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A Group Intervention Project For Eight Rural Mothers In a Tragic Dance With Alcohol

Trudee Ettlinger, R.N., M.S., CADC, CS
Outreach Home-based Practice
Grand Isle County, Vermont

Abstract A community-based, women-centered, therapeutic alcohol treatment group served eight rural mothers in Grand Isle County, Vermont. Both the clinical and structural approaches recognized the distinct treatment needs of these women. All the women described improved coping and developed supportive relationships with each other. The results led to the conclusion that limited projects may initiate and establish continued social support mechanisms.

A woman's linkage to alcohol may alter her safe passage through childbearing, have an impact on her child rearing, and affect her relationships. This alcohol attachment may jeopardize her adaptation to life course roles. During the past decade, robust research has identified significant biopsychosocial health risks of alcohol abuse for women (Amaro 1990; Blume 1990; Gomberg 1993; Hennessy 1992; Sokol and Abel 1988; Wilsnack 1984). Other research reports that women underutilize treatment because programs are often structurally inaccessible, particularly for women with dependent children, and are perceived as empathetically unresponsive (Finkelstein 1993; Kauffman et al. 1995; Wallen 1992; Wilsnack 1984).

This paper describes and discusses an intervention project for a group of rural childbearing-age women from Grand Isle County, Vermont. The project was called the Mothers, Alcohol, Relationships, and Kids Group (MARK). A structurally accessible group treatment effort was implemented that addressed alcohol abuse within the context of these women's lives.

Purpose

The MARK group was based on a multilevel perspective and provided a women-centered, community-based therapeutic group for a special aggregate experiencing the health risks of alcohol abuse. The goals of this intervention group were to (1) provide education about the biological and psychosocial health risks of alcohol abuse for women, families, children, and the community; (2) promote individual strengths and adaptive coping strategies, and (3) create helping relationships.

Setting

Grand Isle County lies in the most northwestern corner of Vermont. It is a chain of connected islands within Lake Champlain. The 5,268 residents live in five distinct townships (each an island community) which support five elementary schools. In this county there is the office of the State's Attorney and Victim's Advocate, the District Court, the local sheriff's office, one physician, a Parent Child Center, and a total of 15 outlets for beer and wine, two of which are State liquor stores with $0.9 million in gross spirit sales annually (Vermont State Liquor Board 1993). There are no supermarkets and no large businesses. Individuals and families travel 23 to 40 miles to access the human service network and depend on outreach workers. In this county there are clear differences between the lavish lakeside estates and the trailer homes. Many families need to supplement their nutrition by fishing all year from the lake despite the health warnings limiting fish meals because of toxins.

The challenged women from this community are stoic and silent. They are proud and dedicated to their families and children. Their perceived powerlessness and disadvantaged status produce mistrust and fear of others and often result in social networks so enmeshed that they produce conflicted rather than supportive associations.

Community Involvement

The actual prevalence of women from Grand Isle County, Vermont, who were in harm's way from their own or others' alcohol abuse was unknown. However, the community's parent educator, school nurse, child protection worker, public health nurse, victim's advocate, probation and parole officer, school principal, and the owner of a liquor store felt that many women and families were experiencing the health risks of alcohol abuse. This group was also troubled by the inaccessibility of treatment services for these women. There are no local community-based alcohol treatment group programs in this county.

The framework for launching this intervention was based on the concepts found in Adams and Krauth's (1994) Professional Approaches to Community Health (PATCH), which assumes that human services provide a single strand in the complex web of relationships and services that provide care in the community. It emphasizes a focus on the community's identification of a health problem and involves the community in addressing the concern.

Fundamental to PATCH practice is the collaboration, cooperation, and partnership among informal groups, voluntary organizations, schools, businesses, and other health and human service providers. This shift from individual efforts to a team approach enables coordination of activities and lowers the perceived barriers between the professionals and the community they serve. The PATCH model interweaves formal and informal care; it calls for responsive services that are directed by the community, not the service system, and values the community as a reservoir of assets and strengths.

A mosaic of community professionals identified a need, formed a partnership, and collaborated on the design and implementation of an intervention project that served 8 women and 12 children. This small but significant effort reflected local health concerns and identified community health resources. Community groups provided the place, the child care, and the transportation. Other groups provided the referrals. The Vermont Office of Drug and Alcohol Programs funded $1,000, the community's Health Council funded $500, and a local liquor store contributed $50 to support this project.

Clinical Issues

A voluminous literature exists on alcoholism, and current research is now indicating that a host of background and precipitating factors differentiate men from women. The clinical rationale of the MARK group was guided by the significant gender differences in life context in which abusive drinking is embedded. The psychology of women's development provided the organizing treatment framework, and group-based approaches provided the process. The cornerstone of MARK was the sensitivity to the developmental needs of the members and their critical life transitions.

Increased knowledge and understanding of alcohol abuse may motivate change, and learning more effective skills may alter the impact. However, both these treatment principles must recognize the other factors that influence health outcomes. The MARK group leaders understood the lives of these women and their layered health risks. The linkages between the legacy of abusive drinking, Vermont culture, poverty, social disadvantage, motherhood, poor education, and lack of personal power were recognized. The therapeutic approaches stressed process-oriented work. The leadership style was supportive and underscored the importance of being a mentor and role model.

Implementation

The MARK group was implemented in June 1995 at the community's Parent Child Center. The group was led by two women, one of whom is a parent educator and the other, the author of this paper, a psychiatric nurse practitioner with certification in alcohol and drug counseling. Both are experienced community outreach professionals and are familiar with the culture, values, and traditions of this community and its women.

The group met weekly for 2.5 hours. The mothers met in an inviting and private setting. The children were cared for in a nearby but separate area within the same building. A typical group meeting began with greetings, settling the children with the sitters, making coffee, and setting up chairs. The first 15 minutes were spent checking in and reporting the events of the week, followed by discussions of scheduled topics. A 30-minute break allowed the group to go to the adjacent store, get snacks and a beverage (charged to the group fund), and return to sit on the steps of the Center to chat. The final hour was devoted to processing and sharing experiences.

From the beginning, the women were encouraged to assume ownership of the group. Everyone's successes were immediately rewarded and new information was presented in a relevant context. Humor abounded and was often a welcome emotional relief. Over time a base of trust, motivation, and ownership allowed the members to work through the far-reaching impact of chemical abuse.

The group celebrated 12 weeks of committed attendance by going out to a restaurant for supper, and all members were given a T-shirt with the logo "On your MARK, stretch and grow." T-shirts were also given to everyone who helped launch and support this project, both professional and natural community caregivers.

Findings

A wide range of consequences of abusive drinking was represented in this small group of eight women. All reported familial abuse of alcohol which (they perceived) resulted in troubled childhoods and substance abuse in adolescence. Three women had been adolescent runaways and five had been teenage mothers. Three women had experienced alcohol-related motor vehicle accidents, with one woman recently severely injuring her spinal cord. This trauma resulted in complete paralysis below her waist. Another woman was on probation from an alcohol-related incident.

All had experienced an alcohol-abusing partnered relationship, and five women's partners continued steady or episodic drinking. Three women were in early recovery. Although the experiences were different, abusive drinking had altered the life courses of each of these women.

This group of eight ranged in age from 21 to 36 years. There were members who had completed high school, had dropped out; had been employed, had never worked; who lived as married, or who were single parents. All found a place to share common experiences and learn from each other.

The original intent of the project was to run the group for 12 consecutive weeks (June-August 1995) and evaluate the intervention using a pre- and post-survey on (a) increased knowledge and understanding of the health risks of alcohol abuse, (b) identification of new coping skills, and (c) perception of social support from the process. The results of the survey found both increased knowledge and better coping, but an unexpected finding was the overwhelming positive response to the perception of social support. The women wanted to continue meeting, and it was decided to continue a supported meeting twice monthly until December 1995. From the onset, this group was made fully aware of the funding and our current shrinking assets. As a group, they decided to save money by providing their own snacks and meeting when some of the children would be in school, to save on child care expenses.

In December 1995, the group announced it wanted to continue and is presently meeting without the artificial supports of child care, transportation, and place. Although the leaders still attend, the women have taken complete responsibility for all arrangements. They decided to meet in each other's homes and provide care for the children. This commitment to each other and the process was unexpected.

Another surprise was the group's evolution from dependence upon the experts for support to reliance upon each other to discuss problems and seek advice for stressful situations. This movement away from professional help (which all of these women had used extensively) was not anticipated. These women began to deal with their own problems and gain the confidence, power, and skills to make choices in their lives.

The individual findings were as unexpected as the group commitment results. One woman, who had dropped out of high school, is now enrolled in a completion program; probation requirements have been fulfilled, and recovery continues. One woman joined a parent education program; one woman separated from her partner; one woman enrolled in a college course; and no one became pregnant.

Conclusions

This health promotion effort set out to address a need voiced by a concerned group of community professionals. It involved these professionals in the creation of a program that was guided by a multilevel

perspective. This intervention was developed within the community's existing organization, the Parent Child Center, which serves families. It also recognized the need to involve both the professional and lay caregivers in the community.

This project demonstrated that small programs can be implemented at the local level without a complex organizational structure, months of strategic planning, and substantial funding. It also demonstrates that one-time grants can spark independent ongoing support mechanisms.

Several elements contributed to the success of this pint-sized project. The community supported and facilitated this health intervention, all structural barriers were addressed, and the treatment approaches were comprehensive. It is believed that the life courses of the women in the group were guided toward greater health. It is hoped that these changes will be durable enough to carry the women through future life events.

The design of this limited project rests on the principles that chemical abuse and dependency cannot be separated from the totality of a woman's experiences and context. Furthermore, programs woven into the fabric of the community create a spirit of engagement and empowerment.

Recommendations

Those of us who sincerely care about the health of women face an enormous challenge in the drug and alcohol field. We are more aware of the complexity of alcohol and other drug problems among women. The challenge calls for programs that reach all women and empower them to promote their own health. Furthermore, we must work closely with communities to create and deliver services at the local level and regard all efforts as important. After all, even the smallest initiative has the potential to make a larger impact.

References

Adams, P., and Krauth, K. Community-centered practice to strengthen families and neighborhoods: The PATCH approach. In: Adams, P., and Nelson, K., eds. Reinventing Human Services. Hawthorn, NY: Aldine de Gruyter, 1994.

Amaro, L. Violence during pregnancy and substance abuse. American Journal of Public Health 80:575-579, 1990.

Blume, S.B. Chemical dependency in women: Important issues. American Journal of Drug and Alcohol Abuse 16(3 and 4):297-307, 1990.

Finkelstein, N. Treatment programming for alcohol and drug-dependent women. International Journal of the Addictions 28:1275-1309, 1993.

Gomberg, G. Recent developments in alcoholism: Gender issues. Recent Developments in Alcoholism 11:95-107, 1993.

Hennessy, M. Identify the woman with alcohol problems: The nurses' role as gatekeeper. Nursing Clinics of North America 27(4):917-924, 1992.

Kauffman, E.; Dore, M.; and Nelson-Zlupko, L. The role of women's therapy groups in the treatment of chemical dependence. American Journal of Orthopsychiatry 65(3):355-363, 1995.

Sokol, R., and Abel, E.. Alcohol-related birth defects. Neurotoxicology Teratology 10:183-186, 1988.

Vermont Liquor Control Board. Fifty-ninth Annual Report. Montpelier, VT: State of Vermont, 1993.

Wallen, J. A comparison of male and female clients in substance abuse treatment. Journal of Substance Abuse Treatment 9:243-248, 1992.

Wilsnack, S. Alcohol Problems in Women. New York: Guilford Press, 1984.

Last Updated 11-7-02