lots of options and decided to work to get on. I am still quite young…before I was destroyed, I wanted to die…eventually I plucked up the courage and said to my him (the husband) if you want to go, just leave and I stopped paying attention to him. I don’t want to sink now, I want to rise. He (the husband) also changed and learnt a lesson because of my attitudes and those of my children. If he became unpleasant he would have to go or I would…” We see how enthusiasm arises as another form of experience (Turner, 1988) as she learns how to cope with the situation.

Lastly, the participant enters a phase of readjustment and reconstruction. Formal and informal actions are oriented towards dealing with a certain type of crisis or legitimizing other means of reaching agreements and processes of reflection take place. The women acknowledge the strength they have acquired and evaluate their possibilities of negotiation and capacity for action. They can look at themselves to transform themselves into an active subject, by looking at the future without ignoring the past. They modify their personal and collective identities and resignify traditions.

This last step is delimited by an action that shows the woman’s reconciliation with herself and her social reintegration. Testimonials such as the one given below show that if women take the world into their hands, they become the subjects of their own lives. Juana begins to acknowledge the fact that her children need her, that he is no longer that important and that she is entitled to be happy and to seek things on her own. Several of them express themselves differently. “Thanks to you, (the counselor) I have recovered my balance. Things are different now because I feel happy and I thank you for your support. I am grateful to my daughter for having supported me too.” The process involves restoring the balance in herself and to a certain extent, the community. “I don’t want to die,” says Juanita, as supportive links are formed. “Now I know he won’t change, he’ll stop drinking when he wants to.” (Rosa). Or Clementina who, during the process, decided to go to church to obtain support for her life and said, six months later: “Now I realize he did not want me to go out, since I did not even go shopping…Now they say that I’m in control, that I go around on my own…I  say I don’t like to be insulted. If you carry on like that, I will continue fighting and you will find out that I won’t answer you back, I don’t want to fight. I don’t want to leave what I have found, I am happy to have become a woman; I don’t need to be a nun.

“He won’t do anything against me now, because if he does, I’ll sue him, if he dares.” Months earlier, her husband had destroyed the kitchen when he was drunk, and “On that occasion (she said) I was frightened and cried but now I would defend myself.”

All these changes have an impact on the community sphere, even if it is only in her circle. Now her friends and neighbors say, “Go and get that help, it has done her a lot of good.” So the community finds out that it can be helped in similar circumstances. The notion of their bodies is also resignified. “I won’t let him touch me or sleep with me,” says Clara, which she confirms six months after the evaluation.

Discussion

We tried to carry out an analysis with an anthropological rather than a psychological approach, which we still do not know if we have achieved. We think that this is a means of understanding the effects of alcohol consumption from a cultural point of view. An intervention can resemble a ritual while the stages in Turner’s Social Drama provide the opportunity to explain women’s mental processes. Since the last intervention, they have not been the same. They have learnt to face the world differently, they have acquired power over their own lives and hope that this learning will be interiorized and last. It has also caused an effect on the community, particularly because the place where the research was carried out are villages with 400 to 500 persons, so news about what happens to one person spreads quickly. Nowadays, the intervention has been recommended to other people undergoing similar circumstances. Lastly, it could be the transmission of an individual process to a collectivity. In the long term, the community could alter its relationship with the world through a new look at women’s lives, in this case, as regards their partners’ alcohol consumption and they realize that they no longer have to put up with the effects of alcohol consumption.

At the same time, the study proved the usefulness of the intervention for indigenous communities, despite the fact that the model could be considered counter-cultural, since it goes against the cultural habits of alcohol consumption and obedience in a highly patriarchal society that tends to seek victims and culprits as a means of dealing with situations that cannot be solved or understood.

Despite the limitations these women experienced in attending their appointments, they group studied here managed to go to them. They all completed their program, because in the last analysis, they feel better and know that this is good for them and their children.

This is the only model that has been developed on the basis of direct experience of research with families. There is also scientific evidence of its effectiveness, which is one of its greatest strengths. The intervention achieved the desired results since it was able to give a person the tools for dealing with a relative’s alcohol consumption and proved particularly effective in reducing depressive symptoms and psychological and physical disorders.

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Author(s)

Guillermina Natera, Instituto Nacional de Psiquiatría, México

Guillermina Natera is on the faculty of the Instituto Nacional de Psiquiatría, México.

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