Sisters In Support Together Against Substances (SISTAS): An Alcohol

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Sisters In Support Together Against Substances (SISTAS): An Alcohol Abuse Prevention Group for Black Women Karen McCurtis Witherspoon, PhD Alesia Williams Richardson, PhD

ABSTRACT. This paper examines the existing literature for alcohol abuse prevention and treatment of African American women and offers a group counseling intervention to address the culturally specific needs of this population. The group, SISTAS: Sisters In Support Together Against Substances, includes a curriculum that focuses on key components such as spirituality, self-esteem, racial identity, social support and intimate relationships. The purpose of the group is to raise awareness of and educate members about the factors that can lead African American women from drug abuse to dependency. doi:10.1300/J233v05n03_03 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. African American women, prevention, alcohol abuse, support group Karen McCurtis Witherspoon is Associate Professor and Alesia Williams Richardson is Assistant Professor, both affiliated with Department of Psychology, Chicago State University. Address correspondence to: Karen McCurtis Witherspoon, Department of Psychology, Chicago State University, 9501 South King Drive, HWH 328, Chicago, IL 60628 (E-mail: [email protected]). Journal of Ethnicity in Substance Abuse, Vol. 5(3) 2006 Available online at http://jesa.haworthpress.com © 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J233v05n03_03

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Alcoholism among African American women has increased dramatically (Hutchinson, 1999). Many problems result from their racial, historical, and structural position in American society. For example, most African American, female, heavy drinkers live in an urban environment and are likely to be the head of household, poor, and seem to share a particular abuse pattern of alcohol on the weekend (Baruth & Manning, 1991). Epidemiological studies indicate that both the prevalence and consequences of alcohol abuse are higher and more severe among Black women than White women (Caetano, 1984). There is a small group of studies that point to culture-specific substance abuse prevention for Blacks (Maypole & Anderson, 1987). However, most treatment studies have focused on alcohol abuse among African American men and have not included women. The purpose of this paper is to provide a model for working with African Americans who are currently misusing alcohol and who are at risk for alcohol dependence. The group, entitled, SISTAS: Sisters in Support Together Against Substances, is a culturally specific framework for assisting African American women who are abusing alcohol as a way to cope with life stressors.

SISTAS: ORGANIZATION AND SELECTION The stigma associated with the label of alcoholism and stereotypes attached to African Americans has resulted in African American mistrust toward the white dominated rehabilitation counseling profession (Harley, 1995). For this reason, culturally competent counselors are necessary to facilitate this group, especially counseling practitioners with an African-centered framework, in particular those practitioners that place importance on African values and culture. The recommended size for SISTAS groups is approximately eight to ten members. Important group rules pertaining to abstinence, confidentiality, and absences are covered before the group begins. Women will go through an individual assessment with group counselors for selection for participation prior to the first group. The following case study was developed from a compilation of many women seen by the authors during treatment. It is given as an example of the characteristics that a woman might exhibit who is selected for inclusion in this group model.

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Case Study Rhonda is a 29-year-old African American female. She is a single mother of three children, ages 12, 10, and 7. The father of the eldest two children is incarcerated, and the youngest child’s father was killed in a gang-related incident. She is currently dating a 30-year-old African American male, Wayne, who also has several children and is not employed. Rhonda would not reveal her current partner’s drug of choice but later stated that “he smoked weed” occasionally. Wayne and his children often reside with her because of financial hardship. Rhonda is employed as a cashier at the local gas station but her hours are irregular, contributing to childcare issues. She is often unable to meet her basic household expenses and currently has an eviction notice. Rhonda is hoping to find a job that offers healthcare, higher pay and first shift hours. She would like to be at home to more closely monitor her children since the eldest two children are failing in school and her baby was recently diagnosed with a learning disability. Rhonda feels guilty that she often works second and third shift and cannot attend properly to the children. Rhonda admits to drinking heavily on weekends to relax. She typically consumes a fifth of vodka and a case of beer during the weekend, and is often hung over on Monday. Rhonda’s mother and father were both alcoholics but she denies addiction. They both come by weekly to borrow money or food. Rhonda’s current alcohol use has been elevating for the past twelve months from only drinking one day on the weekend to drinking three full days. Rhonda also admits to feeling the urge to drink during the workweek when her stress is high. She reports feeling depressed because of her weight gain and subsequently has not been taking proper care of her appearance. She confided in the group leader that her boyfriend was not attracted to dark-skin women and this is a message that she has heard most of her life growing up. She admits to sexual promiscuity in the past with any man who has shown her affection while she is inebriated. She was referred to the SISTAS group by her caseworker that was helping to find her housing. The group facilitator felt that Rhonda was appropriate for the group because she did not meet the criteria for alcohol dependence based on a more thorough substance abuse evaluation. The facilitator explained to her that without intervention, her current abuse was likely to progress to dependence. The facilitators also explained to Rhonda that the group approaches are particularly helpful to attain social support, learn new skills, and practice

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new roles (Manhal-Baugus, 1998). In particular, group work can establish a context in which participants learn new coping skills using didactic techniques, role modeling, and information sharing lifestyles (Washington & Moxley, 2003).

SISTAS: CURRICULUM Group participants will experience each two-hour module weekly in the order presented below. Week 1: Introduction: The First Step Forward The purpose of the first group session is to provide substance abuse education. Facilitators define key substance abuse terms, such as abstinence, addiction, alcoholism, dependence, relapse, tolerance, and withdrawal. The last two terms are especially important in determining appropriate inclusion in this group. The Diagnostic Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) differentiates alcohol dependence from alcohol abuse by two key characteristics: tolerance, the increasing need for higher dose of a substance to maintain its effects, and withdrawal, a set of physical and psychological effects that occur when use of a drug is stopped. Facilitators help the women to identify with each other by explaining that they have all been selected for participation in this group based on the fact that they are currently abusing alcohol and are at risk for addiction without further intervention. Members are encouraged to explore the signs of alcohol abuse, such as needing alcohol to cope with strong emotions; using alcohol to relive stress; being uncomfortable in situations where alcohol is unavailable; wanting to continue drinking when others have said that you have had enough; being irritated when someone talks to you about your drinking; regretting things you did or said while drinking; and having an increasing number of work, family, social, or school problems. Specific drinking patterns of African Americans, who tend to be group drinkers, to drink with family and friends as opposed to in isolation, to drink more frequently and heavily on the weekends, and to either drink heavily or not at all (Harley, 1995; Jones-Webb, 1998), will also be reviewed.

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Week 2: Defining Self: Who Am I and Why Am I ? This week’s group will consist of a discussion of self-esteem, selfworth, self-efficacy and one’s global sense of self. Low self-esteem is an emotional issue for African American women from a wide array of economic and educational backgrounds and can lead to alcohol use as a means of covering feelings or producing false positive feelings of selfesteem (Greene, 1994; Jordan, 1997). Thus, this group session will center on members understanding what impact each of these have had upon their definition of self. By gaining knowledge of how one’s self-concept was shaped members can develop a sense of power over their destinies. Self-esteem is defined as one’s feelings about self. Self-worth is defined as the value one places on their person, and self-efficacy is one’s believe in their ability to achieve a goal (Cole & Cole, 2001). Group members will examine the messages received during development, how they were valued by others, and feelings about their ability to shape their lives. Each of these composite the total self and will help members understand who they are and why they are. A woman who feels little regard for her self is going to have a hard time achieving recovery (Rowe, 1986). Teaching participants strategies for self-respect and recognition of one’s accomplishments concludes the second group. Week 3: Understanding Racial Identity: I Am Because We Are An exploration of racial group identity, African American cultural norms, and African-centered theoretical perspectives will be the focus of this group. Azibo (1998) suggests that it is impossible to separate personal identity from collective or racial group identity in healthy African Americans, because self is viewed as an extension of the collective, as reflected in the wise saying, “I am because we are” (Azibo, 1998, p. 212). Blacks who abstain from drinking alcohol tend to score higher on traditional Black cultural variables than those who do not (Klonoff & Landrine, 1999) and have a stronger preference for Black people (Herd & Grube, 1996). Belgrave, Brome, and Hampton (2000) assert that drug prevention information presented in formats and contexts that are meaningful and culturally relevant to the targeted population is more likely to be retained and used than information presented in ways that do not reflect group values or norms. While there is great variability among African Americans, a discussion of distinct cultural norms that serve as a basis for individual identity and community unity are presented. Because racial identity is believed to be a protective factor against sub-

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stance abuse and African-centered beliefs have been identified as a preventive strategy for a number of problematic behaviors, individuals will identify their specific beliefs about their race and cultural values and can gain an understanding of how these beliefs can influence alcohol use. Week 4: Family Dynamics: Is It My Mama’s Fault ? Statistics indicate that children whose parents abuse alcohol are likely to abuse alcohol as adults themselves (Caetano, 1984) and African American women are more likely than both white and Latina women to abuse alcohol and to come from homes where one or both parents abused alcohol. This week’s group will examine family of origin issues that can and have led to alcohol abuse and the roles that adult children of alcoholics take on. Survival roles associated with adult children of alcoholics include the hero, scapegoat, lost child, and mascot, and according to Harley (1995), African American adult children of alcoholics exhibit a cluster of addiction-related symptoms that show unique cultural influences. For example, African American females are often viewed as the heroine, which makes it less likely for her to seek help. Rodney (1996) investigated African American adult children of alcoholics and found that health in the family of origin and availability and use of a supportive mother were related to fewer drinking problems. Thus, addressing social support from their mothers may serve as a buffer from adverse consequences of parental alcoholism. Additionally, group members are assisted in examining current family dynamics and attempt to link current roles to those learned in their family of origin. Week 5: Sexuality and Intimate Relationships: I Ain’t Jezebel or Aunt Jemima! Historically African American women have been labeled sexually insatiable, domineering, and hard (Hooks, 1993). This may have led to negative self-images for many African American women, resulting in unfulfilling or unhealthy sexual and intimate relationships. Group members will discuss past and present intimate relationships and sexual encounters. Women who abuse alcohol and drugs are at particular risk for sexual assault, unprotected sex, unwanted pregnancies, and sexually transmitted diseases (Hutchinson, 1999). This discussion is extended to how they were taught about sexuality and the images they saw of intimate relationships. In relationships where one or both partners abuse

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alcohol, they often become stuck in patterns repeating mistakes of their parents or linking with others who remind them of parental figures. African American women who abuse alcohol may look to male partners to supply self-esteem and are often dependent on others for their selfworth. Signs of codependency (Cermak, 1988), such as trying to control others with anger or love, sacrificing one’s own identity for intimacy, and feeling responsible for other people’s needs, will be identified. Participants will be educated about healthy relationships based on mutual satisfaction and respect. Week 6: Mental Health & Well-Being: Airing Dirty Laundry, It’s Okay! This group meeting will address the social and psychological risk factors for drug and alcohol abuse and dependence, such as childhood abuse and lack of support from friends and family, that are also risk factors for other psychiatric disorders. The term “dual diagnosis” is usually reserved for individuals who have two or more disorders in which one of the disorders involves drug or alcohol abuse or dependence, and over 70% of female alcohol abusers were found to have had at least one other psychiatric disorder at some time in their lives (Harvard, 2003). Taylor and Jackson (1990) found a positive association between internalized racism and alcohol consumption in African American women. The relationship between racial discrimination and psychological distress has been well documented (Jackson et al., 1996; Landrine & Klonoff, 1996; Thompson, 1996; Ren, Amick, & Williams, 1999; and Williams & Williams-Morris, 2000). Perceptions of discrimination have been linked to higher levels of psychological distress, lower levels of life satisfaction, and poorer physical health. Participants are encouraged to confront their destructive behaviors to explore new ways of dealing with people, with emotions, their physical health and with cravings for alcohol. Special attention is paid to guilt and feelings of shame that are often expressed by alcoholic women, especially mothers. Week 7: Environmental Factors: Makes Me Wanna Holla! Alcohol abuse is a means to cope with feelings of social and economic frustration, hopelessness, racism, and discrimination (JonesWebb, 1998), and many African Americans blame these conditions for their drinking. Black women have been portrayed as four controlling images, according to Roberts, Jackson, and Carlton-Laney (2000): wel-

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fare queen, mammy, matriarch or sapphire, and jezebel. Black drinkers have a greater distrust of Whites and are more negative toward them than Black abstainers (Klonoff & Landrine, 1999). Black feminist theory is used to challenge negative images of African American substance abusers and to help members resist oppressive environmental conditions. Group work can be used to empower women by increasing their general and specific self-efficacy in life domains (i.e., parenting, selfcare, vocational development, and employment) in which successful outcomes are particularly important to the achievement of substancefree lifestyles (Washington & Moxley, 2003). Facilitators provide linkage to specific program resources that promote literacy, basic skills, job training, and housing assistance. Week 8: Spirituality and Healing: We’ve Come This Far by Faith Research indicates that spirituality plays an integral role in the lives of African American people (Idowu, 1992; Jones & Block, 1984; Myers, 1987; Richards, 1985) and is a vital resource to the self-esteem and mental health of African Americans (Smith, 1981). Potts (1991) agrees and suggested that as part of treatment for alcoholism, particularly for African Americans, the role of spirituality needs to be considered because of the alienation from mainstream society that many feel. Brome, Owens, Allen, and Vevaina (2000) found that African American women who were in recovery from substance abuse and expressed a high level of spirituality demonstrated a more positive self-concept, a more active coping style, more positive attitudes toward parenting, more positive perceptions of their family climate, and more satisfaction with their social support than those women who were in recovery but expressed a lower level of spirituality. Two major themes characterize African American spirituality: the pursuit of liberation from injustice (Hopkins, 1993) and the belief that the spiritual is present in every aspect of life (Mbiti, 1990; Mitchell & Mitchell, 1989). Therefore, in this group session, members discuss their spiritual beliefs, reconnecting with them, forgiving themselves, and self-love. The central theme of the group session is for each member to construct a positive image of herself and connect with the goddess within. Prayer and exploration of losing and finding one’s faith, in connection with the reliance on God as a source of power higher than one’s self (a key belief in 12-step recovery programs), are explored. African American women who present for counseling with emotional themes of isolation, devaluation, internalized oppression, and low self-esteem and quest for a positive racial

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identity are especially receptive to interventions that support and encourage the development of their spiritual selves (Frame, Williams, & Green, 1999). Week 9: Developing Resiliency: We Fall Down BUT We Get Up! Resiliency is defined as the ability to bounce back or recover from negative experiences with little long-term psychological problems in the future (Cole & Cole, 2001). The ninth group meeting includes a discussion of ways to prevent relapse and promote recovery growth. Group facilitators will ask members to access that part of themselves they reconnected with in group eight and to continue forward movement. Facilitators emphasize that each member is a survivor, not a victim of her life. The first of the Twelve Steps to recovery addresses powerlessness. Participants are asked to identify things that can versus cannot truly be changed with the objective of empowering women to action or to cope. Participants examine choices that they have made and challenge the beliefs that they are stuck with a particular choice. This meeting concludes with a discussion of how each member has bounced back from adversity and survived. Week 10: Group Termination & Recovery: I Am Changed! The focus of the last session is to celebrate one’s progress over the course of the group and to continue the discussion of recovery from the week prior. Recognition of positive coping strategies and healthy attitudes gained are important in developing a plan for the participants to continue to apply the lessons learned during the support group. Triggers to reverting to old or dysfunctional behaviors are also identified. Participants discuss their skills for sober living and factors that motivate them for change. Essential to recovery is learning how to spend leisure time productively and substance-free. Recreational activities that are enjoyable and alcohol free are introduced during this celebratory session. CONCLUSION This group is designed as a secondary prevention tool that targets African American women who are abusing alcohol, but do not meet the criteria for alcohol dependence or addiction. Substance abuse programs that foster a sense of belonging to the community and include participation in support groups are believed to be more effective than those that

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do not. Women who are addicted to alcohol will need formal assessment, comprehensive substance abuse treatment and education, in addition to random drug testing. These topics identified are especially relevant for African American women based on the extant literature. Initial qualitative data from the participants suggest that members welcomed the inclusion of culturally specific exploration of the relationship between their substance user histories and their African American heritage. For example, one participant told the facilitator the discussion on racial identity helped her to be more accepting of how she felt about herself as a Black person. She felt pressure from family members to be “militant and pro-Black” in all of her interactions. Although she saw her Blackness as a primary frame of reference and she felt positive about being a member of this racial group, her beliefs about her identity were more consistent with Internalization identity attitudes. Internalization is characterized by pride and security in her own race but is accepting of other cultural groups (Parham & Helms, 1985). During week four, many group members commented on the connection between their current alcohol use and the drinking patterns of family members. Certain culturally specific messages about alcohol were passed on to them, such as, “alcohol is not a drug, or a disease.” Some members have also been taught that drinking in a social gathering, even if excessive, was appropriate and not considered alcohol abuse. Group participants seemed particularly engaged in weeks five and six. The discussions in these groups centered on sexuality and mental health. Many women felt that had to suffer in silence because they were attempting to live up to the common perception of the “strong Black woman” and the belief in many minority communities that you do not seek help from mental health providers (Hooks, 1993). These examples are given as preliminary qualitative support for the effectiveness of culturally specific group intervention with African American women abusing alcohol. Further outcome research on the application of this therapeutic framework is encouraged. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental Disorders: Text revision. 4th Edition. Washington, DC: APA. Azibo, D. (1998). The distinction between African personality personologists and other African personality scholars: Implications and entreatment for reconceptualization

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of racial identity issues. In R. L. Jones (Ed.), African American identity development (pp. 207-215). Hampton, VA: Cobb & Henry. Baruth, L.G., & Manning, M.L. (1991). Multicultural counseling and psychotherapy: A life span perspective. New York, NY: Merrill, Macmillan Publishing. Belgrave, F.Z., Brome, D.R., & Hampton, C. (2000). The contribution of africentric values and racial identity to the prediction of drug knowledge, attitudes, and use among African American youth. Journal of Black Psychology, 26, 386-401. Brome, D.R., Owens, M.D., Allen, K., & Vevaina, T. (2000). An examination of spirituality among African American women in recovery from substance abuse. Journal of Black Psychology, 26, 470-486. Caetano, R. (1984). Ethnicity and drinking in California: A comparison among Whites, Blacks, and Hispanics. Alcohol and Alcoholism, 19, 31-44. Cermak, T. (1988). A time to heal: The road to recovery for adult children of alcoholics. Los Angeles, CA: Tarcher. Cole, M., & Cole, S.R. (2001). The development of children. 4th Edition. New York: Scientific American Books. Frame, M.W., Williams, C.B., & Greene, E.L. (1999). Balm in Gilead: Spiritual Dimensions in counseling African American Women. Journal of Multicultural Counseling & Development, 27, 182-192. Greene, B. (1994). African American women. In L. Comas-Diaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy. New York: Guilford. Harley, D. (1995). African American adult children of alcoholics: The impact of cultural influences. Journal of Rehabilitation, 61, 36-40. Harvard (2003). Dual diagnosis: Part I. Harvard Mental Health Letter, 20, 1-5. Herd, D., & Grube, J. (1996). Black identity and drinking in the U.S. Addictions, 91, 845-857. Hooks, B. (1993). Sisters of the yam. Boston: South End Press. Hopkins, D.N. (1993). Shoes that fit our feet: Sources for constructive Black theology. Maryknoll, NY: Orbis Books. Hutchinson, I.W. (1999). Alcohol, fear and woman abuse. Sex Roles, 40, 893-920. Idowu, A.I. (1992). The oshun festival: An African traditional religious healing process. Counseling & Values, 36, 192-200. Jackson, J.S., Brown, T.N., Williams. D.R., Torres. M., Sellers. S.L., & Brown. K. (1996). Racism and the physical and mental health status of African Americans: A thirteen year national panel study. Ethnicity and Disease, 6, 132-47. Jones, J.M., & Block, C.B. (1984). Black cultural perspectives. The Clinical Psychologist, 37, 58-62. Jones-Webb, R. (1998). Drinking patterns and problems among African Americans: Recent findings. Alcohol Health & Research, 22, 260-264. Jordan, J.M. (1997). Counseling African American women from a culturally sensitive perspective. In C.C. Lee (Ed)., Multicultural issues in counseling: New approaches to diversity. Alexandria, VA: American Counseling Association. Klonoff, E., & Landrine, K. (1999). Acculturation and Alcohol Use Among Blacks: The Benefits of Remaining Culturally Traditional. Western Journal of Black Studies, 23, 211-216.

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Landrine, H., & Klonoff, E.A. (2000). Revising and improving the African American acculturation scale. Journal of Black Psychology, 26, 235-261. Landrine, K., & Klonoff, E. (1996). The schedule of racist events: A measure of racial discrimination and a study of its negative physical and mental health consequences. Journal of Black Psychology, 22, 144-68. 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, 78-85. Maypole, D.E., & Anderson, R.B. (1987). Culture specific substance abuse prevention for Blacks. Community Mental Health Journal, 23, 135-139. Mbiti, J.S. (1990). African religions and philosophy. 2nd edition. Portsmouth, NH: Heinemann. Mitchell, E.P., & Mitchell, H.H. (1989). Black spirituality: The values in that or time religion. Journal of the Interdenominational Theological Center, 17, 98-109. Myers, L.J. (1987). The deep structure of culture: Relevance of traditional African culture in contemporary life. Journal of Black Studies, 18, 72-85. Parham, T.A., & Helms, J. (1985). Attitudes of racial identity and self-esteem: An exploratory investigation. Journal of College Student Personnel, 26, 143-146. Potts, R. (1991). Spirits in the bottle: Spirituality and alcoholism treatment in African-American communities. Journal of Training and Practice in Professional Psychology, 5, 53-64. Ren, X., Amick, B., & Williams, D.(1999). Racial/ethnic disparities in health: The interplay between discrimination and socioeconomic status. Ethnicity & Health, 9, 151-165. Richards, D.M. (1985). The implications of African American spirituality. In K. Asante & M. Asante (Eds.), African culture: Rhythms of unity. Greenwood Press. Roberts, A., Jackson, M., & Carlton-Laney, I. (2000). Revisiting the need for feminism and afrocentric theory when treating African-American female substance abusers. Journal of Drug Issues, 30, 901-918. Rodney, H.E. (1996). Inconsistencies in the literature on collegiate adult children of alcoholics: Factors to consider for African Americans. Journal of American College Health, 45, 19-25. Rowe, K. (1986). Women’s issues. Hazelden Foundation. Smith, A. (1981). Religion and mental health among blacks. Journal of Religion and Health, 20, 264-287. Taylor, J., & Jackson, B. (1990). Factors affecting alcohol consumption in Black women, Part II. The International Journal of Addictions, 25, 1415-1427. Thompson, V. (1996). Perceived experiences of racism as stressful life events. Community Mental Health, 32, 223-233. Washington, O., & Moxley, D. (2003). Group interventions with low-income African American women recovering from chemical dependency. Health & Social Work, 28, 146-156. Williams, D.R., & Williams-Morris, R. (2000). Racism and mental health: The African American experience. Ethnicity & Health, 5, 243-268.

doi:10.1300/J233v05n03_03

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Sisters In Support Together Against Substances (SISTAS): An Alcohol

Sisters In Support Together Against Substances (SISTAS): An Alcohol Abuse Prevention Group for Black Women Karen McCurtis Witherspoon, PhD Alesia Will...

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