Group interventions with low-income African American women recovering from chemical dependency

Return-path: Received: from jaguar.mail.utk.edu (jaguar.mail.utk.edu [160.36.0.84]) by tiger.mail.utk.edu (iPlanet Messaging Server 5.2 HotFix 1.12 (built Feb 13 2003)) with ESMTP id <0HJ2003SD1BYDJ@tiger.mail.utk.edu> for dpatter2@ims-ms-daemon; Sun, 03 Aug 2003 13:45:34 -0400 (EDT) Received: from pqdmail1.umi.com (pqdmail1.umi.com [192.195.245.151]) by jaguar.mail.utk.edu (8.12.9/8.12.9) with ESMTP id h73HjWrL021056 for ; Sun, 03 Aug 2003 13:45:32 -0400 Received: from msub1 (msub1.umi.bhowell.com [165.215.65.94]) by pqdmail1.umi.com (8.11.6/8.11.6) with SMTP id h73HNu718822 for ; Sun, 03 Aug 2003 13:23:56 -0400 Date: Sun, 03 Aug 2003 13:45:26 -0400 (EDT) From: ProQuest Subject: Group-CD and African American Women To: dpatter2@utk.edu Message-id: <114227496.1059279354.9439@proquest.com> MIME-version: 1.0 Content-type: MULTIPART/MIXED; BOUNDARY=+++++++++++++1059932726+++++114227496++++++++ X-Virus-Scanned: by amavisd-milter (http://amavis.org/) X-Spam-Status: No, hits=3.5 required=100.0 tests=HTML_00_10,HTML_FONT_BIG,HTML_MESSAGE, HTML_TABLE_THICK_BORDER,MIME_HTML_NO_CHARSET version=2.54 X-Spam-Level: xxx X-Spam-Checker-Version: SpamAssassin 2.54 (1.174.2.17-2003-05-11-exp) Original-recipient: rfc822;dpatter2@mail.utk.edu This message is in MIME format. You are seeing this message because your Email reader does not understand MIME format. Therefore, some or all of this message may not be legible. --+++++++++++++1059932726+++++114227496++++++++ Content-Type: text/plain; charset=us-ascii The following article has been sent by a user at UNIVERSITY OF TENNESSEE LIBRARY via ProQuest, an information service of the ProQuest Company Your formatted ProQuest document is enclosed. --+++++++++++++1059932726+++++114227496++++++++ Content-Type: text/html; name="2043655661_1.html" Group interventions with low-income African American women recovering from chemical dependency

Group interventions with low-income African American women recovering from chemical dependency
Health & Social Work
Silver Spring
May 2003

Authors:	Olivia G M Washington
Authors:	David P Moxley
Volume:	28
Issue:	2
Pagination:	146-156
ISSN:	03607283
Subject Terms:	African Americans Women Drug abuse Group therapy

Abstract:

This article presents findings from an investigation of two group therapy modalities involving 93 women who were generally single, with dependent children and limited education and income levels. The article presents an overview of intervention activities that participants found beneficial. Although the group interventions warrant additional rigorous evaluations, these programs helped participants develop a sense of community, reduce stress, identify and minimize gaps between current circumstances and potential positive outcomes, and improve self-efficacy and the ability to think positively.

Copyright National Association of Social Workers, Incorporated May 2003

Full Text:

Key words

chemical dependency

group work

intervention activities

residential treatment

women in recovery

Addiction to drugs affects women from diverse cultural, ethnic, and socioeconomic backgrounds. These women can experience serious consequences as a result of substance abuse, with treatment complicated by physiological, psychological, and social concerns. Female cocaine and heroin users appear to develop a dependency to substances much sooner than their male counterparts (Goldberg, 1995). Women also are more likely than men to suffer greater negative consequences, in part, because of their physical reaction to chemical use and addiction and greater stigmatization and negative social reactions (Manhal-Baugus, 1998).

Women use most of the amphetamines and antidepressants prescribed in the United States (Davis, 1990; United Nations International Drug Control Programme, 1997) and are more likely to use prescription drugs for nonmedical reasons (Blumenthal, 1998). In addition, more than two-thirds of AIDS cases that occurred among women were drug-related. Effects of drug dependency on low-income women from ethnic minority groups can be devastating, because chemical dependency is frequently an ineffective attempt to cope with oppressive conditions in their lives. Once dependency develops, these women suffer even greater discrimination (for example, economically, socially, and psychologically; Washington, 2000). With increasing numbers of women of childbearing age becoming addicted to cocaine, the cost to women's health and productivity can be substantial.

Although many approaches to the treatment of substance abuse exist, group work is particularly promising because it can integrate different treatment strategies to achieve social support, skill development, and role change (Manhal-Baugus, 1998; Van Den Bergh, 1991). In particular, group work can establish a context in which participants learn new coping skills using didactic techniques, role modeling, and information sharing. Group work may be especially relevant to women who cope with addiction, because it can decrease isolation and increase support by fostering interaction, affiliation, and social involvement among group members (Marshal-Baugus). It can help motivate participants to acquire skills needed to resolve personal and family issues that can undermine recovery.

Recovery- focused group work must be flexible and robust enough to help participants negotiate discrete phases of recovery to confront and resolve social and legal issues, secure roles and resources that increase their functioning, prevent relapses, and facilitate their economic independence. Longterm substance abuse gradually disempowers women and induces learned helplessness that makes those who struggle with recovery decide that they cannot be successful in their efforts to eliminate substances from their lives. Group work can be used to empower women by increasing their general and specific self-efficacy in life domains (that is, parenting, self-care, vocational development, and employment) in which successful outcomes are particularly important to the achievement of substance-free lifestyles.

Although group work appears to be an important approach to the facilitation of recovery, it may not be apparent which group intervention activities actually contribute to recovery. Practitioners need to examine practices or intervention activities that can produce important recovery outcomes and understand types of group work that participants find useful and supportive in recovery. Thus, practitioners involved in recovery-focused group work may find the discussion of effective recovery-focused interventions relevant to their work. Although all interventions may not be relevant to a particular group, treating activities as modules can allow their inclusion or exclusion as practitioners assess contributions that these activities can make to their work. By combining these modules into group work models that address different phases of recovery, various needs of group members, and diverse social issues, interventions can be effectively customized to address particular proble! ms with substance abuse. For example, women who struggle with poverty and unemployment and face challenging child care and family responsibilities may require different modalities of intervention than either men or women who experience different circumstances.

We used a research and development strategy involving the design and use of two group modalities and focused group intervention activities to illuminate their potential contributions to recovery-based group work. Our objective was to consider experiences of group work participants that used these modalities and activities and identify promising techniques that warrant more rigorous evaluation for use with this population.

BACKGROUND AND THEORETICAL PERSPECTIVE

Group therapy and group work are among the most common modalities used in substance abuse treatment (Lenihan, 1995; Matano & Yalom, 1991), and various group modalities have proven to be effective, economical, efficient, and practical in providing support to people who can easily become isolated (Stuart & Sundeen, 1995). Also, group work is appropriate for women with diminished status because of their "other-ed" and outsider positions that include dual ethnic and gender statuses that can amplify social rejection and discrimination (Pack-Brown, Whittington-Clark, & Parker, 1998).

Group work can facilitate the formation of alternative learning communities in which women come to reflect on their lives, the dynamics of their addictions, and how to overcome the factors that threaten recovery (Lee, 1989). Groups form a context that enables their members to learn from one another, and, as a result, participants can obtain a vicarious understanding of their situations and of their own issues by hearing and listening to others. Participants can take advantage of a number of factors relevant to recovery, including a safe place to share what they view as stigmatizing behavior, test and evaluate new behaviors, and expose personal issues to stimulate feedback from others to resolve these issues. In addition, group work can bring assumptions, thoughts, and feelings that may be outside of immediate awareness into consciousness to act as catalysts for action (Washington & Moxley, in press). Participants can effect behavioral change by learning to think in mo! re empowered ways, reducing excessive emotional reactions, and overcoming self-defeating behaviors (Beck, Wright, Newman, & Liese, 1993).

Group work also can offer a conduit through which chemically dependent women can achieve such important proximate treatment outcomes relevant to the realization of recovery. For people who experience sustained oppression to obtain the resources they need and desire, empowerment suggests that they must proactively resolve and overcome challenging situations, engage in persistent and prolonged struggles to gain control over their situations, and escape stigmatizing statuses (Gutierrerz, Parsons, & Cox, 1998). Empowerment is particularly important to individuals who have social characteristics that can undermine their selfefficacy and their willingness to act (Cox & Parsons, 1993). Interventions that seek to empower people also can heighten their social awareness and personal understanding of what creates negative outcomes (GlenMaye, 1998).

Empowerment requires that people increase and strengthen personal efficacy, which enables them to take advantage of opportunities, overcome challenges and barriers, and establish new roles (Bandura, 1997). Group work can foster effective social interaction, and such interaction can be structured to create empowering experiences. Bandura identified four important sources of selfefficacy that can be vital to helping people coping with long-term substance abuse begin to take control of their recovery:

(1) vicarious experiences designed to change self-defeating beliefs by helping group participants compare themselves to role models and reflect on how these role models overcame challenging circumstances to achieve success despite factors that could have easily defeated them.

(2) emotional arousal, which can heighten group participants' awareness of self-defeating feelings, facilitate their expression of these feelings, and stimulate their resolve to act in new ways. The probability that group members will follow through with behavioral change may be increased when women learn to use

(3) verbal persuasion to engage in recovery. Through these efforts participants can establish new expectancies for success by

(4) practicing new ways of behaving and performing that allow them to accumulate evidence validating their ability to change.

We noted a fifth source of self-efficacy relevant to empowerment, witnessing life history events that lead to decisions to disengage from self-destructive activities such as substance use. Substance use is not initiated and maintained in a vacuum, and many women who turn to this lifestyle may endeavor to cope with past and current traumatic events. These events may include physical and sexual abuse, poverty and deprivation from a very young age, the absence of work and income, and discrimination. A recovery group can provide a context in which healing begins as participants witness each other's personal experiences and the negative psychological consequences the experiences produce. Witnessing these events and their personal toll can stimulate self-reflection and help participants reconsider their life directions. Using new frames of reference, participants can learn to identify and understand nonproductive, and even self-destructive, adaptations they may have made to neg! ative events.

From a theoretical perspective, using these five sources of self-efficacy to structure relevant group activities can provide powerful tools for fostering recovery (Walker, 2001). By integrating sources of self-efficacy, behavioral, affective, cognitive, and life history domains, participants may be more likely to initiate sustained action that long-term recovery requires of people coping with substance use (DiClemente, Prochaska, & Gilbertini, 1985).

Traditional concepts of recovery defined the process of change as movement of people through discrete stages of precontemplation, contemplation, preparation, and action. This movement may be punctuated by loss of motivation, negative expectancies for success, and relapse; all of which people can overcome as they learn to think, feel, and act in new ways (Prochaska, Norcross, & DiClemente, 1994). Incorporating the five sources of self-efficacy into the recovery career may be an important strategy to empower women from ethnic minorities who are coping with chemical dependency as they learn to embark on and sustain drug-free lifestyles. Identifying promising group interventions based on these sources of self-efficacy may offer an appropriate direction for research and development activities that focus on recovery facilitation.

METHOD

Participants

Ninety-three women volunteered to participate in two similar, but independent, research projects. Group members in both investigations were predominantly African American women exposed to similar treatment conditions (cognitive-behavioral and experiential) provided in the same settings, and conducted by the same group facilitator. The groups were conducted more than a year apart, with new members included in each cycle.

The sample for the first treatment cycle included 52 women who had a mean age of 32.7 (SD = 5.3) years. Twenty-seven (51.9 percent) of these women volunteered for the cognitive group, and 25 (48.1 percent) composed the experiential group. No differential dropout of the treatment groups occurred in the first study. Fifty-three women volunteered to participate in the second treatment cycle; 41 of them completed all sessions and pre- and posttesting. The women had a mean age of 34.5 (SD = 5.2) years, with 24 (58.5 percent) of them volunteering to participate in the cognitive group and 17 (41.5 percent) assigned to the experiential group. Twelve women dropped out of this study, including five from the cognitive group and seven from the experiential group. (See Table 1 for a demographic description of the women in the two treatment cycles who completed all testing and participated in all sessions. Women in the wait-list control group were included among participants in the sec! ond experiential group.)

Criteria for participants' inclusion in the study were living in a residential inpatient treatment setting for recovering chemically dependent women, speaking and reading English at a sixth-grade level, receiving treatment for a minimum of 10 days, and having no additional psychiatric diagnoses. Informed consent was obtained from all prospective participants, who thereafter received their group assignments. For each cycle of research, no statistically significant differences were found between the groups on demographic variables. Demographic characteristics of the study participants appeared to be consistent with those of the populations where the research was conducted.

[IMAGE TABLE] Captioned as: Table 1.

Treatment Settings and Overview of the Group Work

Three urban, nonprofit, residential inpatient treatment programs linked to community-based services and supports for chemically dependent women were used in both studies. Generally, 20 to 40 women were in treatment programs at any time, with lengths of stay ranging from less than one month to as long as two years. Because our group interventions were not intended to be primary treatments for helping participants become substance free, the length of time in recovery was not considered essential to the present research. Residential inpatient treatment facilities have policies regarding the confidentiality of their residents' treatment programs. Thus, information regarding participants' progress in becoming recovering substance abusers was unavailable.

Both studies used two group modalities (cognitive-behavioral and experiential therapy) and sought to augment self-efficacy using five sources-- vicarious experiences, verbal persuasion, performance accomplishments, emotional arousal, and witnessing. The cognitive-behavioral condition used a structured time-limited approach focused on changing behavior by changing faulty thinking. The experiential condition was less structured and focused on members' establishing the direction for work on self-awareness, personal issues, and changing attitudes. This treatment modality encouraged the expression of feelings and enhancement of personal growth through sharing experiences. To ensure consistency across the groups, a facilitator's manual detailing treatment protocol was used to guide each group treatment approach.

This article reports on five of several intervention activities used in the groups: (1) engaging in gestalt exercises; (2) sharing prayerful homework; (3) reflecting and discussing powerful stories about women role models; (4) reflecting and discussing successful African American women, incorporating the use of photographs; and (5) analyzing and discussing visual art to promote reflection associated with change inherent in recovery.

The use of gestalt exercises encouraged experiential group participants to increase their awareness and source of their feelings and to integrate their polarities. Reflections on prayerful homework encouraged cognitive group participants to share stories of experiences and concerns. Members of the cognitive group also were shown pictures and read stories of some pre-eminent women who have made a difference in society (for example, Leontyne Price, Toni Morrison, Janet Powell, and Marva Nettles). Members discussed how the women had overcome adversity to become role models for people who wanted to make a difference in their worlds. During the discussions, the women told stories oftheir own adversity and how they planned to move forward in mastering their substance abuse and become productive members of society. Visual art was used in the second cycle of the experiential group to engage emotions and enhance participants' awareness and verbal self-expression without being over! whelming. The paintings allowed the women to focus on personal issues and bring their polarities into awareness, where they could be explored and discussed.

Design

We used a quasi-experimental design with pre- and posttest assessment in the first research cycle. The order of group offerings was staggered to counterbalance the treatments and diminish crossover contamination. The cognitive intervention was offered first. In the second research cycle, the methods developed during the first cycle were modified and further tested using an experimental design with pre- and posttesting. Participants were randomly assigned to the two types of therapy (cognitive and experiential) or to a wait-list control group. Because the number of women available to participate in the study was limited, treatment interventions were conducted sequentially rather than simultaneously. The cognitive intervention was provided first, with the control group pre- and posttested at that time. After completion of the cognitive interventions, experiential interventions were held at the three treatment sites and included a combination of women who participated in the! wait-list control group and women new to residential treatment centers.

In the first research cycle, the quasi-experimental group intervention lasted three weeks and included six, 90-minute sessions conducted at two of the three urban residential inpatient treatment sites for chemically dependent women. The second research cycle lasted five weeks for both conditions and included 10, 90-minute sessions conducted at all three urban residential inpatient treatment sites for chemically dependent women. All group strategies and activities used in the initial cycle of research were repeated in the second cycle with the addition of a visual art component to the experiential condition to facilitate self-expression (see Table 2). In both cycles, qualitative data were collected on participant's perceptions of self-reported benefits and personal changes that resulted from group participation.

Through reflective narratives (for example, unstructured interviews and anecdotal comments) during the sessions, group members described benefits derived from group interventions and perceptions of changes they experienced that resulted from their participation. To identify group benefits, participant perspectives were incorporated into a database, with Ethnograph Version 5.0 (Seidel, 1998). The analysis provided information on discreet benefits that participants identified in unstructured interviews during group therapy. We used these data to identify promising group work practices to foster recovery. The positive effects of these practices are preliminary and require additional testing to establish their effectiveness.

RESULTS

[IMAGE TABLE] Captioned as: Table 2.

Benefits of Group Participation

Helping participants, particularly those in the experiential groups, "calm their spirits" was a principal aim of group work. This focus was designed to help members experience catharsis through the reduction of emotionality as a starting point for personal change. Calming their spirits provided an enabling condition to facilitate personal change by helping participants express pent-up feelings, which were often the result of negative consequences associated with long-term drug use. Before group therapy, many participants were reluctant to share their feelings with others. This process was described as taxing and draining, leaving group members unable to cope with other stressful circumstances encountered in their daily lives. Participants tended to express these feelings through negativism, cynicism, and hopelessness.

Twenty participants identified benefits they derived from "calming and releasing energy." One participant said that she "learned to work on troublesome problems without becoming hostile and losing control." Another participant emphasized the benefit of learning to clarify her own perspective in situations and label feelings in addition to expressing them. The usefulness of the group experience in helping participants engage in catharsis as a direct benefit of calming and releasing energy is important. Catharsis may be a crucial feature of the recovery process because it helps individuals unburden themselves, redirect their energy, and open their perceptions. Many participants had limited practical and emotional support available to them. Consequently, the group experience helped some participants connect with other group members and share their prior experiences, intimate emotional traumas, and negative feelings about themselves.

Twenty participants identified decision-making benefits. As one participant emphasized, "I learned to weigh good and bad points before making a final decision." Another participant noted that the group experience helped her "analyze a reaction or situation to the fullest." Insight was a principal benefit that participants considered important. These women generally concluded that they obtained more insight into themselves, their life aspirations, and their present situations. One participant reflected on bow the group experience helped her understand herself and explore areas she had formerly suppressed. The group experience helped another participant "realize that it was not too late to improve [her] life and do something with it." Other participants said that the group experience gave the women time to get to know themselves. Much of women's success is based on knowing themselves ". . . getting some balance in [their] lives.. keeping problems from getting the best of th! em.

Twenty-seven participants identified benefits of confronting chemical dependency by addressing denial, confronting their fears, or engaging in reasonable risk taking to change their lifestyles. Participants who identified "confronting their feelings" perceived that the group helped them deal with denial of their chemical dependency and the life style it fostered. They perceived the group as a safe environment for confronting themselves. One participant captured the flavor of this benefit, noting:

"It helped me to confront myself and the issues and feelings rather than run away from them. I got more courage out of the group, but most of all I learned how to confront painful feelings."

Participants who indicated that a principal benefit of their group involvement was "cutting through denial" identified the important role of group interventions. The framing of this benefit was somewhat different from framing benefits described as "confronting one's feelings." "Confronting fears" as a benefit suggested that more than a few of the women genuinely feared leaving their comfort zone by moving into the world, facing responsibilities, and improving their circumstances. One woman noted that the group helped her recognize that she was afraid of many things. Another participant emphasized the value of the group in helping her participate socially, saying: "I'm no longer afraid to go out, be among people, and ask questions. I can ask my children how they feel. I can ask them if they want to go with me or not."Another woman who indicated that she was better able to take reasonable risks and try new roles said, "I'm not being afraid to go for job interviews. Before t! he program I would have hesitated, fearing the outcome. I [now] risk chairing AA meetings. The group program helped me to get courage and not be afraid."

Promising Practices

Although the activities used in the two group modalities differed in the ways they helped women with substance dependency, each activity made distinctive contributions toward recovery. In particular, five intervention activities offered promise in facilitating recovery of women coping with long-term substance use, because each activity incorporated several sources of self-efficacy identified as important to empowerment:

1. Use gestalt experiments to facilitate expression of feelings, awareness regarding involvement in substance use, as well as identification and integration of synergistic solutions in their lives.

2. Engage in prayerful homework, meditating, and sharing prayers to facilitate participants' catharsis, clarification of values, and commitment to personal priorities.

3. Incorporate powerful stories of women role models through guided inquiry to frame lifestyle change and motivate personal change.

4. Reflect on and discuss photographs of successful African American women to motivate personal change and enhance positive expectancies about change potential.

5. Analyze and discuss visual art to promote participant reflection about changes inherent in recovery.

Using Gestalt Experiments. Members of the experiential group completed three gestalt activities (two sentence-completion and one top-dog/underdog exercises; Thompson & Rudolph, 1992). During one sentence completion activity, members filled in sentence blanks by reflecting on their feelings and the percentage of responsibility they were willing to assume for their feelings. For the second sentence-completion activity, participants recorded how they both help and hurt themselves. Examples of these respective activities are:

"Right now I am feeling lonely and vulnerable and take 70 percent responsibility for how I feel"

"I also take 50 percent responsibility for the way I manage my life."

"I help myself when I am being productive and focused."

"I block or hurt myself when I feel I'm not being trusted and I feel lonely."

Participants in the top-dog/underdog debate were divided into two subgroups. Members of the topdog group listed reasons for engaging in certain tasks or behaviors (that is, remaining clean, being better parents), with underdog group members listing reasons for engaging in other tasks or behaviors (that is, desiring to reunite their families, gaining custody of their children, being happily married). Compiling and discussing lists led to spontaneous discussions among participants endeavoring to reconcile gaps between what they thought they should and wanted to do.

Engaging in Prayerful Homework and Meditation. Participants were asked to compose a prayer and share it at a group meeting. Qualitative analysis of these prayers suggested that they helped participants engage in quiet reflection. Prayers and attendant meditation provided a calming effect and encouraged participants to contemplate, which many participants found physiologically and emotionally comforting.

Most prayers revealed participants' concerns: finding new life directions, caring for their children, mourning the loss of health, and obtaining jobs, housing, and income. This intervention appeared to draw from participants' spirituality and deeply held religious beliefs. One participant noted that prayerful homework enabled her to "get closer to her spirit.'

A salient area of prayerful reflection related to participants' family life and raising their children. The prayers reminded a participant of what was important-her children's well-being and "right" to a drug-free mother. Because of their chemical dependency, some participants expressed grief about loss of their children or their need to make up for lost time with them. The intrusion of social control was very real for these women given changes in federal entitlement programs and the state of Michigan during the latter part of the 1990s regarding child welfare policies, chemical dependency, and income support. New laws require recipients of Temporary Aid to Needy Families (TANF) to obtain employment within two years of receiving benefits and limit benefits to five years over the course of an adult's lifetime. The women also understood that continued substance use could jeopardize their parental status, result in possible loss of their family home and permanent loss of the! ir children if their drug dependence resulted in abandonment of young children (Binsfeld Law, 1997).

Constructing prayers supported participant hopes for attaining their goals of positive employment outcomes. Beliefs of 23 participants were initially expressed as general propositions (for example, getting on their feet, starting to work, becoming motivated, and accepting responsibility for self). In contrast, other participants were very specific about vocations they wanted to pursue: teaching special education students, accounting, real estate/property-management, and retail sales. Prayer, as a cognitive exercise, could heighten participants' awareness of their environment and facilitate ego functions pertaining to perceptions, awareness, and analysis.

Sharing Powerful Stories of People Overcoming Obstacles. Relating "powerful stories" during the group interventions was precipitated by the facilitator who read stories (that is, "Who to Believe," "Just Like You," "And Justice Has Been Served") that emphasized people overcoming obstacles (Canfield, Hansen, Hawthorne, & Shimoff, 1996). After each story was read aloud to participants, the facilitator posed exploratory questions to stimulate group interactions and members' stories. The facilitator asked group members to express their feelings about each story, including the meaning or importance. The facilitator then elicited perspectives about recovery, asking "How did you like the story? What meaning or importance did the story have for you? What pictures developed in your mind as I read the story?" Two additional questions followed: (1) "What did you hear that can strengthen your resolve to get and stay dean?" and (2) "What was it like for you as I read the story?" Gr! oup members were asked to reflect on these stories and use them to foster introspection into their own lives.

The stories may have provided members a safe forum to develop their perspectives, helped increase their awareness of factors that influenced the use of drugs and fostered addiction, and enabled participants to listen and learn from one another. This narrative technique could be used to facilitate participants' appreciation of common experiences and development of a group identity.

Discussing the Lives of Successful African American Women. Twelve photographs of accomplished African American women, including novelists, scientists, educators, classical musicians, physicians, engineers, and artists, were used to stimulate group discussions about their lives and encourage participants to share their conjectures about how these women overcame societal barriers. At the end of the group session preceding their use, the pictures were shown to the group members, and group members were asked to select a woman they wanted to discuss at the next meeting. At that session each member was encouraged to lead a discussion about her selected woman's accomplishments and the barriers she had overcome to attain her goals. To facilitate this process, members were given a brief synopsis of the women's lives.

In subsequent group meetings, participants led discussions regarding their feelings about the woman in the picture, her perspectives on life, and the relevance for their own lives. These observations stimulated considerable reflection among group participants, with several women describing the importance of the exercise in fostering change, planning for recovery and careers, furthering their education, developing relationships, and caring for their children.

Participants' responses to the photographs often paralleled ideas and themes they incorporated into their personal prayers. Themes dominating their responses centered on children, family responsibilities, and feelings of guilt resulting from exposing their children to an addicted lifestyle. Participants also reflected on how the successful women in the photographs managed their lives. Through discussions of the women in the photographs, participants were enabled to express their perceptions of important normative themes (that is, obtaining employment, managing a household, and rearing children). They also emphasized themes related to overcoming social discrimination and subjugation. Hearing stories and struggles of prominent individuals motivated participants to reflect on their chemical use, current life situation, and how to begin a new life. One participant said:

The first two pictures made me think about the possibility of losing my sanity. Not being able to make any progress and listening to my peer's struggles made me really want my sobriety for myself-not just being clean, but also desiring a whole new life. I want to be able to learn to manage my money, secure stable housing, and learn to be a stable parent to my children.

Exploring Visual Art. The experiential group condition incorporated 15 reproductions of classical paintings to foster opportunities for participants to engage in self-reflection. Few participants had exposure to classical art and its interpretation. The artwork served as a stimulus for self-expression and was useful in helping participants "open up." Group members found the use of art to be a novel, interesting medium through which they could express their perspectives about addictive lifestyles, recovery, and future hopes. Nine participants reported benefits from the experiential group intervention by highlighting the importance of art in their recovery process.

One participant said: "The art made me feel compelled to open up and share what I would normally have suppressed." Another participant elaborated by saying, "The art made me talk about feelings and reminded me of unpleasant things that I would have not shared normally." Participants who were exposed to art reproductions seemed to identify with the fear and anxiety expressed in Munch's paintings, The Scream and Anxiety. Through discussions about these pictures, the women were able to get in touch with these feelings and were able to describe similar fearful or anxious situations related to the world of drugs in which they had lived, as well as difficulties they had with their addictions. Munch's The Scream moved some participants to say, "We don't want to face reality. If we go back that way, its death and if we move forward, we might fail ... What then?" Thematic discussions about Munch's Anxiety expressed the thought that "The people in the background were all dressed up! and yet they appeared to be miserable."

CONCLUSION

This article identified promising practices derived from unstructured interviews with group members regarding the perceived benefits they obtained from their participation. Benefits identified by participants suggested that they were contemplating their recovery and increasing their readiness to engage in substantive changes in their lifestyles and patterns of behavior. Each group intervention was designed to contribute to recovery by helping participants recognize the void that chemical dependency had created in their lives, reflect on pentup emotions they rarely expressed to others, learn to make important life decisions, and decide how to manage their behavior without drugs. This type of self-appraisal can help participants strengthen their commitment to make positive life changes. Taken collectively, interventions presented in this article suggest that development of readiness for change is an important intentional early phase of recovery-based group interventions. Ef! fective group interventions can help participants develop this important resource.

Interventions described as helpful in realizing positive treatment gains can identify gaps between current circumstances and potential positive outcomes of living substance free. The relationship between completion of interventions and the extent to which participants were ready to minimize these gaps requires additional exploration. Members also can develop a sense of community and identify what can reduce stress while increasing their abilities to think positively and become empowered. Thus, benefits that help calm group members also can help them become more receptive to messages regarding the need for personal growth and development as precursors to their substance-free lives.

Although tentative, findings suggest that recovery interventions incorporating sources of self-efficacy may facilitate empowerment of women coping with serious challenges to achieving substance-free lives. Studying groups living in restricted locations may limit the generalizability of findings to chemically dependent women residing in similar settings. During their treatment stays, the women were required to participate in counseling and educational programs, which could have affected their outcomes. Considerable social control was exercised by these facilities. Women in the present study volunteered to participate in these additional interventions that were not part of the typical treatment interventions provided to all women in residential facilities.

Developing specific modules that contribute to increased self-efficacy and a sense of empowerment are important goals of recovery-based intervention research. Rigorous and systematic evaluations of these modules used in group interventions with chemically dependent minority women can determine which practices are most effective in the recovery process.

Original manuscript received September 25, 2001

Final revision received April 27, 2002

Accepted June 25, 2002

REFERENCES

Bandura, A. (1997). Self-efficacy: The exercise of control New York: W. H. Freeman.

Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.

Binsfeld Law. (1997). PA 168 of 1997. Blumenthal, S. J. (1998). Women and substance abuse: A new national focus. In C. L. Wetherington & A. B. Roman (Eds.), Drug addiction research and the health of women (pp. 13-22). Rockville, MD: National Institute on Drug Abuse.

Canfield, J., Hansen, M. V., Hawthorne, J. R., & Shimoff, M. (1996). Chicken soup for the woman's soul. Deerfield Beach, FL: Health Communications.

Cox, E. O., & Parsons, E. J. (1993). Empowermentoriented social work practice with the elderly. Belmont, CA: Brooks/Cole.

Davis, D. J. (1990). Prevention issues in developing programs. In R. C. Engs (Ed.), Women: Alcohol and other drugs (pp. 71-77). Dubuque, IA: Kendall/ Hunt.

DiClemente, C. C., Prochaska, J. O., & Gilbertini, M. (1985). Self-efficacy and the stages of self-change in smoking. Cognitive Therapy and Research, 9, 181-200.

GlenMaye, L. (1998). Empowerment of women. In L. M. Gutierrez, R. J. Parsons, & E. P. Cox (Eds.), Empowerment in social work: A sourcebook (pp. 29-51). Belmont, CA: Brooks/Cole.

Goldberg, M. E. (1995). Substance-abusing women: False stereotypes and real needs. Social Work, 40, 789-798.

Gutierrez, L. M., Parsons, R. J., & Cox, E. P. (1998). A model for empowerment practice. In L. M. Gutierrez, R. J. Parsons, & E. P. Cox (Eds.), Empowerment in social work: A sourcebook

(pp. 3-23). Belmont, CA: Brooks/Cole.

Lee, J.A.B. (Ed.). (1989). Group work with the poor and oppressed. New York: Haworth Press. Lenihan, M. W. (1995). Morning support group: Use

of a triweekly support group in outpatient treatment of chemical dependence [Notes from the Field]. Social Work, 40, 127-131.

Manhal-Baugus, M. (1998). The self-in-relation theory and women for sobriety: Female-specific theory and mutual help group for chemically dependent women. Journal of Addictions & Offender Counseling, 18(2), 78-85.

Matano, R. A., & Yalom, I. D. (1991). Approaches to chemical dependency: Chemical dependency and interactive group therapy-A synthesis. International Journal of Psychotherapy, 41, 269-293,

Pack-Brown, S. P., Whittington-Clark, L. E., & Parker, W. M. (1998). Images of me. Boston: Allyn &Bacon. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C.

(1994). Changing for good. New York: Avon Books. Seidel, J. (1998). The ethnograph: A user's guide (Version 5.0) [Computer Program]. Thousand Oaks, CA: Scolari.

Stuart, G. W., & Sundeen, S. J. (1995). Principles and practices of psychiatric nursing (5th ed.). St. Louis: C.V. Mosby.

Thompson, C. L., & Rudolph, L. B. (1992). Counseling children (3rd ed.). Pacific Grove, CA: Brooks/Cole. United Nations International Drug Control

Programme. (1997). World drug report. London: Oxford University Press.

Van Den Bergh, N. (Ed.). (1991). Feminist perspectives on addictions. New York. Springer.

Walker, J. (2001). Control and the psychology of health. Philadelphia: Open University Press.

Washington, O.G.M. (2000). Four key characteristics of chemically dependent women. African American Research Perspectives, 6(3), 24-34.

Washington, O.G.M., & Moxley, D. P. (in press). Developing psychological readiness for employment rehabilitation among chemically dependent women. Journal of Social Work Research and Evaluation, 4(1).

ABOUT THE AUTHORS

Olivia G. M. Washington, PhD, APRN, BC, NP, LPC, is assistant professor, College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, M148202; e-mail: o.washington@wayne. edu. David P. Moxley, PhD, is professor, School of Social Work, Wayne State University, Detroit. Address all correspondence to Dr. Olivia G. M. Washington. This research was supported by grants from Wayne State University's Humanities Center, Harriet H. Werley Faculty Research Award, Minority/ Women Summer Grant Program, and the University Faculty Research Grant Program.

Reproduced with permission of the copyright owner. Further reproduction or distribution is prohibited without permission. --+++++++++++++1059932726+++++114227496++++++++--