SPIRITUALITY & SEXUALITY: A PROGRAM FOR WOMEN IN RECOVERY

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The author, a sexologist in recovery from alcoholism, was employed by the city government of an eastern metropolis where she inaugurated a program of group therapy called Family Focus. Forty-three African American women volunteered to meet daily for three-hour group therapy. Participants started each therapy group with an Alcoholics Anonymous meetingand closed with discussions of sexuality and spirituality guided by the author. Participants maintained abstinence for over four months until the program was administratively disbanded. Proof of abstinence came from daily urine analyses, including weekends when no theraty groups were held.

Although one finds a paucity of optimism when reviewing the research literature on substance abuse among minority women, there are researchers whose cultural analysis gives their material a less bleak perspective (Levi & Easley, 1999; Davis, 1997). These researchers explicate the cultural context behind the everyday experiences characterizing the lives of women. Other researchers have focused on the special relationships of women, seeking to elucidate how such co-factors as drug usage and partner abuse can impact suicidal behavior (Kaslow, Thompson, Meadowns, Jacobs et al; 1998). Still other researchers have traced the nurturing process by characterizing the ways in which drug-using mothers relate to their dependent children (Uziel-Miller, Lyons, Kissiel & Love, 1998; Boyd, Guthrie, Pohl, Whitmarsh & Henderson, 1994; Oyemade, Cole, Johnson, Knight &Westney, 1994).

One of the most impressive studies in this category (Boyd, Hill, Holmes, Purnell, 1998) studied “life-lines” or turning points (pro and con) in the women's subsequent drug behavior. Three studies hold promise because they offered African American women ways to better understand their behavior by gaining insight into their motivation (Saulnier, 1996; Harris, Bausell, Scott, Hetherington & Kavanagh, 1998; and Boyd & Pohl, 1996).

The author became aware that the reality of her personal life and the values of her professional worker were in conflict. In 1988, during the last part of a seven and one-half year tenure with a public health facility located in the eastern part of the United States, the author recognized her own alcoholism. She joined the fellowship of Alcoholics Anonymous and began a lifelong commitment to the process of personal recovery. After a year in recovery, she was promoted to the rank of special assistant to an administrator who was launching a Women's Center as a specific recovery tool in the administration's alcoholism and drug abuse recovery services. The author obtained permission to launch an innovative approach to group therapy. As a recovering alcoholic, she would lead as well as relate to other women who were recovering from alcoholism and addiction to other drugs by following the daily tenets of the program of Alcoholics Anonymous. She called this approach, Family Focus.

METHODS
Participants were recruited into the Family Focus program the week the Women's Center opened. The author obtained permission to post a sign asking for volunteers who wanted to live in sobriety to meet with her on a daily basis, Monday through Friday, for three-hour sessions in the morning or afternoon. Forty-three women signed up within a single day. The author had planned to have only twenty women in each session; however, during the last hour of registration, three women pleaded to be included. The author was able to have three extra chairs brought into the general meeting room on every afternoon. Thus, Family Focus totaled twenty participants in the morning group and twenty-three in the afternoon session for its duration.

The author served as a participant-observer in every group therapy session of Family Focus. Her presence and participation fostered continuity and illustrated what is meant by spiritual practice — in this case, sobriety.

Participants ranged in age from eighteen to fifty-two. Although a few participants had entered college, there were no graduates and the median level of education was eleventh grade. At the time of the study, 95% of the participants were unemployed. Though less than half the participants were married, more than half of them had children of their own and/or cared for other women's children.

In this qualitative description of the program called Family Focus which took place over a four-month period, three case studies will be presented illustrating the demographics of the forty-three participants.

MONTH ONE
Participants decided within the first two days that a woman who was unable to attend her assigned morning meeting, could attend the afternoon session for that day, reporting to her regular morning meeting on the following day. Surprisingly, participants had a high degree of group identification, seldom exchanging therapy groups. Participants were punctual, arriving early to get the results of their urine analysis since sobriety was the only requirement for membership in Family Focus.

Several women remarked to the Women's Center Director that they felt elated knowing their behavior contributed to the success of the group. The idea of staying sober as a goal for which each participant shouldered her own responsibility engendered a special type of optimism within these women. Most participants developed group loyalty to their therapy group; however, for about a third of the women, early recovery was characterized by self-discovery and a growing sense of individualism they said they had never experienced before.

Almost all the participants commented within the first month on their heightened sensory awareness as well as their as their keener recognition of the variety of emotions they were experiencing. The flatness of the affect which they had become accustomed to feeling, due to the highs and lows of drug usage, was disappearing.

About one third of the participants expressed intellectual curiosity about the drugs that had become the center of their lives — e.g., many admitted not knowing that alcohol is a drug. Discussions about other factual topics such as hygiene led to a desire for more accurate knowledge concerning the ovulation/pregnancy/contraception complex as well as better understanding of STDS, with particular emphasis on HIV/AIDS awareness and prevention because of its prevalence in the African American community.

Participants developed a protocol for the Family Focus sessions. Each therapy session began with an open discussion meeting of Alcoholics Anonymous. The reference for conducting meetings was Alcoholics Anonymous' anonymously written publication, copyright 1939, commonly known as the Big Book. Participants used, or learned to use, the parlance typically found in Alcoholics Anonymous meetings as well as customs such as not interrupting or correcting others. Participants began to compliment each other on their observance of such factors.

After the Alcoholics Anonymous meeting, each session of Family Focus held a discussion on human sexuality and family relationships. Many participants had followed the author's monthly column entitled “Sexual Health” as it was featured in a national women's magazine. Welcoming the opportunity to close each therapy session with a rap session, they simply called it talking about sex.

With a protocol established, participants began to see how the Alcoholics Anonymous slogan “progress, not perfection” represented the tasks they were working out in their therapy groups:

A) learning to hare their intimate problems,
B) developing listening skills, and
C) gaining objectivity by observing the growing coping skills of
their peers.
The author defined the word spiritual as meaning conscious efforts to live a moral life of sobriety — i.e., absence of intoxicating chemicals whether legal or illegal. Recognizing that stopping drinking is merely a prelude to living a sober or spiritual life, the participants sought to incorporate a daily regimen of spiritual practice by practicing the Twelve Steps of Alcoholics Anonymous. Participants recognized this as a process and verbalized the following rules for membership in Family Focus:

1. Participants would abstain from drinking and drugging;
2. Discussing would be about solutions, not problems;
3. Participants would rotate in chairing each therapy session;
4. Participants would address each other by first name only.
A greater sense of maturity in expressing anger and a deeper understanding of the dynamics underlying their behavior both surfaced within the first month of Family Focus. Discussions focused on interpersonal, predominantly heterosexual, relationships ranging from informal dating and live-in arrangements called shacking, to legal marriage and the intricacies of divorce. Throughout the therapy sessions, there was an emphasis on developing and listening to one's own sense of conscience. This barometer regulated the women's most intimate sexual need to achieve parity and respect — within sexual as well as non-sexual relationships — and pertained equally to male/female as well as same sex relationships.

Toward the end of the first month, the challenge of finding the right name for this innovative approach to therapy took on symbolic significance. When the author expressed ambivalence about the name she had chosen, Family Focus, all the participants saw the dilemma: how was the woman supposed to keep the focus on herself, as a woman, when she had spent her life focusing on her family?

MONTH TWO
Participants were asked to bring in a photograph taken while the participants were intoxicated. Participants entered this homework assignment with alacrity, however, merriment was only a transient reaction. When the morning group passed its photos on to the afternoon group, and vice versa, their reactions elicited pain and suffering.

Participants said they had learned the Alcoholics Anonymous dictum, “follow the drink on through”. From the initial picture of a frosty beer on a hot summer night, or an elegant “flute” of champagne held high by a bridal party — participants were able to visualize and verbalize their own alcoholism/drug progression to the ultimately unpleasant scene of throwing up in the women's bathroom and beyond — to a personal journey into drug addiction.

MONTH THREE
Although the topic of childhood molestation had been mentioned continuously, it was during the third month that an intense discussion of the etiology, consequences, and prevention of child sexual abuse took place.

Participants discussed sexual awareness in early childhood and its crucial importance in the formation of their own sense of identity. This was the impetus for many participants' joining an Alcoholics Anonymous home group in addition to the Family Focus therapy groups at the Women's Center. Attending an Alcoholics Anonymous home group signifies greater commitment in one's sense of membership because that is the place one attends on a regular basis. There is a distinct difference between attending an ad hoc, temporary, Alcoholics Anonymous meeting taking place for a limited rime in one's workplace versus joining others who attend, on a regular basis, an established and credentialed meeting in a church or an Alcoholics Anonymous clubhouse. Joining commitment could not be verified by the author; however, many participants said they were led to this commitment because of the discussions on child sexual abuse.

Since the overwhelming majority of participants had themselves been sexually molested as children, discussion of this aspect of human sexuality held great relevance for them. Participants began to better assess their own feelings whether they pertained to hurt, anger, rage, jealously, or joy. This, in turn, led to more fruitful discussion of their need to learn how to establish psychosexual boundaries. Such discussion also clarified, for many participants, how to adopt measures giving greater protection to the youngsters in their charge. The overwhelming majority of the participants voiced appreciation for the opportunity to discuss a topic they had never heard articulated before with respect. The following three case studies were presented as composite summaries of the participants' determination to remain abstinent from alcohol and other drugs.

CASE HISTORIES
ANN, an attractive woman in her late twenties had grown up in numerous foster care facilities. She had only reached fifth grade in Maryland public schools. Ann had been sexually abused often as a child. She was incarcerated often since age eleven for drug possession and solicitation as a prostitute. Her negative outlook on life was expressed in sarcasm. When the author introduced the mirror exercise, Ann scoffed. Participants, seated in a circle, would pass around a small hand mirror. Each person would look into the mirror briefly, as though in greeting, and say “I love you -----” addressing herself by her first name. Ann was the only one of the forty-three participants who could not perform this task. When queried, she replied,

“Look, I know exactly what I've done to myself. How can I say ‘I love you,’ now?”

It was Ann's daily goal to become able to carry out this simple exercise, though she never fully achieved it over the four months in which Family Focus existed. She commented that although it would have been a miracle for her to be able to love herself, and to say it to the group, it was a greater miracle that she had remained clean and sober. Participants used Alcoholics Anonymous parlance by agreeing that this was “the only criterion for membership” in the therapy group. Nevertheless, they urged Ann to try, one day at a time with the mirror exercise serving as additional incentive for her to remain in the group.

BOBBIE, an obese woman with impaired eyesight, was in her late thirties when the group started. Arrested for selling drugs out of her home, Bobbie was more distraught because she had been forced to relinquish her cousin's four-month old baby. The young mother had abandoned the baby after asking Bobbie to “hold him for a few minutes” while she went to the store, but never returned. Childless and never married, Bobbie was surprised to find that she loved someone (the baby) for the first time in her life. When a neighbor asked her to “hold his supplies” as he faced arrest, Bobbie discovered that his cache was drugs. Though she had never used drugs, Bobbie joined the drug culture, reasoning that God had forced on her this moneymaking potential so that she could remain at home and care for the unnamed infant whom she called my son. When the baby was taken away by city authorities, Bobbie was inconsolable — but clung to her therapy group.

CANDY, attractive, intelligent, and a lesbian at age 19 was the youngest participant. Growing up as one of two children in a moderately dysfunctional family, she had attended one year at a private college. She had been arrested repeatedly for drug possession and solicitation as a prostitute. Turned off from alcohol by the excessive drinking of her parents, Candy balked when asked to use the customary Alcoholics Anonymous greeting, “Hello, I'm Candy and I'm an alcoholic” before speaking in-group. She felt it was completely ludicrous since she had never tasted alcohol. The group pointed out that Alcoholics Anonymous language represented any mind-altering chemical or behavior. They told Candy, further, that since she had not yet found a spiritual way to live — in 19 years of searching — perhaps she could learn by adopting the simple Alcoholics Anonymous way of life. The slogan “fake it til you make it” appealed to her pragmatic frame of mind, and she stayed sober to her own surprise.

MONTH FOUR
Approximately midway in the fourth month, the author was informed that Family Focus was to be disbanded by the city governmental authorities. No explanation was given despite the authors attempts to document the merits of this unprecedented approach to group therapy. The exemplary record of the participants' abstinence from alcohol and other drugs for a four month period of time was a matter of official clinical recordkeeping, unparalleled in the history of the city's drug abuse programs. The author was at a loss to interpret this decision, but found solace in the resiliency of the participants. The discouraging news was received by the participants as a frontier to cross rather than a cause for resentment. Participants said the dissolution of Family Focus was a challenge to them to show tough love.

RESULTS
In their last session, participants asked the author to record the key ideas they had learned — supplemental to — but in no way supplanting the Twelve Steps of Alcoholics Anonymous. The author called these statements spiritual practice for they could only have been forged in the crucible of each woman's daily living. These guidelines are presented as a personal credo:

Group Pledge:

As a spiritual being having a human experience, I choose to live DRUG-FREE one day at a time.
I am responsible for my thoughts and behavior.
I will attain and maintain the best health I can — physically, mentally, and spiritually.
I release myself and others from daydreaming about tomorrow.
I ask God's forgiveness for the errors of yesterday — what I did to myself first of all — and what I did to others.
DISCUSSION
The participants' sustained level of 100% cooperation meant all remained abstinent during the four months that Family Focus was in effect. None of the 43 participants was ever rejected by her therapy group since chemical abstinence, including alcohol, was the only criterion for membership. The program was an unqualified success, unprecedented in any of the city's treatment programs. The undaunted courage of the participants looms large not only in interpreting the results, but gives hope to future researchers seeking to shed light on women's recovery issues.

The chief advantage inherent in the author's participant-observer role was that it minimized the social distance between her and other group members. Being in recovery brought them together in purpose and in deed. She was less aware of blind spots (clinical disadvantages) inherent in her role. Hopefully, future researchers will explore the parameters of this methodology. It would be helpful as well as interesting to determine whether group cohesion is attenuated if the leader is not herself in recovery from alcohol and/or other drugs. FT.-The chief limitation of this study was the lack of documentation available. Had recording devices been allowed, the author would have been better able to monitor the turning points in group dynamics more accurately than was possible from memory.

Another discernible limitation of the study was the lack of follow-up on the participants. Although the author no lone lives in the same city, her repeated inquiries have yielded no information on subsequent follow-up measures. Because of the stringencies placed on people in recovery to respect the anonymity of others, there is little follow-up done on recovering people. FT.-For these reasons, the author is currently interested in research related to stigma reduction (lack of anonymity) for recovering people. The author encourages others, particularly researcher who are in personal recovery from chemical and behavioral addictions, to explore how they may participate in — and benefit from — similar research.

REFERENCES
Boyd, C.J., Hill, E., Holmes, C., Purnell, R. (1998). Putting drug use in context. Life-lines of African American women who smoke crack. Journal of Substance Abuse Treatment, 15 (3) 235–49.

Boyd, C.J., & Pohl, J. (1996). Nicotine and alcohol abuse in African American women who smoke crack cocaine. Journal of Substance Abuse, 8 (4) 463–9.

Boyd, C., Guthrie, B., Pohl, J., Whitmarsh, J., & Henderson, D. (1994). African American women who smoke crack cocaine: sexual trauma and the mother-daughter relationship. Journal of Psychoactive Drugs, 3, 243–7.

Davis, R.E. (1997). Trauma and addiction experiences of African American women. Western Journal of Nursing Research, (4) 442–60; discussion 460–5.

Harris, R.M., Bausell, R.B., Scott, D.E., Hetherington, S.E., & Kavanagh, K.H. (1998). An intervention for changing high-risk HIV behaviors of African American drug-dependent women. Research in Nursing Health, 21 (3) 239–50.

Kaslow, N.J., Thompson, M.P., Meadowns, L.A., Jacobs, D., et al (1998). Factors that mediate and moderate the link between partner abuse and suicidal behavior in African American women. Journal of consulting Clinical Psychology, 66(3) 553–40.

Levi, D.B., & Easley, C. (1999). African American women and substance abuse: an overview. Journal of Cultural Diversity, 6(3)102–6.

Oyemade, U.J., Cole, O.J., Johnson, A.A., Knight, E.M., Westney, O.E., (1994). Prenatal substance abuse and pregnancy outcomes among African American women. Journal of Nutrition, 124 (6 Suppl) 994S-999S.

Saulnier, C.F. (1996). African-American women in an alcohol intervention group: addressing personal and political problems. Substance Use/Misuse, 31 (10) 1259–78.

Uziel-Miller, N.D., Lyons, J.S., Kissiel, C., & Love, S. (1998). Treatment needs and initial outcomes of a residential recovery program for African American women and their children. American Journal of Addiction, 7 (1) 43–50.

The following books are highly recommended: FT.-Alcoholics Anonymous, 3rd edition (1976). New York: Alcoholics Anonymous World Services, Inc.

Carnes, Patrick (1989). Contrary to Love; Helping the Sexual Addict. Center City, MN: Hazelden Educational Materials. FT.-Kasl, Charlotte Davis (1992). Many Roads, One Journey; Moving Beyond the 12 Steps. New York: Harper Perennial.

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By June Dobbs Butts, Ed.D., CPIV, June Dobbs Butts is a Research Fellow in the Department of Community Health and Preventive Medicine at Morehouse School of Medicine.

Address all correspondence to Dr. Butts at the Department of Community Health & Preventive Medicine; Morehouse School of Medicine; 720 Westview Drive, SW; Atlanta, GA 30310-1495; Ph: 404.752.1946; Fax: 404.752.1051.

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