Coping strategies for domestic violence: Testimony of women involved with drugs

Objective: To understand strategies used by women involved with alcohol and/or other drugs to cope with domestic violence. Methods: A qualitative study using the theoretical framework of coping strategies proposed by Folkman and Lazarus. 19 women with reports of domestic violence and involvement with alcohol and/or other drugs attended to at Family Health Units in a city of Bahia, Brazil. The data were systematized based on Discourse of the Collective Subject. Results: Given the context of domestic violence and drug use, women confront their partners; they try to have a conversation; they seek family and institutional support and take responsibility and blame for the aggression suffered. Conclusions and implications for practice: The strategies listed may support actions to prevent and cope with the phenomenon, especially from the intersectoral articulation.


INTRODUCTION
The magnitude of domestic violence in Brazil and worldwide compromises the country's economic system, demanding strategic actions to prevent and cope with this phenomenon, especially given its interface with drug use, whether by the woman and/or the partner.
In Gauteng, South Africa, a study found that at least half of the 511 women investigated were victims of an intimate partner at some point in their lives. 1In Cancun, Quintana Roo, Mexico, 30% of a population of 392 women reported having experienced some form of domestic violence. 2A similar context was found in a Brazilian study carried out in Recife, Pernambuco, Brazil, with 245 women, which estimated a prevalence of violence perpetrated by the partner around 33.3%. 3 The state of the art on domestic violence shows a close relationship of this problem with the consumption of drugs.A national study points to consumption of drugs as a precipitating factor of violence perpetrated by the spouse. 4In Mexico, the percentage of violence in the marital relationship can reach 95% when it comes to men who abuse alcohol. 2 With respect to the women consumption, a survey carried out in Spain with 100 women calls attention to the significantly greater use of psychotropic substances in the group of women who have been mistreated by their partners. 5Although the association between drug use by women and violence is evidenced, this study, like others, does not enable to infer if the use of the substance motivates or is the consequence of the abuses.
It is known that their separately repercussions are already disastrous, perhaps associated.] Given the morbimortality of the violence, it is necessary to prepare professionals to recognize women in this situation as early as possible, in order to welcome and direct them to put an end in the abusive relationship.In this context, attention is called to the professionals working at the Family Health Strategy (ESF), in particular the nurses, whose actions in the primary health prescribe health promotion actions, early diagnosis, and prevention of damages.
Although the conjuncture about the interface between domestic violence and drug use is not recent, but still current, it is notorious the difficult to face this problem.Considering the relevance of actions directed to intervene with this phenomenon and how the consequences are mitigated or disregarded, the study intends to understand women's coping strategies for domestic violence related to alcohol and/or other drug abuse.

METHOD
Research with a qualitative approach based on the theoretical framework of coping strategies proposed by Folkman and Lazarus.This theory assumes that cognitive changes and behavioral efforts undertaken by people for purposes of managing and/or adapting the stressful context are based on the following coping strategies: Confrontation, Spacing or Distancing, Self--Control, Social Support, Accepting Responsibility, Escape--Avoidance, Problem Planning and Solving, and Reappraising. 10he study scenario was the territorial area of two Family Health Units (USF) located in the urban area of a city in the countryside of the state of Bahia, Brazil.The choice of these scenarios passed through the context of social vulnerability of the community.The participants were identified through shared home visits by the researchers and the community health agents (ACS) of the two USF.Home visits enabled the identification of 21 women who met the criteria of the research, namely: being enrolled in such USF, aged 18 years or above, and reporting domestic violence and involvement with alcohol and/or other drugs.For this last criterion, the women and/or their partners who abused these substances were taken into consideration, regardless of the time of use and the cause-effect relationship with the experience of violence.
The exclusion criterion adopted was to present characteristics that suggested emotional instability.This criterion was adopted considering that the associated experience of involvement with alcohol and/or other drugs and domestic violence represents a situation that predisposes to mental suffering, so that the risk of intensifying such suffering was considered during the interview.It is worth mentioning that an evaluation of the women's emotional state was performed at the time of the interview and was supported by professionals from the USF team and the psychologist from the Reference Center for Social Assistance (CRAS) or the Center for Psychosocial Care (CAPS) of the city, and they were also reference for the psychological treatment, if necessary.According to the study criteria, among the women identified as potential participants, two were excluded from the study and referred to psychological care as they presented signs of emotional instability.There were thus 19 women.
The semi-structured interview technique was used.The interview was guided by a script with closed questions to characterize the participants and two guiding questions about the strategies adopted to confront domestic violence.The interviews were conducted in the houses of the women or people close to them, as long as the space secured privacy.Data were collected between October 2016 and February 2017, on a day and time defined by the participants, during home visits and/or through phone calls.The data collection began after approval of the project in the Ethics Committee (opinion No. 424.473/2016).
The content of the interviews was recorded on digital device and transcribed in full.The data were systematized based on the Collective Subject Discourse (DSC) method, which trans-

Dealing with domestic violence
Carvalho MRS, Oliveira JF, Gomes NP, Campos LM, Almeida LCG, Santos LR forms, through induction, individual statements into collective representations.For the construction of the speeches, the methodological figures were extracted: Key phrase (Ech) and Central Idea (IC).After these identifications, the construction of the DSC was feasible, with five categories emerging, presented through a speech-synthesis written in the first person singular and that included the Ech with the same IC. 11Data analysis was based on the coping strategies proposed by Folkman and Lazarus 10 .

RESULTS
Of the 19 women participating in the study, 16 reported using benzodiazepines and cigarette and alcohol abuse, and 17 reported that their partner was also abusing alcohol and cigarettes, thereby confirming direct or indirect drug involvement.They were aged between 20 and 69 years old, most of them declared themselves black, Catholic, married or in domestic partnership, with children, with little schooling, and with monthly personal incomes lower than a minimum wage.
Based on the theoretical basis adopted, the five coping strategies below were identified in the analysis of the empirical material:

Central Idea 01 -Accountability for domestic violence
According to Folkman and Lazarus' assumption, 10 accepting responsibility as a coping strategy occurs when the individual recognizes himself as the cause of a stressful event and seeks to reestablish the problem by attributing to himself the guilt over the problem.From this perspective, in the collective discourse, women blame themselves for the violence they suffer, as they believe they deserve the domestic violence due to their "inappropriate behavior", which justifies the use of violence, especially because this occurs in scenarios with alcohol and/or other drug consumption by the partner and they believe that they have a 'good husband'.

Central Idea 02 -Drug use
The collective discourse of the participants denotes the use of alcohol and other psychoactive substances as a strategy of self-control since it provides escape from reality and allows them to regulate their emotions before the stressors experienced.
Self-control, a coping modality also defended by Folkman and Lazarus, 10 refers to the strategy of seeking the balance of feelings and actions.In this study, 16 of the 19 participants reported using drugs due to the violence they suffer in the marital relationship.

Central Idea 03 -The confrontation with the partner
The participants reported reacting to situations of domestic violence, confronting the partner physically and/or verbally, or divorcing him.These confrontations, in general, occur with aggressiveness.Understanding that the confrontation is a coping strategy for the situation experienced through aggressive behaviors, 10 it is observed in the collective discourse the women's reactivity to domestic violence, ranging from distancing from the partner to the use of violence.

I have already obeyed him [partner] a lot, but I have changed! [...] I started by telling him to change rooms. Nowadays, when he starts arguing and cursing me, I don't keep my mouth shut and I confront him! If he locks
the doors and takes the keys, I break the window and I also leave.At the time of his fits, I only think that I will not take a beating, so I fight back: I make a scene, I break everything, and I hit him.Last time he came all aggressive and slapped me in the face.At the same time I fought back with another, I took the knife from the table and said that if he hit me again I would cut him.He knew I was telling the truth because I already cut him twice with a knife and the doctor said he barely escaped.I lived in fear because he said he was going to kill me.Out of fear, I decided to divorce.We are divorced and today he has no right to beat me (DSC 3 -E1, E2, E3, E4, E5, E7, E8, E9, E13, E14, E15, E16, E17, E18, E19).

Central Idea 04 -The dialogue
Within the context of the problem solving strategy or the appropriate planning proposed by Folkman and Lazarus, 10 it is possible to note the women's commitment to reduce or eliminate the conflicting and/or stressful situation.In this sense, given the Dealing with domestic violence Carvalho MRS, Oliveira JF, Gomes NP, Campos LM, Almeida LCG, Santos LR marital relationship permeated by violence, women change their attitudes and try to dialogue, believing that this is an effective strategy to cope with this daily stressful event.
He [the partner] is ignorant, he does not know how to talk, he curses me, he says words that hurt me, and when he does not hurt me, he threatens to beat me.I also don't know how to talk, but I try to change anyway, instead of responding to the aggression with a fight, I try talking to him, I speak slowly, I give him a lot of advice to stop drinking because when he drinks he becomes more intolerant.I try a dialogue to make him aware that he could explain his point of view by speaking more slowly, building a lighter relationship, only then we can reconcile our relationship.I explain that everything can be resolved by talking and that only without violence we can live a peaceful and happy life (DSC 4 -E2, E7, E8, E9, E16, E19).

Central Idea 05 -Social support: family and institutional support
Another strategy defended by Folkman and Lazarus 10 is related to social support, which includes information-based support, which is a positive psychosocial factor.In this sense, the discourses revealed the family and institutional support as elements that favor the confrontation of domestic violence.

Central Idea 5A -Family support
The speeches demonstrate the importance of family support to make the decision regarding divorce, as well as to enable women to be secure in maintaining their basic needs (shelter and family livelihood).Family care is also observed with regard to the protection of the woman, often trying to distance her from the spouse or even confronting him.

Central Idea 5B -The institutional support
Considering the several demands of women in situation of domestic violence, the discourse also revealed that they seek support in health, social, and legal-police services.
I was very depressed, until I could only think about killing myself and only then I decided to look for a psychologist.During our conversation, she asked me about several things, violence, drugs, and also gave me lots of advice.I also went to the health center because of hypertension, because I always had a headache after fighting with him.There I was assisted by a doctor who identified the beginning of a depression.He told me no to stay home all the time, not to isolate myself, seek help from my family and, especially, hide objects that made me want to commit suicide.[...] only after six years of suffering I pressed charges against him.At the hearing, the judge scolded him and issued a preliminary injunction for him not to approach me.After the divorce, he would not give me money to support his son and I started to get food at the CRAS and I even went to a lawyer in the city hall to sue him.Only then he was obliged to register the son and to pay child support (DSC 5B -E1, E2, E3, E4, E5, E8, E9, E10, E11, E13, E14, E16, E17, E18).

DISCUSSION
The study showed that women involved with alcohol and/or other drugs, when inserted in a marital context permeated by violence, use as a coping strategy the acceptance of accountability, defended by Folkman and Lazarus, 10 which happens when the woman believes that she is responsible for the stressful event and, given the situation, tries to re-signify it.For decades, the understanding that women were responsible for violence was shared even in the courts when, in arguing for 'legitimate defense of honor', men were cleared of aggression or even femicide. 12his perception was also pointed out in a study carried out in Uganda, which findings indicate that men and women connect the aggressions to the women's posture, such as: neglecting to take care of children; not preparing the food; denying sex; leaving without the permission of the spouse or contesting him in public. 13he fact that the woman does not dedicate herself to the partner and/or does not take care of the domestic tasks was also recognized by family members of women in situations of violence as justifiable reason for aggression. 145][16] It was also noticed that, anchored in the belief of inadequacy of the woman's clothing, the spouse perpetrates violent acts as a way of controlling them, which represents a symbolic and imperceptible violence Dealing with domestic violence Carvalho MRS, Oliveira JF, Gomes NP, Campos LM, Almeida LCG, Santos LR in the female imaginary. 17Thus, gender asymmetry, which feeds the social beliefs of women being seen as the property of men, "empowers" them to "educate" women even if they have to use violence. 14till in the light of gender, as a category of analysis, the study points to the social construction of "being a good husband", since the discourse illustrates its root in the idea of the man provider.The research corroborates showing that men are responsible for tasks and activities related to making family decisions, paid work, and providing to the family. 12This explains why the provider spouse, although an aggressor, is socially perceived as a "good man" 14 , a situation that makes it difficult for women to perceive themselves as experiencing violence.
Considering the social construction of gender, it is necessary to point out that the accountability of the aggression suffered does not necessarily represent an action that objectifies the confrontation of the stressor. 4,10However, studies with women in situations of violence indicate that this behavior of passivity minimizes exposure to violence, 15,18 since they reduce domestic conflicts.However, this female posture does not annul violence and favors the permanence in the abusive relationship, often in long years of suffering, according to a research conducted with African-American, Caucasian, Latin, and Native American women. 14,18he women's insistency in the relationship permeated by violence has repercussions on irritability, sadness, and loneliness, as revealed in the speeches.In this context, the participants tend to use drugs (alcoholic beverages, tobacco derivatives, hypnotic medications, and sedatives) in a process to escape from reality, control the emotions and/or in response to illness due to violence, as pointed out in a study carried out in Brazil, Nigeria, and Italy. 14,15,19In Folkman and Lazarus' classification, 10 this strategy represents a way for women to seek, by virtue of a stressful event, the self-control of their feelings and actions.
That is because the use of drugs has effects on the body, such as: feeling of relaxation, well-being, joy, and decreased anxiety.These effects may, in some cases, minimize the consequences of aggressions, mainly due to the feeling of well-being, even in the face of evidence of association with violent episodes. 20owever, studies in the world recognize that some substances, such as alcohol and crack, may exacerbate irritability, predisposing to situations of confrontation with the stress factor. 9,21Thus, although initially used to reduce stress from domestic violence, alcohol also appears as a trigger for anxiety and aggression.
The confrontation, a strategy that also emerged in the discourse, is revealed in the scenario in which the woman adopts the role of confronting the spouse as a way of coping with violence, regardless of whether or not she is consuming some kind of drug.By being configured sometimes as a hostile and aggressive response to the situation of omission experienced, 10 confrontation can intensify violence.In this regard, the study reveals that women confront the disrespectful attitudes of the partner by refusing to accept the private jail, refusing to sleep together, or even fighting back the aggressions.However, the confrontation may represent more female exposure to more severe forms of violence, including death. 15,17iven the gravity of this problem, it can be inferred that confrontation and hostility serve as non-pacific strategies for coping with domestic violence. 10In this perspective, it is necessary to create spaces that promote female reflection on the risks of the coping strategies adopted, as well as peaceful but effective means of negotiating marital conflicts.In this sense, this study showed the dialogue as a method of conflict mediation that values the culture of peace and respect, understood as a strategy of planning and problem solving through sharing of ideas. 10Thus, through dialogue, it is proposed that couples identify alternatives to facilitate communication, ease discord, and end violence in the interpersonal relationship, according to a study that understands dialogue as a way of reaching consensus and avoiding violence. 4lthough genuinely peaceful, the divorce, strategy also revealed in the study, can be configured as a risk of death. 22Although divorce is among the main forms of coping with domestic violence chosen by women in Canada, 23 this has been a risky decision, given the increased risk of aggression and femicide in this period. 21This phenomenon, rooted in gender inequality, is based precisely on the socially naturalized belief that men own women. 17In view of this, it is necessary to implement concomitant strategies for coping with domestic violence, which can be articulated with the support of families and institutions, as indicated by the participants.
Family and institutional support is also defended by Folkman and Lazarus. 10Regarding family support, this can act as an emotional and financial support for ending violence 14,17 whereas, in its absence, it may be a reason for the woman's permanence in the violent relationship. 24A study in Mexico showed that the family is not always a positive support in situations of domestic violence, which causes women to seek support only from formal institutions, 23 which meet the social, legal-police and health demands.In this regard, in the United States, a research reveals that professional support encourages women to engage in more active coping strategies. 18pecifically in the health sector, there are women with physical injuries, caused by direct aggression, to situations of depression and suicidal behavior, resulting from the somatization of their experiences. 6However, a research carried out with health practitioners reveals that some of them act inadequately, such as: calling the police, stating that the woman is also responsible for the situation, and preparing an expert report. 25Considering this context, nurses who work in obstetric or emergency care recognize the need for a differentiated approach to the care of women in situations of violence, especially in relation to listening and qualified care. 26egarding social demands, the isolation caused by domestic violence and financial dependence, for example, have been identified as factors that hinder access to health care and legal-police institutions.Other obstacles are: delay in care, lack Dealing with domestic violence Carvalho MRS, Oliveira JF, Gomes NP, Campos LM, Almeida LCG, Santos LR of closure, and experiencing humiliations. 27This context refers to the need for professional preparation to improve the care of these women, especially in order to support these women in their demands and empower them to get away from the violence. 16o this end, researches carried out in Spain and Angola point to the importance of training on the matter in order to sensitize professionals and health care managers. 16,23uch actions should lead to the understanding of the social construction of gender, which leads to the acceptance of violence as something natural of the marital relationship; to reflection on the non-resolving nature of drug use, even if initially and punctually alleviate their emotional pain; as well as for the encouragement of dialogue as a peaceful method of conflict resolution, especially considering that, according to the collective discourse, women sometimes confront their partners also in a violent way.
Given the above, it can be inferred that the identification of coping strategies from the proposal of Folkman and Lazarus 10 enables the delineation of care actions.Regarding this, the research that approached the use of the Strategies Inventory of these authors in Brazil already indicates the applicability of this strategy in the different health follow-ups, including clinical practice. 28Its use in Primary Health Care, especially in the ESF scenario, enables health practitioners, mainly nurses and physicians, to target interventions to fight against aggravations, such as the domestic violence.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
The study revealed that women in situations of domestic violence and involvement with alcohol and/or other drugs confront their partners, try to dialogue, and seek family and institutional support as coping strategies.Other resources that emerged from the DSC include accountability for the aggression and drug use, which, despite re-establishing the problem and regulating the feelings, do not constitute strategies to end violence.
Although the study is limited because it does not indicate the effectiveness of each of the strategies listed for the participants, the findings show the importance of the assumptions established by Folkman and Lazarus to identify the profile of coping strategies used, which may guide nurses and other health practitioners for care actions, especially in the field of health education.The study also refers to the relevance of intersectoral articulation and professional preparation for the early identification of the problem, as well as to welcome and refer women according to their demands.

FINANCING
PhD scholarship granted to Milca Ramaiane da Silva Carvalho, by the Program for Support of Teacher and Administrative Technician Training of the State University of Bahia (UNEB), from November 2016 to June 2017.
[partner]is full of violence.[...] causes me sadness, insomnia and loneliness!I do not have the strength to react, so I keep my mouth shut, I am silent, and I do not ask anyone for help.Because of this, I started to take sleeping pills, smoke, and drink.I have taken the pills for over ten years.I smoke to fight loneliness and sadness because, even though I live with my husband, I have no one to talk to.It's very sad to feel alone!The reason I drink almost every day is always the stress and the anger.So I drink a lot to try to relax, forget about the problem since I cannot get rid of the violence.In the end, I take the medicine, smoke, and drink because I know they keep me quiet and help me to tolerate this situation[of violence]