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Master's Theses Theses and Dissertations

2012

Ritual as Clinical Intervention in Groupwork with African American

Women
Kathryn Kristin Berg
Loyola University Chicago

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Copyright © 2012 Kathryn Kristin Berg
 LOYOLA UNIVERSITY CHICAGO

RITUAL AS CLINICAL INTERVENTION

IN GROUPWORK WITH AFRICAN AMERICAN WOMEN

A THESIS SUBMITTED TO
THE FACULTY OF THE GRADUATE SCHOOL
IN CANDIDACY FOR THE DEGREE OF
MASTER OF ARTS

PROGRAM IN WOMEN’S STUDIES AND GENDER STUDIES

BY

KATHRYN K. BERG

CHICAGO, IL

AUGUST 2012
Copyright by Kathryn K. Berg, 2012
All rights reserved.
 ACKNOWLEDGEMENTS

Thank you so much to Terry, my thesis director, for helping me to integrate the

clinical with the woo-woo, for allowing this thesis to be a structured, creative process, for

challenging me to conduct interviews and take this research project to another level, and

for being an awesome model of life balance, with humility and humor every step of the

way. Your guidance has helped to me to recognize and actualize my potential as a social

work clinician and educator.

Thank you to Prue, my reader, for helping me to incorporate feminist

methodologies and for challenging me to fully appreciate research as an act of social

justice. Your commitment to ritual has helped me to take the potential of ritual seriously,

and to see it as a risk worth taking.

Jesi, my love, thank you for helping me to make magic and stay organized. And

for transcribing my interviews and for help with technology—my laptop also thanks you

for preventing injury. And for motivating me to have good time management so you and I

have time to be together.

Mom, thank you for the steady supply of chocolate chip brownies to power me

on. Dad, thank you for your encouragement and for respecting women’s group ritual.

Sarah, thank you for supporting my ceremonies. Never forget...if the broom fits, ride it!

Thank you to C.I., Sophia, Kristen, Natalie, Kate, Amy, Juanita, and Alana for

iii
taking the time to participate in an interview, and for all the work that you do. Your

commitment to your clients and dedication to social services, in spite of all the obstacles,

is the foundation of this research.

Additional thanks to Margot, Amanda, and all agency staff (known and unknown)

who helped me to contact facilitators for interviews. Your networking behind-the-scenes

made the study possible.

Thanks to those “mental health” professionals from near and far who shared their

experience of ritual with me by phone, including Gary Matthews, Leal Abbott, Deb

Marie Denome, Toby Neal, and Eric Greenleaf. You reminded me that when intervention

is effective with clients, the scholarship follows. Thanks also to Kenny Klein.

Thanks to Leigh-Anne, Carrie, Lauren, and Anna for your kind words. Thank you

so much to Karen and Rachel F. who helped me push through a major writing block.

Your insight helped me remember why I took this research project on in the first place.

A thank you to all of those who responded to posts and messages, offering their

perspectives on ritual and spirituality: Gaby, Beth, Linda, Colleen, Ken, Megan, Angela,

and everyone. You were a vital and accessible sounding board on short notice. I greatly

appreciate it!

Aanmona, thanks for freaking out with me. Thanks also to the thesis and

dissertation support group for freaking out with me confidentially, and for helping to put

my thesis in perspective.

Thank you to Stephanie and David and Ginnie and Morgan for forgiving my short

attention span on nights when my brain was fried. Thank goddess for your friendships!

iv
 Thank you to my proofreaders and my other sets of eyes, Linda, Jenn, and Rachel

T., your feedback was so very helpful. Thank you to Kristina from the Graduate School

for your assistance with final formatting.

Thank you also to Kuan Yin for modeling the compassion and persistence of a

true social worker, and to Oya who creates the storms sometimes needed to engender

painful yet empowering change.

v
 PREFACE

The purpose of this preface is to incorporate standpoint theory. Standpoint theory

is a research methodology which critiques the concept of neutrality, or pure objectivity,

in research. It argues that there is not one ultimate truth to be discovered by one

exceptional genius, but rather that there are multiple truths of equal value. Standpoint

theory asserts that all social locations are places of insight, and marginalized peoples

often have a unique vantage point for critiquing systems of privilege and oppression.

Marginalized people are challenged to develop a nuanced understanding of systematic

oppression as a matter of necessity, in order to navigate these systems through their lives.

Furthermore, standpoint theory suggests that all research ought to be read with a

critical eye, regardless of the status of the researcher. It asserts that the life and identities

of an author influence the outcome of her research, and that awareness of those factors

strengthens a study. Researchers bring emotion to their subject matter just as clinicians

experience feelings in therapeutic relationships with their clients. With this in mind, the

author has chosen to disclose some basic information that bears relevance to the study.

The author is committed to feminist and anti-racism practices, which shaped the

course of this research. She initially chose to research ritual as clinical intervention in

groupwork with women. Over a year into the project, she realized that she could not

address women so broadly, within the scope of this research, without also compromising

vi
cultural competency. She then narrowed her focus to African American women, a

demographic selected in part because it is underrepresented. The author was also aware

that religious beliefs are strengths of the African American community, and predicted

ritual would be a relevant clinical intervention. In addition, she aimed to grow her

knowledge about the needs of this particular population in the realm of social services.

Several characteristics of the author informed the study. She is a White European

American woman in her late twenties and presents as gender-variant. These aspects of

appearance influenced the interview process by impacting how group facilitators

responded to questions. Additionally, the author uses ritual in her spiritual practice in

addition to integrating ritual therapy within her clinical practice. This experience with

ritual informed her research on the subject of ritual as clinical intervention in the context

of mental healthcare.

vii
 TABLE OF CONTENTS

ACKNOWLEDGMENTS iii

PREFACE vi

LIST OF TABLES x

ABSTRACT xi

INTRODUCTION 1

CHAPTER 1: LITERATURE REVIEW 5

Introduction 5
Spirituality in the Treatment of African American Women 6
Ritual as Clinical Intervention 9
Social Work with Groups 12

CHAPTER 2: RITUAL IN GROUPWORK 16

Ritual in Society 16
Defining Ritual Based on the Literature 17
Ritual and Spirituality 20
The Role of Mental Health Clinicians 22
Ritual in the Context of Groupwork 23
Ritual and the Code of Ethics 23
Spirituality and African American Women 25
Intersection of Race and Gender 26

CHAPTER 3: INTERVIEWS WITH GROUP FACILITATORS 28

Interviews with Groupworkers 28
Defining Key Concepts 30
Barriers to Conducting the Interviews 31
Sensitive Nature of the Topic 33
Creating a Sense of Safety 34
Discussion of Representation 34

CHAPTER 4: RITUAL IN GROUPWORK AT THE AGENCY SETTING 36

Defining Ritual Based on Agency Practice 36
Ritual as Repeated Action 37
Opening Rituals 38
Serenity Prayer 39
The ‘I Am’ Ritual 40
Ritual as Ceremony 40
Birthdays and Holidays 41
Working Through Past Traumas 42

viii
 Art Therapy Rituals 43

CHAPTER 5: CULTURAL FACTORS IN TREATMENT 45

Naming Cultural Differences 45
Role as Caretakers 46
Trauma and Violence 47
Stereotyped as Emotionally Unstable 48
Similar Religious Background 48
Comfort Discussing Race 49

CHAPTER 6: IMPLEMENTATION AT THE AGENCY SETTING 51

Choosing Rituals 51
Client Consent 52
Assessment 53
Therapeutic Benefits 54
Recommendations of Groupworkers 58
Attention to Use of Language 59
Response of Agencies 60

CHAPTER 7: ASSESSMENT AND CONCLUSIONS 62

Limitations of the Study 62
Recommendations for Clinical Practice 63
Conclusions 64

REFERENCE LIST 65

VITA 69

ix
 LIST OF TABLES

Table 1: Information on Groups Represented in the Study 29

x
 ABSTRACT

This paper is an exploratory study on the subject of ritual as clinical intervention

in groupwork with African American women. It is predicated on the idea that ritual has

the potential to foster emotional growth in clients by creating structure and facilitating

processes of transition. Ritual has largely been underexplored in the literature as a clinical

intervention. However, there is a particular gap in research on ritual in groupwork with

African American women. The first half of this paper provides an overview of social

work scholarship covering individual branches of the subject, including spirituality in

social work, spirituality in the treatment of African American women, and groupwork

with women. This is followed by an exploration of ritual therapy as it applies to a wide

range of populations. The second half is an analysis of eight one-hour qualitative

interviews conducted with group facilitators working out of social service agencies

located in a large, Midwestern city. The interviews focus on the use of ritual therapy in

groups and on its specific relevance to the treatment of African American women.

Findings and recommendations for implementation are discussed.

xi
 INTRODUCTION

Many women in the United States participate in some form of group ritual with

other women as part of their cultural customs. When rituals are embedded in a culture,

they are not perceived as esoteric or unfamiliar. Participants may, in fact, take these

occasions for granted without labeling them such. They could be as simple as presenting

a cake with lit candles for someone to blow out on their birthday, or as complex as a year

of specified preparations which precede a traditional wedding event. Rituals have the

potential to foster group cohesion and aid in individual development. They can serve as

markers in time outside of everyday behavior to observe a change that may otherwise

occur gradually or without much notice (Griffith & Griffith, 2002). Rituals often draw

upon cultural identity or invoke spiritual significance in order to assign symbolic value to

an action. This action may allow for feeling as a way of knowing, which offers an

alternative to dominant cultural norms that emphasize cognitive learning (Watt, 2004). In

clinical practice, rituals have the capacity to support clients’ therapeutic growth and

emotional well-being.

Two everyday examples of women’s group ritual in United States are bridal

showers and baby showers. In both of these instances, women gather to offer support

around major life-changing events, namely marriage and pregnancy. These ritualized

gatherings, at their best, offer an individual woman the space to experience the support of

1
 2

community in the process of adjusting to the changes in her life. Both bridal showers and

baby showers help to facilitate a process of transition. The events essentially have

templates that anyone familiar with their cultural practice can use and modify without

great imagination. They are expected and anticipated events in the United States. These

ritualized celebrations recognize rites-of-passage in the life cycles of women.

There are other life transitions common to women which go unrecognized, and

processes of development which meet systematic opposition due to sexism and other

patterns of discrimination. For example, a woman who newly decides to self-identify as

bisexual or lesbian is simultaneously faced with the task of learning how to best function

in the context of heterosexist environments. Similarly, some women who choose to

divorce may encounter resistance from family and religious institutions. In such

instances, clients are required to challenge societal norms and gender roles in order to

experience increased mental health. Consequently, women making positive and healthy

change in their lives may face compromised support systems. Needless to say, these life-

transitions do not tend to have standardized rituals in place. In addition, clients do not

necessarily have the interest, skills or resources to design or implement their own group

rituals. There is the potential for social services and mental healthcare to fill this gap by

facilitating ritual in the context of groupwork (Crisp, 2010).

Existing therapy groups, operating out of not-for-profit organizations and

agencies, provide services that support women who are recovering from trauma. There

are groups to help women heal from sexual assault, recover from an eating disorder, or

transition out of homelessness, to name just a few examples. The demand for these

groups is created, in part, by the marginalization of clients’ traumatic experiences. For

 3

instance, rape survivors often experience the secondary trauma of isolation and “victim-

blaming” in addition to the original abuse. This lack of visibility aggravates existing

symptoms and causes new ones. When there is not support from the larger social

structure for the problems that women encounter individually, social services are

challenged to respond to these mental health needs. Where rituals are generally lacking,

group therapy is an opportunity to intervene. Groupwork presents an opportunity to

provide rituals for women who are going through life adjustments that may otherwise go

unacknowledged in their daily lives.

Mental health researchers and direct service providers have long considered sex

and gender key factors in treatment, largely to women’s detriment. In the tradition of

psychology, women were defined as inherently lacking, and methods of assessment and

treatment alike perpetuated the discrimination of women based on sexism (Marecek &

Hare-Mustin, 1991). Fortunately, in more recent history feminist social workers and

psychologists have advocated for principles of gender equality. While sexist ideologies

continue to compromise the treatment of women, substantial progress has been made. As

a result, there is emerging attention to the differences amongst women. Namely,

treatment of more marginalized populations has been identified as an area of growth in

clinical services for women (Comas-Diaz, 1994).

To talk about women categorically is to cluster roughly half of all people into a

generalizable population. While this is an overly broad category, it is a grouping which

mental health scholarship and mainstream society use with regularity. The consequence is

that writings about “women” have traditionally overlooked populations that are

marginalized due not only to sex, but also gender, class, age and many other factors. As
 4

pertains to race in particular, scholarship about women has most often represented the

experiences of White European American women (or women from the dominant racial-

ethnic group in the United States). In an effort to resist universalizing women, and

thereby perpetuate the systems of racism that marginalize women-of-color, this paper

places a specific focus on the treatment of African Americans. Moreover, an effort is

made to recognize the diversity within this population.

In addition to race and class, this paper acknowledges distinctions between sex

and gender, both of which are socially constructed categories. To be a woman is a matter

of identity and not necessarily anatomy. For example, efforts were made to include

transgender and gender-variant women in the following research, whereas transgender

men, regardless of their gender assignment at birth, are outside of this definition. While

transgender and intersex women are not a focus of this study, they are encompassed

within this categorical definition of women. Although the paper focuses on gender and

race as common variables and does not explore differences such as faith, sexual

orientation, ability, or age, the latter issues are equally important and warrant further

research to address the full range of social inequalities.

 CHAPTER ONE

LITERATURE REVIEW

Introduction

This literature review is divided into three subsections: scholarship about

spirituality in the treatment of African American women, ritual and spirituality in social

work, and groupwork with women. Each of these variables individually represents an

area for potential growth in the social work profession. First, mental health professions

representing predominantly White and middle-class women strive to provide service to

some of the most marginalized women in American society with increased effectiveness.

In this context, cultural-competency with African American women continues to be a

work in progress. Second, the role of spirituality in social work remains unclear to many

social workers bound to a code of ethics distinguishing between professional and

personal values. Spirituality and religion are not consistently seen as a standard part of a

client assessment (Crisp, 2010). The role of ritual has not yet been fully explored as a tool

for clinical practice, in part for these reasons. Third, groupwork arguably is underrated

for its therapeutic value as compared to individual treatment. The decline in an

educational emphasis on groupwork in social work programs has led to fewer specialists

in this area, ultimately compromising the effectiveness of groupwork practice. Currently,

social work with groups is viewed as cost effective without much

5
 6

consideration for skills and training (Simon & Webster, 2009). With consideration for

these key variables, this paper adds to each of these three bodies scholarship.

Furthermore, the paper makes a case for continued exploration of the use of ritual as a

clinical intervention in groupwork with African American women.

Spirituality in the Treatment of African American Women

The following scholarship points to the relevance of spirituality in the treatment

of African American women. Faith and faith-based communities are strengths among

African Americans (Boyd-Franklin, 1987). Clinicians will develop more effective

outcomes by exploring what this means for social services and by considering how

secular spaces can best be utilized to enhance spiritual well-being in the interest of mental

health (Banks-Wallace & Parks, 2004). In addition, this population tends to be distrustful

of many health service providers, and will often hesitate to seek treatment (Fong &

Furuto, 2001). With this in mind, it is important to recognize how spirituality and religion

may serve as a means of coping and can be an important hallmark of culturally competent

services for African American women.

“It’s all sacred” by Banks-Wallace and Parks (2004) is a comprehensive study of

spirituality in African American women’s lives. Banks-Wallace and Parks demonstrate a

strong correlation between spiritual well-being and emotional health in African American

women. They conclude that spiritually-based relationships between women are important

to emotional well-being in this population. The authors note that storytelling was

beneficial to participants and should be considered in forming support groups for African

American women. They also point out that spirituality as liberation from oppression is a

hallmark of African American spirituality. These observations are valuable for

 7

approaches to clinical therapy. This article suggests that clinicians should explore what

this means for social services and how spirituality is a strength that can be harnessed for

treatment.

Black (1999) bases her article on interviews with fifty elderly African American

women living in poverty. The study makes observations to learn about how participants’

spiritual beliefs interact with their experiences of poverty. The author provides an

engaging analysis of common beliefs among elderly African American women living in

poverty. Her study challenges stereotypes of poor African American women as abusing

the welfare system or experiencing a “victim mentality.” Instead, she finds that

spirituality is most commonly utilized as a support system.

Musgrave’s (2002) article is an overview of spirituality as it relates to health in

several different populations representing of women-of-color. She touches on a womanist

perspective (a form of feminism focused especially on Black women) in which health is

understood as the absence of oppression. She also speaks to the ways that Black women

meet their religious needs on a regular basis. Musgrave posits that African American

women’s spirituality is grounded in a historical experience of slavery in which women

sought the support and refuge of God. She suggests that building relationships between

agencies and religious institutions is a useful way of reaching area residents and tapping

into community resources.

O’Brien (2001) writes about an empowerment workshop for incarcerated women.

As a White woman of European descent, O’Brien shares how she ultimately managed to

facilitate a group where the participants were able to meet their needs. She had to

acknowledge the institutionalized racism which makes Black women vulnerable to

 8

incarceration. O’Brien explains that her clients create a “sacred space” before addressing

the clients’ issues as inmates. Each session ends with what she calls a “culturally derived

moment of inspiration” in which the facilitator shares a poem, a song, photography or

another uplifting artistic work by an African American woman (p. 47).

Thomas (2004) takes a systematic, strengths-based perspective to explain

spirituality as a valuable coping mechanism utilized by the African American

community. The author examines the relationship between spiritual beliefs and cultural

stereotypes, and how the two interact to affect African American women’s emotional

health. She demonstrates how spirituality and systematic oppression inform the

experiences of this population. Furthermore, she shows that spiritual and religious beliefs

can sometimes be engaged as a coping skill that African American women often already

have in place as a tool for managing emotional difficulty. At other times, a client needs to

examine and shift spiritual views in order to further emotional growth. Thomas shows

that in either case, spirituality must be considered an important factor of treatment in

order to provide culturally competent services.

Watt (2004) writes about spirituality as it relates to the identity development of

African American women who are also traditional college-age students (meaning

students who attend college within one or two years of completing their high school

education). African American women in this group are likely to be upwardly mobile and

represent one of few individuals from their home communities attending college. The

article discusses the challenges these students often face, and the coping skills they have

in response to particular obstacles. There is a focus on the role of spirituality as a means

of coping and resistance. She critiques identity development models that are based on
 9

White cultural norms, in particular models that presume a cognitive way of learning.

Watt shows that African American spiritual traditions emphasize feeling as a way of

knowing, indicating that a cognitive approach is not a fit for many African American

women.

Ritual as Clinical Intervention

This subsection looks at definitions of the term “ritual” used in social work

scholarship in order to provide a foundation for the definition used in this paper. A

pervasive theme of the literature about ritual is the suggestion that in modern American

society there is a lack of meaningful ritual. As a result, clients do not always have access

to the community support and opportunities for transition that are of benefit to their

emotional health. Social service providers can continue to address this deficit by making

ritual an accessible therapeutic intervention, and empowering clients to engage in the

healthy use of ritual on their own outside of the therapeutic context.

Ritual can be defined in a variety of ways. In this paper, it has the potential to

hold spiritual or cultural significance. Griffith and Griffith (2002) aptly describe ritual as

performative. Ritual is an act of literally going through physical motions in order to

enable a client to progress emotionally. Ritual is symbolic but simultaneously gives

meaning to the present. It is an embodied act of creating meaning that can be

conscientiously used to enhance treatment. When a group ritual is done effectively, a

participant experiences growth due to the added benefit of support from one’s

community. Social work scholars have noted that there is a dearth of ritual in mainstream

American culture to the detriment of individual growth (Laird, 1984; Sullwold, 1998).
 10

While not all of the articles addressing the subject of ritual gave clear, concise

definitions of its meaning, those that invoked the term with figurative connotations more

likely to clarify its significance than articles that used the word as a synonym for

“routine.” This suggests that while the word ritual often refers to acts with symbolic

meaning, it is not an everyday usage that can be taken for granted. Laird (1984) asserts,

“Ritual has existed in all cultures, in all ages, and for all time. Yet it remains a notion

insufficiently understood, elusive, underutilized but potentially extremely important for

mental health professionals” (p. 123). Griffith and Griffith (2002) recognize the

significance of ritual in the human lifecycle when they explain, “Rituals and ceremonies

serve a special role in human life by punctuating experience into meaningful chunks of

time” (p. 167). The literature broadly refers to rituals as actions that create meaning for a

client. This meaning-making fosters a sense of purpose and self-worth.

Griffith and Griffith (2002) explore ritual as a fundamentally performative

act. This article is distinctly valuable for its clear conceptualization of ritual as an

embodied act. It is a thorough piece that shows how ritual occurs both within and

beyond the constructs of religious practice. Ritual is a performance that engages

the emotions of a participant. The authors observe the benefits of engaging the

senses:

Rituals, ceremonies, and spiritual practices share some other similarities.

To perform each of them, a person must participate with body as well as
mind. Each of the three goes beyond language to engage the body through
physical action and bodily experience—specific posturing, gesturing,
speaking, hearing, eating, drinking, touching, smelling (p. 165).

Griffith and Griffirth suggest that rituals have distinct therapeutic effects due to the fact

that a participant feels their emotions on a more visceral level.

 11

Aguilar and Wood (1976) propose the use of a specific death ritual with clients of

Mexican heritage. The authors offer an overview on the specific cultural needs and social

situation of monolingual Spanish-speaking people. They write about the significance of

death in Mexican culture, and explain how the American hospital setting interferes with

the traditional Mexican grieving process. The authors recommend that clients enact the

burial of a loved one. One person enacts the role of the dead by lying on the ground. The

therapist encourages clients to share thoughts and feeling that they wish they would have

said to the person who has passed, or perhaps would have like to have been able to say.

Aguilar and Wood advocate for this ritual as a culturally competent treatment option for

grieving Mexican Americans.

Mason and Haselau (2000) write about a co-facilitated workshop with fifteen

participants as part of the South African Association of Marriage and Family Therapy

Conference in 1997. The authors write about the steps of the workshop and incorporate

the verbal and written reflections of the participants. Specific rituals for mourning are

named, including writing a letter that one does not send. The conference also outlines the

structure of a ritual workshop for processing grief. Participants speak as social work

professionals assessing the use of ritual that they have experienced for themselves.

Laird (1984) writes a foundational piece for the subject of ritual studies. She

discusses the value of ritual more generally before moving into an exploration of

underritualized families. She makes suggestions for implementation in family therapy.

These span from establishing shared mealtimes to developing rites-of-passage. The

author argues, “Whatever the condition and fate of ritual today, it is clear that the form of

ritual has considerable power. . . . So may social workers learn how to capture and apply
 12

more effectively the use of ritual in their interventions with families” (p. 128). She offers

an example of how spirituality can be incorporated into clinical treatment using ritual as

an intervention.

Gilbert’s (2000) article addresses the role of spirituality in social work with

groups. She argues that spirituality has been neglected in the social work profession and

calls for more scholarship on this topic within groupwork literature. Her article serves as

a guide and a call for social workers to become increasingly competent with regard to the

subjects of spirituality and religion. She advocates that mental health providers attend to

the impact of spirituality in the lives of clients. She also advises clinicians to remain

attentive to possible oversights and countertransference throughout their practice.

Social Work with Groups

There is need for emerging scholarship on groupwork to ensure continued

knowledge and growth of its value (Simon & Webster, 2009). Groupwork is sometimes

under recognized for its therapeutic benefits as compared to individual treatment.

Additionally, professionals who specialize in facilitating groups are arguably in decline.

Much of the literature on groupwork focuses on the therapeutic benefits specific to this

modality. Several of the following sources are foundational writings that establish key

principles for the practice of social work with groups. A couple of articles specifically

look at how feminist principles are applied to the theories and practice of groupwork.

Another article looks specifically at groupwork with African American women. These

texts may deepen an understanding of groupwork with African American women.

If a social worker interested in groupwork scholarship were to read only one text

on the subject, it would likely be Yalom’s (2005) The Theory and Practice of Group
 13

Psychotherapy. A major contribution of this work is his description of the eleven

therapeutic factors of groups. These factors account for the unique benefits of facilitated

therapy groups. For example, one therapeutic factor utilized in ritual therapy is termed

“universality.” Universality refers to a client’s positive experience of relating to others

who are struggling with problems similar to their own. Ritual can enhance a client’s

experience of universality by creating a shared experience of growth. It could also foster

group cohesion through participation in an action for the purposes of a shared goal.

Yalom makes a clear case for the usefulness of groupwork as distinct from other forms of

therapy.

Toseland and Rivas (2005) complement the work of Yalom with an instructional

text entitled An Introduction to Groupwork Practice. For practical purposes, this book

serves as a guide for how to run a group. Toseland touches on a number of qualities about

groups that are relevant to the use of ritual. For example, he lists the leadership skills

required of a group facilitator who has primary responsibility for ensuring that the group

is effective. These include involving others and attending to others. The skills Toseland

and Rivas name are also relevant to facilitating ritual in the context of a group (p. 104).

He suggests the possible use of “program activities,” an umbrella term that could

encompass ritual (p. 245).

Schiller (1997) contributes to theories of group development with her article

entitled, “Rethinking stages of development in women’s groups.” She builds upon her

previous piece about the unique group development process that takes place in

groupwork with women. According to Schiller, the stage of conflict generally takes place

substantially later than in groups of women as compared to most men’s groups, or even
 14

mixed-gender groups, where group members typically vie for power at the outset. In

contrast, in many women’s groups there is the need to establish a relational base of trust

before engaging in conflict with one another. Schiller demonstrates that Berman-Rossi’s

(1993) model of group development does not apply to most women’s groups. However,

Schiller’s (1997) model for women’s groups does not consistently fit for African

Americans. It has, however, been found to fit a wide range of women’s groups including

African Caribbean women, as Schiller herself notes (p. 17). The author points out that

African American women’s groups are not accurately represented by a model that

generally refers to “all” women. Clearly, additional models are needed to explore specific

patterns of development in this population.

Boyd-Franklin (1987) observes an absence of literature about groupwork for

Black women. Unfortunately, there has been little advancement since she published her

article entitled “Group therapy for Black women” twenty-five years ago. She reports on

her findings from three ongoing psychotherapy groups for Black women. Boyd identifies

recurrent themes in these groups, and considerations for group treatment of Black

women. These include difficulty expressing strong emotions, complaints about male-

female relationships, navigating mother-daughter relationships, religion and spirituality,

and overwhelming responsibilities to their families. The author asserts that therapy

groups for Black women offer group members an experience of “sisterhood” that they

otherwise typically lack in their lives. Group members can serve as a uniquely valuable

support system due to shared experiences of race and gender.

Reed and Garvin (1996) also look at the implications of feminist theory on

groupwork practice. The authors argue that writings on feminist therapy tend not to
 15

acknowledge the extent to which feminist principles are integrated into group therapy

practices. The authors provide an overview of feminist politics as they relate to

groupwork, and then proceed to outline thirteen feminist principles for group therapy.

These include maintaining social justice as a major goal, valuing the process as much as

the product, striving to strengthen relationships among women, and the reexamination of

power within the group. Reed and Garvin continue the work of developing theories for

effective group practice with women. Additionally, they bring a critical feminist analysis

of power and privilege, promoting groupwork as a vehicle for social change.

 CHAPTER TWO

RITUAL IN GROUPWORK

Ritual in Society

Group ritual has been used throughout many cultures, and across time, as a way of

effecting psychological growth (Al Krenawi & Graham, 1996; Gallambos, 2001; Guilmet

& Whited, 1987; Idowu, 1992). Ritual therapy, or ritual as a clinical intervention, is a

treatment modality used in clinical practice more often than the literature would suggest.

The word itself sometimes has ethereal connotations. However, rituals are often

experienced as ordinary events even when they have strong significance for participants.

Group rituals that are expected to foster emotional healingare often taken for granted as

an ongoing aspect of the life cycle and a normal part of building healthy relationships,

families, and larger communities.

Positive rituals can lead to strong mental health outcomes. Inversely, an absence

of ritual may indicate a gap in a client’s resources and support systems. The symbolic

meaning captured by a ritual is, in practice, an actual marker of significance and support

in the life of a client (Crisp, 2010). Gaps in rituals can indicate an area for clinical focus.

For example, some clients who grew up in unstable homes may not have had ritual

around their birthdays in childhood (McWhirter, 2006). For the average American

16
 17

adolescent who lacks a clearly recognized rite-of-passage to adulthood, this gap in ritual

may demonstrate itself as destructive behaviors, including binge drinking and unsafe

sexual practices (Sullwold, 1998). For some LGBT (Lesbian, Gay, Bisexual,

Transgender) clients, patterns of discrimination that interfere with rituals around

committed partnership can indicate barriers for clinical focus (Lanutti, 2005). For couples

recovering from adultery, a deficit in rituals following the trauma of infidelity can

prevent that couple from developing increased intimacy (Winek & Craven, 2003). The

underutilization of ritual may be not only detrimental for individual clients, but also

harmful on the societal level, in which whole populations are underritualized.

Defining Ritual Based on the Literature

There are many different meanings associated with ritual, both within and outside

of mental healthcare. In this paper, the term refers to symbolic action performed by a

participant in an effort to foster growth or change. Canda and Furman (2010) write:

Rituals not only mark transitions, they also create them, celebrate them,
and help us to pass through them safely. Indeed, many rituals of healing
and helping can be understood as rites of passage that help a person to
pass from a condition of distress to a new condition of restored or
enhanced life. Therefore, theory of ritual process provides us with keen
insight into the transformational process that is so important in spiritually
sensitive social work (p. 316).

A ritual takes a client’s desire to change, and through a performed act turns that desire

into an actualized decision. A ritual does not normally lead to instant and dramatic

transformation. Instead, it is more often an important moment or a turning point within an

extensive process. For example, funerals represent a ritual that facilitates a process of

grieving, yet for those experiencing significant loss it is also just one step very early in

the stages of grief. Ritual is typically valuable as part of a longer process, and not a
 18

singular, isolated act. It is an intervention that can be effectively implemented within the

framework of a longer treatment process. The therapeutic benefits of ritual may be

enhanced when facilitated by social workers who are trained and bound to a Code of

Ethics.

The above definition of ritual focuses on three separate qualities: embodied

performance, symbolic action, and a participant’s intention to make change. In

Encountering the Sacred in Psychotherapy, Griffith and Griffith (2003) point out that

ritual is experienced with the body as well as the mind, creating a “direct encounter of

bodily experience with culturally shaped stories, myths, and sagas” (p. 165). A critical

feature of ritual is that an action, apart from language, gives expression to the voice of a

client. This element also distinguishes ritual therapy from more traditional therapeutic

practices. In “Healing rituals for rape survivors,” Gallambos (2001) defines ritual as

“symbolic acts or rites that help people do the work of relating, changing, healing,

believing, and celebrating” (p. 66). This definition of ritual combines the two

aforementioned concepts and adds the element of intention on the part of a client or

participant.

There is the potential for a great deal of variety in ritual. One type of ritual is

repeated action, as in a ritualized process of opening and closing group sessions

(Gallambos, 2001). Rather than one grand gesture which recognizes the change of a

client, repeated ritual may facilitate the development of an individual while it

simultaneously aids in group development. This use of ritual can also serve as a

transition into the therapeutic space. For one African American women’s spirituality

group this meant singing a spiritual each time they began a session (Williams & Green,
 19

1999). A group for homeless and addicted women opened sessions with meditation

exercises (Plasse, 2008). Gillard and Moore (2007) explain how early childhood

educators on a Native American Indian reservation regularly incorporate drumming and

music into the classroom, so that the students’ school culture is not experienced as alien.

The use of these rituals to create a comfortable classroom environment is equally relevant

to social work with groups, both within and outside of the school setting. This form of

ritual can help to create structure and foster safety among group members.

Ritual can also entail a procedure involving multiple stages of action, which could

also be referred to as ceremony. In “Women’s empowerment through feminist rituals,”

Neu (1995) writes about facilitating several group rituals, including that of an incest-

survivor. This woman experienced marked improvements in her mental health following

the death of her father, who had sexually abused her in childhood. She sought support

from a women’s community in the form of ceremony as part of her recovery process. To

open the ceremony, participants lit candles and placed evergreens around her home.

Next, participants each tied a knot in one of the deceased father’s handkerchiefs to

represent their personal objection to violence. After a sequence of several more symbolic

actions, the participants sang and danced before closing the ceremony. This is an

example of ritualized action which serves to facilitate a major life transition.

There is a definite -yet sometimes subtle- difference between ritual and other

activities that can be used as therapeutic interventions. Ritual as it is described here

incorporates all three of the aforementioned qualities, whereas other interventions that

bear similarity may only have one or two. It is possible for a client to sing during a

session without ascribing any symbolic meaning to the act. However, if a client intends to
 20

sing a song and create some sort of personal change upon completing that performance, it

becomes ritualized. Clients and therapists can potentially ritualize an activity by adding

qualities or components to enhance the symbolic significance ascribed to an action.

It is also possible that within a group of clients participating in the same activity,

some would experience an activity as a ritual, while others would not. In situations where

all are asked to stand and recite the pledge of allegiance, some will experience it as a

ritual while others undoubtedly would consider it an empty gesture. The experience of a

ritual then is highly dependent on the motivations and meanings for the client and the

context in which it occurs. In some instances, a ritual may even be repeated numerous

times before a participant begins to experience the action as ritualized. In order to ensure

that ritual is effective, the ritual must engage the client and be attentive to individualized

client needs.

Ritual and Spirituality

An exploration of ritual in clinical practice leads to a question about the role of

spirituality in social work. The subject of spirituality and religion as it applies to a

therapeutic context is sometimes fraught. When the role of spirituality in social becomes

unclear, practitioners tend to shy away from the subject. This may partially account for

why the social work profession underutilizes ritual as intervention. Crisp (2010) writes:

Spirituality involves an awareness of the other, which may be God or

other human or divine beings or something else, which provides the basis
for us to establish our needs and desires for, understand our experiences
of, and ask questions about, meaning, identity, connectedness,
transformation and transcendence. . . . Most, if not all, of these concerns
are, or arguably should be, issues of relevance in social work, and will
now be considered in turn (p. 7).
 21

Spirituality, defined as a way of experiencing self-worth and of relating to others, is of

clear importance to mental health services. In this light, ritual is an intervention

especially beneficial to clients who bring a spiritual orientation.

Ritual is, nevertheless, not inherently religious or even spiritual in nature, nor is it

tied to any particular culture or belief system. In theory, any client can potentially benefit

from ritual regardless of beliefs, cultural background, or other variables in identity.

Regardless, rituals are often felt to be “spiritual” by those participating in them. More

than many other activities, ritual therapy has the potential to be experienced as “sacred.”

This modality allows room for the client to have an experience that fosters spirituality,

yet it does not promote a specific belief system and therefore breech the Code of Ethics.

These qualities make ritual therapy a useful tool for clients seeking an experience of

spiritual growth.

Ritual therapy could be especially suitable for clients who use religion or

spirituality as a way of coping, though the technique could be equally relevant for clients

who do not have a religious identity to facilitate transformation. Ritual can act as a

catalyst to foster an increased sense of well-being. While some rituals traditionally take

place in a religious context, or are informed by a religious belief system, they are not

necessarily religious. Since rituals are different from mundane activities, they may induce

a sense of awe and an altered state of mind, regardless of a client’s experiences with

religion. Rituals have the potential be empowering. They can add direction to clients’

lives by creating periods of intense significance.

 22

The Role of Mental Health Clinicians

Mental health professionals can take several different roles to support the use of

ritual within the life of a client. They can affirm healthy rituals that a client performs

outside of therapy, for example, the use of prayer to cope with difficulties. At other times,

a therapist can help a client develop their own ceremony, such as hosting a “house

blessing” at their new place of residence. A ritual could also be shaped by a client and

take place during a session, as part of therapy. A final prospect is that the therapist could

design a ritual for a group or client, based on the needs of the client. This would be called

for when the client does not have the resources or desire to shape their own ritual, but

would like to experience the benefits of participating in one. It is within the purview of

the mental health field to help create healthy rituals for clients who do not have the

resources or interest in creating them, yet would benefit from participation.

Professional development for the mental health clinician requires ongoing

reflexivity about the distinctions between one’s personal values and professional ethics.

For many therapists, the subjects of religion and spirituality raise challenging questions

over this distinction. Some mental health professionals, for this reason, are wary of

including a client’s spiritual or religious beliefs as part of a mental health assessment. It is

important that counselors not promote their personal values within therapy. However, this

does not suggest that clinicians ought to devalue the role of religion or spirituality in the

life of a client. That is an example of countertransference in which the clinician avoids a

topic of discomfort. Ritual therapy is a clinical intervention in which clients may

potentially have a spiritual or religious experience within the context of a session, and

which can be implemented within the Code of Ethics.

 23

Ritual in the Context of Groupwork

There are compelling benefits to doing ritual therapy in the context of a group. In

a group, members have the opportunity to grow from here-and-now interpersonal

interactions with their peers, rather than solely with a therapist who, however egalitarian

that person may be, is still positioned as an authority. As part of an ongoing, closed

group, ritual therapy could be used in combination with models of group development,

such as those proposed by Berman-Rossi (1993) or Schiller (1997), in order to help the

group achieve its stage-oriented goal. Kelly (2006) explains how, in a women’s

wilderness-based experiential group for survivors of abuse, cohesion was fostered during

a rock wall-climb. Group members put their trust in one another, both literally and

symbolically, when one member would “belay” another as she climbed seventy feet. In

the termination stage of a group for South Asian women who survived intimate partner

violence, group members were given art supplies and asked to trace outlines of their

hands beside each other “as a symbol of the connection the women experienced in the

group” (Singh & Hays, 2008, p. 96). These rituals support the group-as-a-whole by

allowing them to move towards shared goals for treatment.

Ritual and the Code of Ethics

Ritual therapy needs to be implemented with attention to the needs of particular

clients. As part of the social work profession’s client-centered approach to “meeting the

client where they are at” the use of ritual, or lack thereof, will vary for each client’s

individualized needs. If a client resists a ritual, then it is not an appropriate treatment with

that person at that time. Likewise, if a client expresses interest in performing a ritual that

would interfere with their therapeutic goals, then it is the responsibility of the mental
 24

health professional to intervene. There will also be clients who would benefit from ritual,

but who would not want to participate in anything labeled a ritual. For clients who have

had negative experiences with “ritual” the term itself may be offensive and alienating. In

this case, using different language to refer to the same practice is appropriate. Respect for

the client’s culture, preferences, and meaning comes before professional intervention.

It is important for the facilitator to ensure that implementation of ritual therapy is

done in accordance with the NASW Code of Ethics, with special consideration regarding

to race, ethnicity, and culture. If a client wants to appropriate a ritual from a marginalized

culture, at this risk of exploitation, it is the responsibility of the therapist to intervene and

ensure that the profession’s commitment to social justice is not compromised.

Unfortunately, racist exploitations of ritual in U.S society persist. American Indian

traditions have been especially vulnerable to exploitation since this culture is associated

with romantic notions of spirituality. It would not inherently be exploitative for a group

without Indigenous members to use a smudging technique, derived from American Indian

traditions, as a cleansing ritual. However, if a group is not concerned about the

oppression of American Indian people, then there is a likelihood that this ritual would be

unethically appropriated and it is recommended that the mental health professional

encourage the use of an alternate ritual. Regardless of what rituals a group uses,

facilitators are responsible for encouraging members to consider the larger social

implications of their actions, and for challenging clients to learn about the cultures from

which specific traditions originated.

 25

Spirituality and African American Women

As previously described, the relevance of spirituality to social work practice is

sometimes lost within the mental healthcare profession. Consequently, many

professionals who openly integrate an assessment of spiritual or religious well-being into

their services are either drawn or driven to private practice. As a result, ritual therapy

becomes far less accessible to those who only have access to public institutions. The

marginalization of spirituality in treatment becomes an issue of cultural competency for

populations with both a spiritual orientation and socio-economic disadvantage. Clients

who do not have access to private therapy, such as working-class and poor African

American women, may have limited access to ritual therapy.

Numerous scholars point to spirituality as a strength amongst African American

women, and a critical factor in culturally competent clinical treatment (Banks-Wallace,

2004; Black, 1999; Boyles, 2008; Harvey, 2006; Musgrave, 2002; Thomas, 2001; Watt,

2004). The communal nature of this population, intuitive way of perceiving one’s

environment, and a strong experience of spirituality and religion indicate a potential for

ritual therapy to lead to positive outcomes (Black, 1999; Greene, 1994; Thomas, 2001;

Watt, 2004). Although African American women represent a population that may benefit

from ritual more than most, they are less likely than other groups to have access to this

therapy. This presents a larger issue of discrimination and cultural competency within the

field of mental healthcare.

More innovative interventions are needed to meet the needs of African American

women, a population which is largely underserved. There are a couple of reasons that

ritual therapy appears to be especially relevant to groupwork with African American

 26

women. One is the communal perspective of African American culture. Mitchem (2008)

writes that the individualistic, hierarchical, medical model in the United States conflicts

with an African American perspective of healing based around community. Groupwork is

a modality that emphasizes the group itself as a vehicle for growth. A second reason is

that spiritually-based relationships between African American women are important to

emotional well-being in this population. Groupwork potentially offers a therapeutic

setting in which women can form and grow these relationships. Ritual could help be used

to help build spiritually-based relationships between group members.

Intersection of Race and Gender

Evidently, there continues to be a gap in culturally competent care for African

American women. The needs of African American women are not consistently reflected

in literature describing women in general. As Schiller (1997) indicates, this is the case not

only in contrast to White European American women but also as compared to many

groups who represent women-of-color (p. 17). For example, African American women

are burdened with a stereotype of strength and ferocity whereas many other groups of

women are weighted with assumptions of weakness and frailty. Although African

American women experience trauma that bears similarity to women from other racial-

ethnic groups, they are often seen as a backbone of strength within their community.

In order to effectively serve a marginalized population, the clinician requires a

working knowledge of the stereotypes clients from that demographic face in daily life.

Watt (2004) observes that treating African American women effectively means resisting

the myth of the “strong Black woman” who is able to endure endless hardship. Thomas

(2001) deconstructs three stereotypes of this marginalized population in American

 27

culture, the mammy, the sapphire, and the jezebel. The “mammy” is a dark-skinned obese

woman, who is seen as nurturing to others at the expense of her own needs. The

“sapphire” is an angry, arrogant African American woman who can never be satisfied.

This stereotype can have an impact on how women experience and express their anger.

The “jezebel” is an oversexed and sexually aggressive woman. This image can shape how

African American women experience and express their sexuality. These stereotypes are

relevant to the clinical treatment, including but not limited to groupwork and ritual

therapy.
 CHAPTER THREE

INTERVIEWS WITH GROUPWORKERS

Interviews with Groupworkers

The researcher conducted eight, one-hour interviews with facilitators of groups

having a membership of at least thirty percent African American women. This interview

process received approval from the Institutional Review Board of the sponsoring

university. The researcher explained that the interviews would be confidential, and

interviewees would be asked to provide a pseudonym. The primary recruitment methods

were e-mail outreach and phone solicitation to not-for-profit agencies that provide mental

healthcare services. During recruitment calls, the researcher explained that she was

arranging interviews on the subject of ritual in groupwork with African American

women. She described the research as anthropological and exploratory in an effort to

learn about current uses of ritual with this population. Her expressed purpose was to

explore the relevance of ritual in social services for African American women. She

further explained that the groups did not need to be exclusively women, or exclusively

African American. Teenage women, roughly sixteen and older, would be included.

Transgender women were also named as a match for the research. The researcher

conveyed that she aspired to represent the diversity of this demographic as much as

28
 29

possible, and could be available to discuss any questions that group facilitators may have

before accepting an interview.

Table 1. Information on Groups Represented in the Study

Name Population(s) Closed/Open Length Women/Mixed

Women who have

experienced sexual
C.I. violence Closed 10-12 weeks Women

People with an Axis 1

diagnosis who are on
public aid and
medicaid, Receiving
Sophia out-patient care Open Ongoing Mixed

Homeless women
seeking permanent
Kristen supportive housing Open 6-8 weeks Women

Incest-survivors, Ongoing, Running

Natalie Mostly at mid-life Closed for two years so far Women

Perpetrators of
Domestic Violence, Minimum 24 weeks,
Kate Mandated treatment Open Allowed 2 absences Women

Women transitioning
from incarceration,
Typically with a
substance abuse
Amy history Closed Unknown Women

Homeless women,
Typically with a
history of abuse or
Juanita neglect Open Unknown Women

Homeless women and

drop-in clients, N/A, different group
Alana Mostly at mid-life Open members every week Women
 30

Defining Key Concepts

In the United States, it is not uncommon for people to use the terms “Black” and

“African American” interchangeably. The researcher has made an effort to avoid doing

so, in the interest of cultural competency. There are a variety of populations which are

racially Black, yet who do not necessarily fall within the category of African American.

One example is Black people of Caribbean heritage. This population has a different

cultural background than that of many African Americans with a lineage tracing back

most recently to Africa. First generation immigrants from Africa, who often have an

identity is based on their country of origin, also have a different cultural experience that

many African Americans. Some Black Latinos may not self-identify as members of the

African American community. This paper does not attempt to create rigid boundaries

about exactly who qualifies as African American. However, it does distinguish between

race and culture for the purpose of gathering information specific to populations of Black

women with African heritage living in the United States.

In the context of this paper, groupwork with African American women does not

refer only to groups that are exclusively women or exclusively African American.

Although the latter groups are included in this category, the focus here is on African

American women and the interventions most suitable to this population. Mixed-gender

groups may have unique benefits to women that participate as compared to women-only

groups. For example, Antle, Becky, and Collins (2009) write about an African American

women’s breast cancer survivor’s group exclusive to women members. In a survey

conducted upon the conclusion of the group, women expressed a wish that the men who

represent their support systems be invited to participate in future groups. They wanted a
 31

venue in which the men in their lives could be present to offer compassion. These survey

results suggest that it is the interest of some African American women’s mental health

outcomes to participate in a group with men from their communities. Consequently,

mixed-gender groups are still relevant to a discussion focused on women. For this reason,

a mixed-gender group was included in the research.

Barriers to Conducting the Interviews

Whenever there is a gap in the literature, it is valuable to explore the barriers to

research which serve to perpetuate the underrepresentation of that topic. The same

systems of oppression that compromise client services for African American women

become obstacles to creating increased visibility in the scholarship. Many organizations

that serve African Americans are understaffed and underfunded, which limits group

facilitators’ ability to participate in an interview, or even return voicemails or e-mails

from the researcher. For other organizations, confidentiality is such a concern that

participating in even a masked study is too high of a risk to for their clients. Several

organizations shared that they were not currently running groups at their agency in spite

of staff efforts, due to a lack of sustained membership. When providing client services is

itself a struggle, it follows that staff do not have additional time and energy to offer to

research.

The eight interviews were conducted with six employees and two student interns

working at the agencies. Although these individuals are highly functioning professionals,

some showed difficulty with follow-through due to systematic barriers. Two out of eight

interviews were rescheduled after staff did not show up for the interview without

cancelling. They both were generous when rescheduling, indicating their commitment to
 32

the research. One met the researcher at her University after work, and the other came in

to meet for the interview on her day off. In the case of a third interview, the confirmed

agency address was incorrect and several miles away from the actual site. When the

researcher went into a social agency near the incorrect address to inquire about the

agency location, front desk staff asked the researcher if she would like an internship.

Even after the researcher declined, the staff asked the researcher if she could help them

establish an internship with her University. The fact that an agency in this community

was so understaffed they would offer an internship to someone inquiring about directions

speaks to the staffing issues which present barriers to the research.

Location presented a challenge in several different ways. A number of the

interviews were conducted at sites located in areas with limited access to public

transportation as compared to neighborhoods with more socio-economic privilege.

Several of the interviews took place in spaces within the agency where the facilitator was

interrupted. Two group facilitators who originally identified as potential interviewees

asked that the researcher call back several weeks after the initial contact, due to issues of

agency relocation. In the case of one of these agencies, when the researcher called back

within the recommended timeframe the facilitator directed her to contact an attorney for

permission to conduct the interview. This occurred the same week that the closing of this

same facility appeared in the news. The attorney did not return the researcher’s

voicemails. Evidently, the systematic issues that lead to instability in these agencies also

presented practical challenges to conducting research.

 33

Sensitive Nature of the Topic

It is also important to note the sensitive aspects of this research as pertains to race,

ethnicity, and culture. The topic lends itself to appropriation and could be used to

perpetuate racist stereotypes about African American women. The fact that the researcher

represents the dominant racial group in the United States is also an important

consideration since she is situated to perpetuate systemic racism. There is hierarchy built

into in the research process, whereby a researcher carries the power to represent research

“subjects” through her own lens. White researchers too often present distorted and biased

images of racially marginalized communities.

Many people-of-color have responded accordingly by taking precautions to

protect these marginalized communities from misrepresentation. Natalie (personal

communication, April 9, 2012) called attention to this dynamic during her interview:

I definitely want to bring up my concerns that I had. The sense of when a

Caucasian person is interested in African Americans and gathering
information about them and rituals, sometimes the tone that I have heard
from professors who have done that research is, “how primitive people are
organized and their cultural ways are . . . really advanced for who they
are.” . . . So, those are definitely concerns that come up for me because I
don’t want to be the person that’s going to feed into that.

Natalie identifies patterns of racism and stereotyping in research about African American

people which present barriers to research about racially marginalized groups. The

researcher responded by affirming these concerns and expressed a mutual interest in

resisting racism that oppresses African American women. She also professed a

willingness to challenge and educate White people as part of her commitment to racial

justice. Open dialogue about the role of research in perpetuating racism are essential to
 34

addressing gaps in research about people-of-color. These conversations are also required

to recognize barriers that stymie research on the treatment of African American women.

Creating a Sense of Safety

There are several reasons that the aforementioned group facilitator may have felt

comfortable enough to express her concerns about the research. Before meeting the group

facilitators in person, the researcher e-mailed each of them with a description of the

project, a list of the interview questions, and an offer to answer any questions that they

had about the research prior to meeting in person. The researcher began the interviews by

building rapport, and asking group facilitators about their day. She explained that

although the purpose of the interview was to learn from the facilitator’s insight and

experience, there was also room for the facilitator to ask questions of the researcher. In

addition, she explained that it was permissible for the interview to be conversational at

points. Furthermore, during the course of the interviews the researcher affirmed the value

of what group facilitators expressed, especially when they stated a lack of experience or

knowledge around the topic. The researcher encouraged group facilitators to share

incomplete thoughts. She told them they would have the opportunity to review a draft of

the paper and provide input on how the content of their interview would be represented.

Discussion of Representation

Although the title of the paper refers to the treatment of African American

women, the paper does not aim to represent African American women as a general

population. The researcher interviewed the first eight people who met the criteria for the

study and who were also willing to participate, without attempting to obtain a randomized

sample. As a result, four of the eight groupworkers she spoke with ran their groups out of
 35

agencies that either primarily or exclusively serve homeless women. The ratio of African

American women facing homelessness is disproportionate to that of the U.S. population.

Nevertheless, the ratio of agencies serving homeless women represented in the study still

does not reflect the rate of homelessness within the African American community.

Instead, it speaks to the relevance of group therapy as an intervention at agencies which

offer housing and support services.

The remaining four agencies that participated serve clients with a broader range of

presenting issues. A fifth agency works with perpetrators of domestic violence who are

mandated to choose between participation in group treatment or incarceration. A sixth

agency serves clients with severe mental illness receiving out-patient care. The remaining

two agencies provide services to survivors of sexual violence. One is open to anyone who

has been victimized by sexual assault, and the other is a group specific to incest

survivors. Very few middle-class women were represented in these groups. Lesbian,

bisexual, and transgender women were included, although no groups specifically serving

these populations were part of the study. The groups represented in the study do not

target the needs of either middle-class women or LGBT populations, just to name two

examples. In the remainder of this paper, references to African American women refer to

the subpopulations that utilize these social services.

 CHAPTER FOUR

RITUAL IN GROUPWORK AT THE AGENCY SETTING

Defining Ritual Based on Agency Practice

Due to the exploratory nature of this topic, a majority of the groupworkers

interviewed had not previously considered the role of ritual in their groups. Since ritual in

these terms is not consistently used a part of clinical vocabulary, many of the group

facilitators had not thought about ritual as intervention prior to the interview. Kate

(personal communication, April 13, 2012) remarked, “Up until you called and I got to

this interview I didn’t give it any thought whatsoever. I was like ‘Oh crap, she wants to

talk about ritual. We don’t do ritual.’” Sophia (personal communication, April 5, 2012)

similarly reflected, “I really didn’t think of it that way and then I started thinking about

and we do have a lot of ritual that is sort of created and perpetuated.” C.I. (personal

communication, April 2, 2012) also expressed this sentiment saying, “I would never have

thought about this, so I was thinking about how am I going to answer the questions, but it

is completely going in a different way.” Although the term itself was new, most group

facilitators were able to identify numerous examples of rituals in their groups. In these

eight interviews, two primary usages of ritual emerged that are discussed here. These are

ritual as repeated action and ritual as ceremony.

36
 37

Ritual as Repeated Actions

When asked to define rituals and provide examples, the most common answer

provided by groupworkers was the definition of ritual as a reoccurring action. Kate

(personal communication, April 13, 2012) clarifies, “For me ritual is something that

happens repeatedly, even if it happens repeatedly with not the same person. We are an

open group so our group membership is constantly changing, which is why we do these

exercises again and again and again.” Facilitators talked about opening and closing

rituals as a way of transitioning into and out of the group session. Sophia (personal

communication, April 5, 2012), who uses yoga poses and meditation exercises when

facilitating her groups, explains,

It’s comforting for students to know exactly what they need to do when
we come into a class. It’s like, “Okay, come into this pose, this pose is
what you are going to stay in for meditation.” So it’s like a regular class,
we do that at the end as a ritual. It creates this circle of completion.

Facilitators talked about expectation being a key benefit of ritual. Repeatition allow

clients to experience consistency in their lives in general, and particularly in their mental

health services. “There is the ritual of the daily; the things that are set up that are

consistently done that help create a sense of safety and consistency in the space that we

meet” (Natalie, personal communication, April 9, 2012). Kristen (personal

communication, April 5, 2012) notes that in her groups, actions are repeated when they

have a positive impact on clients: “So the way that things become ritualized is that they

work.” These rituals serve to create structure and stability.

 38

Opening Rituals

Multiple facilitators shared that their groups have an opening ritual of checking-in

with one another. Alana (personal communication, April 27, 2012) describes this

process, saying, “We have a check-in and they can talk about how they are feeling that

day. Everyone has to go around and introduce themselves, and say one little thing about

them as it related to that specific day.” Additional opening rituals include reading poems,

quotes, or bible verses. A specific technique Amy (personal communication, April 16,

2012) uses to open her dance/movement therapy movement groups is a warm-up ritual:

I let that be guided by the women, in terms of what body part they want to
warm up next. Where are you sore? Where do we need more energy? So
we always start that way and the way I do it is that the person changes the
movements. So if we are moving our arms and someone starts rolling
their shoulders then we will start to roll our shoulders.

These various ways of opening a group help ease the transition from daily activities into a

therapeutic space.

Kristen (personal communication, April 5, 2012) names two opening rituals

practiced by groups at her agency. The groupworkers invited the group members to create

their own ritual. She describes an opening ritual that her Moms Group chose:

They do a thing where they go around the circle one by one. They say,
“Take your hand in my hand and together we’ll make it,” and go around
the circle until everybody is holding hands with each other and then we
start the meeting. That is something we asked them about, “Is there
anything you want to do, a chant, anything you want to do at every
meeting that brings you together at the beginning or at the end or
wherever?” And that’s what they decided.

The Moms Group provides an example in which the clients were able to establish a ritual

with the support of the facilitators who helped them come to a group decision. Kristin
 39

also discussed food as a ritual. In this instance, the agency offers a nurturing gesture to

clients while also setting an expectation that they will reciprocate with participation:

We always have food. We talk about it a lot actually, it’s expected. . . .

“We feed you because you have kids and you come in around dinner time
or after school, you are coming here to participate in something and we
really value and respect your time so this in exchange for your time.” . . .
We talk about it a lot and why food is there, and the ways it’s not okay to
come eat and then leave the group and not participate, because this is
something that you share together and that we provide because we respect
you and your time. So this is a give and take.

Kristin notes that food is a draw for many different populations in a variety of settings,

regardless of race or socio-economic status. Providing food to group members is a way to

demonstrate respect for participants and to create a nurturing environment.

The Serenity Prayer

Two facilitators noted the use of the serenity prayer has been used as a closing

ritual in their groups. Alana (personal communication, April 27, 2012) explained that it

was an easy ritual to incorporate since many clients in Alcoholics Anonymous were

familiar with the prayer from that setting. She observes, “[In trauma group] they did the

AA prayer at the end because a lot of the members found that helpful. So we would get in

a circle and do the AA prayer at the end of each meeting.” Amy (personal

communication, April 16, 2012) did her internship at a faith-based agency, where the

clients developed their own ritualized way of performing this prayer:

We always end with a prayer, so we say the serenity prayer together in a

circle holding hands and we kind of have a different way of doing it. So
one person always starts it and says, “Whose father?” and they start, “Our
father.” The next part is, “Who woke us up today? God, grant us the
serenity. . . .” Then everyone holds hands and says, “Have a blessed day,
all day long.” They do kind of like a let-go of energy and that’s how we
end group.
 40

This ritual is already familiar to many women with a history of substance abuse, and also

reflects the religious and spiritual beliefs of many, though not all, African American

women. Subsequently, the serenity prayer is one closing ritual that is relevant to groups

for African American women who are transitioning out of homelessness.

The “I am” Ritual

Kate shared an activity that she and other staff members at her agency developed

for working with perpetrators of domestic violence. The purpose of this ritualized activity

is to help clients gain self-knowledge about their needs and learn skills for

communicating those needs to others in healthy ways, rather than resorting to violent or

harmful behaviors. Kate (personal communication, April 13, 2012) describes the steps:

They have to sit facing each other and then make eye contact, which they
hate. And one person can only listen. The other person has to spend about
three minutes speaking, sentence after sentence, starting with “I am.” The
listener is only allowed to say, “You are?” They hate it. One, they don’t
like the attention. They also don’t like the knowledge that it brings up that
they don’t know themselves very well. But I have had more than one
client say to me, “You know during the week when I was sitting on the
bus, I was thinking about it and I can use that.”

The facilitator points out that the repeated use of this activity adds significance and

increases the therapeutic outcomes for group members. It challenges the clients to deepen

their self-awareness in the context of relationships, and to develop active listening skills

as a form of support to another person who is facing many struggles similar to their own.

Ritual as Ceremony

A second kind of ritual that group facilitators identified is ritual as ceremony. It is

an event based around a symbolic action that recognizes a change in the life of a client.

As discussed earlier, ceremony as groupwork practice can serve to foster change and
 41

offer a support system to clients where they are otherwise lacking in the life of a client.

Familiar ceremonious rituals, such as birthdays and holidays, can be enhanced to add

therapeutic value. Original ceremonies provide community support for accomplishments

that otherwise remain unacknowledged in the broader culture. This type of ritual creates a

special occasion.

Birthday and Holidays

The celebration of a birthday or a holiday can take on added significance for

specific populations. Natalie facilitates a women’s group for adult survivors of incest.

This closed group has run for two years without a stage of conflict. The members are

highly intentional about creating a system of support for one another. Natalie describes

the use of ceremony in the group:

The other things that I see happen are ceremonies that occur during certain
occasions or commemorate certain things that are going on. Birthdays can
be considered a ritual. We definitely celebrate birthdays in the group. But
also if it’s something they want to make that is big, acknowledging
something (personal communication, April 9, 2012).

Juanita (personal communication, April 20, 2012) reports that her clients also have rituals

around customary celebrations. For the homeless populations served by her agency,

standard cultural rituals represent stability and “normality” that group members have

lacked in their lives. Juanita comments, “The other [rituals] I would say are holidays and

the way we celebrate, celebration in general. You can see rituals when it’s a person’s

birthday. Surprising enough, the ladies will tell you in advance.” Rituals provide a

healthy means for clients to develop supportive relationships.

Birthday celebrations take on special significance in the group for incest-

survivors. Natalie (personal communication, April 9, 2012) explains that for this
 42

population, a core part of the treatment process is recognizing the inner child. Birthday

celebrations become an opportunity to use ritual as intervention:

The group wants to share and acknowledge their birthdays. Usually we

have cupcakes and sing happy birthday. I think this year actually I sang
happy birthday to them. I have used tiaras or some kind of thing. One of
the pieces of child sexual abuse is working on your inner child. So really
trying to make it a space where there is fun and just acknowledgement.
We have cupcakes and fruit, play a game, something to just kind of play
together and fellowship together.

Natalie adapts birthday celebrations to meet the needs of her group members by adding

extra childlike components. These festivities provide corrective experiences to address

abuses that the clients faced in childhood.

Working through Past Traumas

Facilitators also identified rituals that enabled clients to work through previous

traumas and relieve pain associated with the past. Natalie facilitated a ritual honoring the

group’s second anniversary. The ritual aimed to empower group members recovering

from the traumas of childhood incest. Natalie explained that she derived the underlying

idea for this second anniversary ceremony from a first anniversary ritual, developed by a

former group facilitator, in which the women participated in a literal washing of their

hands to symbolize cleansing themselves of their past. She (personal communication,

April 9, 2012) describes the process of design and implementation:

So what I came up with after consulting with some of my co-workers was

that . . . they took paper streamers and wrote down [three] things they
wanted to break ties with. The facilitators held the streamers and the client
said, “I break ties with the past,” so they walk through it and they break it.
As they walk through these ties that they have broken, they go to the other
end of the room where their group members are standing. There was also a
bowl full of rocks that had different sayings on them, so they chose a rock
they wanted that represented what they wanted to claim in life now.
 43

One particularly positive outcome Natalie observed was seeing the group members

looking towards one another for affirmation, rather than looking to the facilitators. This

ritual marked an occasion commemorating the longevity and cohesion of the group.

In a group for women transitioning out of homeless, Juanita (personal

communication, April 20, 2012) guided members through a ritual where they

symbolically released painful emotions by actually releasing balloons in the air. She says,

“For us one time, we wrote out different issues that hurt the heart, put it in the balloon,

blew up the balloon, went outside and let it go.” Juanita reassured clients that it would not

matter if someone found the contents of the balloon, since the balloon would not be

linked to the client. This ritual allowed her clients to feel less tied to negative experiences

in their pasts. As a result, they could look more positively towards the future in order to

fully realize their potentials.

Art Therapy Rituals

Two facilitators described the use of art therapy techniques which functioned as

ritual in their groups. C.I. (personal communication, April 2, 2012) facilitates groups for

survivors of sexual violence. She once led a ritualized activity in which group members

were asked to reflect on their growth process during their time in the group. C.I. says, “I

gave them two papers. One paper is what they look like the first day in the group and [the

other is] how they look now. It was the 7th week-ish. So they can perform each part on

the paper.” Kate (personal communication, April 13, 2012) also describes the use of an

art therapy technique in her mandated group for perpetrators of domestic violence. She

explains, “Back in the fall, there were some clear anger issues going on the group, so I

got a piece of poster board and markers and put them on the floor and everyone had to
 44

draw anger. That prompted a really interesting discussion.” Art therapy rituals pose a

different means of engaging clients through symbols and embodied action.

 CHAPTER FIVE

CULTURAL FACTORS IN TREATMENT

Naming Cultural Differences

Directly questions about the specific relevance of ritual for groupwork with

African American women proved to be a sensitive subject in most of the interviews.

Identifying cultural differences too often leads to stereotyping, so facilitators expressed

hesitation as well thoughtfulness when sharing a response. The researcher typically

prefaced these questions by explaining their purpose: recognizing difference in the

interest of developing culturally competent intervention. C.I. (personal communication,

April 2, 2012) answered the question by saying, “I think because I’m an Asian I do not

distinguish between the [racial] groups.” Natalie (personal communication, April 9,

2012) initially challenged the question, stating, “Rituals are relevant to any culture, to be

perfectly honest. It’s not just because it’s a norm, but that’s why people get married,

ceremony, daily whatever, every ethnic group.” Sophia (personal communication, April

5, 2012) asked for a moment to consider the question before answering. She shared her

thought process aloud, asking, “Can you give me a moment to think about it? I do work

with non-African American women and I teach them yoga and I need to think about if I

do something differently with one population versus another.” Overall, the subject of race

and culture remained a sensitive topic in the exchanges between the researcher and

45
 46

facilitators. Regardless, most groupworkers identified cultural factors that they take into

consideration when working with the African American women in their groups.

Role as Caretakers

Several facilitators identified the enormous responsibilities that many African

American women have as caretakers within their communities. Kate (personal

communication, April 13, 2012) describes this demographic as the conservator of ritual:

So the African American women are the conservator of family which

means conservator of ritual and you can see it in . . . the women in my
group. They are almost all single women who were raised in most cases by
single women or with a father who was not in the picture. And the cycle is
perpetuated. . . . They are the ones who create . . . the family meal, which
is a huge ritual. They are the ones who take everybody to church. They
are ones who organize the family reunion or call everybody together.
They are the ones who are responsible for remembering birthdays creating
birthday parties, for getting the presents for celebrating religious or other
holidays.

Kristin (personal communication, April 5, 2012) observed the significance of this role in

African American women’s lives during the process of promoting a leadership training

group to clients. Her original recruitment strategy promoted the group as an opportunity

for participants to gain new skills along with a certificate in leadership. When this initial

approach did not appeal to clients, the facilitators reframed its purpose:

We started going through the organizing tools. The organizing model we

use is through COFI (Community Organizing and Family Initiatives) and
they have a model that starts with the self and moves up to the family; the
idea being that if you are not taking care of yourself you’re not going to be
able to create change in your community.

Kristin’s second strategy, which focused on creating healthy families and communities as

a goal of the group was successful at recruiting new members. Sophia (personal

communication, April 5, 2012) also comments on the responsibilities that many African
 47

American women have to extended families. One intended outcome of ritual therapy is

that clients to develop new strategies for self-care. Rituals stress the importance of self-

care to group members:

I think that any of these practices/rituals are extremely important for them
to be more connected with themselves. African American women are the
caretakers. They are the matriarch. They are the ones who take care of the
kids, the grandkids, the nephews, everyone in the neighborhood. . . . They
have to do everything. So if these rituals can just help them create, help
empower them so they are more aware of what their needs are so that they
can take care of themselves. I am hoping that that is happening . . . They
are strong --they have to be. But I think it comes at a very high cost to
themselves.

Group facilitators spoke of the far-reaching responsibilities that many group members

have as caretakers, calling attention to the role that women in African American

communities play as distinct from other racial-ethnic groups.

Trauma and Violence

Several facilitators identified a common experience of violence and trauma in

African American women. These observations were made by facilitators whose groups

are not specifically geared towards survivors of violence. Amy (personal communication,

April 16, 2012) is particularly tuned into her clients’ physical symptoms:

There is a strong, vast trauma history for almost all of the women; a lot of
sexual abuse, physical abuse, emotional abuse starting pretty early into
their childhood. So that is something I always take into consideration and
be sensitive about when working with the body. And I am a
dance/movement therapist, and working with the mind, body and spirit
connection. So going into the body can be very scary or challenging for
somebody who has experienced so much trauma. Also, because of that a
lot of the women are very defensive or have a lot of defense mechanisms
built up.

Sophia (personal communication, April 5, 2012) concurs that, “There’s in general a

common experience of African American women of trauma and some sort of abuse or
 48

violence, whether it is direct or witnessed.” This common experience of bodily trauma is

a consideration for mental health clinicians to be aware of when working with African

American women seeking mental health services.

Stereotyped as Emotionally Unstable

Kate (personal communication, April 13, 2012) points out many of the women in

her groups are surprised when others display a show of empathy. She observes, “They’re

not used to people genuinely, insightfully caring about their emotional well-being. It’s

assumed that if they are not screaming they are fine and if they are screaming they are

crazy. . . . As a whole the word ‘crazy’ seems to be applied to African American women

far more readily than it does to White women.” She notes that many group members are

apologetic for crying or for taking up time in the group. The response of group facilitators

is to validate their feelings and assure clients that this is a purpose of the space. Kate

explains that, following a particularly difficult disclosure, facilitators will directly ask

individual clients if they received the support that they needed. “I get this flash of

surprise, like huh, and they usually tell us they did. The question is so unexpected.” The

opportunity to display vulnerability in a group has tremendous therapeutic value for her

client population.

Similar Religious Background

There are common experiences around religion and spirituality for many of the

women represented in the group memberships. Kristen (personal communication, April 5,

2012) notices a shared language among her members:

A lot of our clients for various reasons are very Christian, very strong in
their faith. . . . A lot of them go to all Black churches, they talk about God
 49

a lot. . . . Even if they are not super religious they know they share that
common language in talking about faith.

This common experience among clients can potentially be a basis for connection between

group members. Amy (personal communication, April 16, 2012) observes that religious

background is an important aspect of culture in the lives of her clients:

I think that is part of the cultural piece is that familiarity with religion. I
think that the movement, bringing gospel music sometimes, bringing
music choices they enjoy, I think it invokes certain movements or rhythm
that African America women relate to or have experienced in a church
setting growing up.

The shared religious beliefs introduced to many African American women as part of their

upbringing are often tied to shared rituals. Religious practices are informed by racial-

ethnic culture as well as religion in the strictest sense. It follows that some Christian

rituals in African American communities are distinct from those of other racial-ethnic

groups. For example, it is not uncommon for African Americans to converse with

deceased relatives through prayer (Banks-Wallace & Parks, 2004). Sects of Christianity

influenced by traditional European American cultural values do not typically incorporate

ancestral prayer.

Comfort Discussing Race

Some group facilitators have found that their clients are comfortable talking about

systems of racial discrimination which impact their lives, even while language around the

discussion varies. Kristen (personal communication, April 5, 2012) supports group

members’ observations and insights about discrimination:

Something I see from all my clients but especially in my groups is that

they are able to talk about power and privilege in a really conversational
way. It is just a part of their conversation, like, “If White people moved
into the neighborhood we would get this. . . ”
 50

Alana (personal communication, April 27, 2012) speaks of a comparable experience in

her groups. She says that they are vocal about their concerns with her as a young, White

woman. “It’s interesting, race and the differences between them come up a lot, and they

are definitely not afraid to talk about it.” In these groups, discussions about power and

privilege are not considered taboo. They are a part of everyday conversations.
 CHAPTER SIX

IMPLEMENTATION AT THE AGENCY SETTING

Choosing Rituals

There are a variety of ways that ritual is chosen in groups, depending on the needs

of the population, the nature of the agency, and the skills and strengths of the facilitator.

In Kristen’s group, which represents women in permanent supportive housing, the

women largely create their own rituals through a client-centered approach:

I think it’s important that if there is ritual involved that it is created by the
women in the room and that is comes from them. Even things like [the
opening ritual I mentioned earlier in which the women clasp hands and
recite], “Put your hand in my hand and together we will make it.” [It’s
important] that it’s not forced and the facilitators—and in my case the
White lady in the room—doesn’t create those rituals or decide what
should happen (personal communication, April 5, 2012).

Kristen’s clients are at a level of functioning where they are inspired to create and sustain

their own rituals. Furthermore, Kristen taps into their empowerment by asking group

members to participate in creating their own rituals and, in essence, invites them to take

part in forming their own treatment plan.

Kate (personal communication, April 13, 2012) leads a group in which clients

demonstrate a need for the facilitators to maintain the rituals. She observes, “They don’t

get to decide very much, it is a mandatory group, a part of me wishes it were otherwise.

51
 52

Even a mandated group with a group of clients that were healthier and possibly better

educated—not necessarily book-learning—but into emotional and logical health and

well-being, there would be opportunity for them to create ritual.” She explains that one of

their group rituals was developed during a staff meeting. The staff shared similar

challenges with helping their clients to gain insight, and developed an exercise in which

clients learn to articulate their identity and their needs.

Some clients with higher levels of functioning are empowered by the process of

choosing their own rituals. Other client groups, such as mandated group members and

women with severe mental illness, receive greater benefit from rituals designed by group

facilitators or other agency staff. It is important that clients have the opportunity to

consent to participation in rituals. Even so, there are situations when a persistent group

facilitator, who challenges the resistance of group members, is perceived as a caring and

supportive leader.

Client Consent

Obtaining client consent is essential when working with most populations.

Generally speaking, clients have stronger client outcomes from a treatment plan that they

have agreed upon. This principle also applies to ritual therapy as much as any other

intervention. The importance of ensuring that a ritual reflects client interests becomes

apparent when Sophia (personal communication, April 5, 2012) talks about directing her

clients to say ‘namaste’ (a salutation originating in Sanskrit) at the close of a session

together: “For while they wouldn’t say ‘namaste.’ Slowly, I explained the meaning and

how it is used in India and then they came around. Since it wasn’t messing with their

belief system it was okay.” Once the facilitator explains the significance of the ritual and
 53

gains the full consent of clients, they are able to gain the benefits of the intervention. C.I.

shares that the responses to an art therapy technique used in her group were varied,

largely because participants signed up for the group expecting to participate in discussion

only. Alana (personal communication, April 27, 2012) gained consent to recite the

serenity prayer as a group by asking members verbally: “I always felt it necessary to say

‘is everyone ok with this,’ to give people the option to not be in the circle or just not do it

at all if they felt uncomfortable.” Do to sensitivity around the subject ritual, it is

particularly important to obtain consent in the use of ritual therapy in order to ensure

positive client outcomes.

Assessment

The researcher asked facilitators how they assessed whether or not a ritual was

affective. Juanita (personal communication, April 20, 2012) explained that in addition to

conducting surveys, the clients provide feedback verbally. Beyond that, group facilitators

observe behavioral changes:

You see it in their behavior, or they tell you verbally, “I really got a lot out
of that.” . . . Or women who never talk start talking. Women who normally
stay ten minutes are staying twenty-five minutes. Women come back the
second day. Ladies who talk real loud start using inside voices because
now they don’t need to get the attention. You can see it now, they are
getting together to have their own mother’s day brunch, but they are fixing
everything. They are saying, “Let’s do our community better.” When you
see them taking more responsibilities and what is going on around them.
But we have to measure it, so we measure it with surveys.

Natalie (personal communication, April 9, 2012) has received similar feedback from

group members who benefit from the ritual, “Some of the women have definitely said

they really like being able to do the reflection and sometimes the contemplation that the
 54

special rituals kind of bring up.” Amy (personal communication, April 16, 2012) knows

specific dance/movement therapy techniques for assessing the effectiveness of ritual:

We all have the ability, we call it kinesthetic empathy. We can feel it. We
can go through the body. Do they look like they are really connected
or committed to what they are saying? What was their expression, affect in
comparison to their posture or gestures—the non-verbal? So that’s part of
it, just being able to see them really commit to their own movement in the
group and seeing that they are really expressing what they are feeling.
Then at the end seeing them truly open about what they are going through.

In contrast to other facilitators, Amy’s training has provided instruction on assessing

ritual as a clinical intervention. Alana, an intern with critiques about how groups are run

in her agency, remarked, “The only assessment is that they have a client survey every

year, that’s it. They survey the women and see what they like or don’t like. They might

have one or two questions about the groups but that is it” (personal communication, April

27, 2012). Current agency operations allow for very limited use of ritual in groups. Alana

observes these constraints as a major shortcoming to providing effective services.

Therapeutic Benefits

The theme of structure emerged as primarily benefit of ritual. Amy (personal

communication, April 16, 2012) eventually chose a more ritualized therapy technique for

working with her clients:

I was trying some other dance/movement therapy methods and I realized

naturally, the Chacian method of dance/movement therapy was working
better. It just naturally emerged, this process of moving from the Warm-
Up to Body Action, Rhythmic Activity and Closure. They know how it’s
gonna progress. They know that we are going to have time to talk about it.
We are gonna have a prayer at the end. They know the process. It gives
the feeling of safety that it’s going to be alright to go there because we
will have a moment to decompress and get back out of it and prepare
ourselves for the day.
 55

Amy demonstrates that the structure of ritual can allow a client to explore emotionally

difficult material while experiencing a sense of safety, since it is done within the

framework of a familiar and supportive structure. “[Ritual is] a kind of way of saying I

am going to leave what’s going on outside, out there, so I can be here and focus on

what’s going on with my life” (Natalie, personal communication, April 9, 2012). This

mental focus is especially significant for women recovering from addiction, and who are

developing resiliency to cope with difficult emotions they previously avoided by abusing

substances.

For many clients from these agencies, the structure of ritual creates a stability they

do not have throughout the rest of their lives. Kate, who works with mandated clients,

says that the experience of structure and consistency found in ritualized behaviors is one

that has been missing in the lives of most of her clients. She says, “For many of our

clients this is the only real structure they got in their life, particularly the women. We

hear a lot: ‘I like coming to group’” (personal communication, April 13, 2012). Ritual

can foster an experience of safety in the environment by creating structure. At an agency

running groups that are open to homeless women and other drop-in clients, the opening

ritual of doing check-ins is an empowering precedent:

The fact that they get to say how they feel that day, who they are and what
rule they want and what they want to happen in the group, I think that is
powerful for them. So the little ritual we are using, I think that’s the
purpose it serves for our population (Alana, personal communication,
April 27, 2012).

Alana’s remark suggests that this check-in, which for many individuals who do not

experience homelessness is somewhat unremarkable, can be a very powerful intervention

for the clients served by her agency.

 56

Facilitators identify a wide range of benefits that can result from ritual therapy.

The repetition of certain activities creates an opportunity for participants to experience

Yalom’s (2005) instillation of hope in which earlier members are motivated by the

accomplishments of other group members. Kate (personal communication, April 13,

2012) perceives the structure of the ritual as a foundation for this outcome:

[Ritual] provides a sense of continuity that’s important in group,

particularly with these clients. . . . They will help each other during the
check-in and check-out. The final self-evaluation is a good learning
experience for the individual but it is also good for the group members to
hear, “Oh, this person like me got a positive benefit out of this, maybe I
can too.”

Several facilitators also spoke to ritual as a technique for fostering cohesion, or feelings

of belonging to the group, which is another of Yalom’s therapeutic factors of groupwork.

Amy (personal communication, April 16, 2012) suggests that the synchronized physical

movement between clients aids in their group development. “The essence of having

[shared] something similar creates a bond between everyone in the group.” A positive

experience of ritual builds trust within the group. In addition, rituals can create an

experience of universality in which clients appreciate that their emotions are shared by

others:

The rituals and the groups help with feeling a sense of togetherness,
reducing the amount of isolation the person was experiencing before or
may continue outside the group experiencing. Definitely feeling that sense
of community can be very restorative. . . . I think that with African
Americans in general, when we see each other there is a feeling of shared
experience, so sometimes familiar rituals help reinforce that shared
experience (Natalie, personal communication, April 9, 2012).

Ritual can be implemented to specifically utilize one or more of Yalom’s eleven

therapeutic factors, such as the instillation of hope, cohesion, and universality.

 57

Sophia (personal communication, April 5, 2012) notes several benefits of ritual in

work with her populations, out-patient clients with several and persistent mental illness

who qualify for social security and Medicaid. First, the use of ritual helps to create

mindfulness by interrupting harmful thinking patterns and intrusive thoughts:

Tapping into the thought process is extremely important. I tend to think

that when we are experiencing mental illness or symptoms of depression
or schizophrenia or bipolar or whatever it is, there is a lot of reacting
going on. I’m hoping that these rituals sort of stop this—stop to intervene
in the thought processes that could be negative or destructive.

Mindfulness techniques lend way to ritual while engaging a cognitive-behavioral

approach. Second, she observed that ritual aids in socialization. “Another thing that is

really cool in these rituals and in these processes is that people start to become more

aware of each other. . . . Them noticing each other is a huge deal as far as the

socialization piece.” Clients who typically demonstrate very limited interpersonal skills

are more perceptive of what others are doing around them. Third, the rituals that Sophia

uses have a positive impact on both mental and physical health of her clients:

They tell me all the time how, “My knee feels better, my shoulder feels
better,” whatever it is, so they feel good physically. . . . They will tell me,
“I woke up and I did down dog [pose] this morning and my back feels
really good.” Or they tell me, “I was in this situation and I was really
angry and I breathed and then I felt better.”

Her effective use of yoga and meditation demonstrates that these techniques can have a

wide range of clinical benefits.

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Recommendations of Groupworkers

Facilitators were asked to share recommendations that they would give to another

groupworker for using ritual with African American women. Facilitators offer a variety

of answers based on their own professional experience. Kate (personal communication,

April 13, 2012) answers, “[Do] not expect deep insight. . . . These clients do not have the

luxury of time and emotional energy to put into insight and understanding themselves,

because that is a painful process. They have too much pain in their life. They do not need

to add to it.” Along similar lines, Amy (personal communication, April 16, 2012) advises

that therapists be persistent and confident in developing rituals, and not be deterred by

some hesitation on the part of clients:

I would say be confident in the structure . . . that you create together and
hold that as a norm, a group norm. Allow time to develop a group norm
and try to keep, find a solid foundation to what that looks like. . . . It’s a
process of trial and error at first, but trusting when you see that something
is working, to go with it. I think that a big part is being open to their
experience, to the resistance. See it and be confident in what you see
working and be able to stand by that.

Her sentiment is echoed by other facilitators as well. Juanita (personal communication,

April 20, 2012) recommends that the facilitator maintain a client-centered approach. She

instructs, “The one thing that ruins the group is when the facilitator does more of the

talking. You are just picking up on a couple of words, and bring your input in, but your

comments are not the ones to focus on. You want to focus on theirs.” In the same vein,

Natalie (personal communication, April 9, 2012) recommends that some disclosure can

be very beneficial to developing rapport with clients. She advises,

I think acknowledging your flaws is helpful and I think showing emotions

is okay—not to the point that the clients are worried about you, but they
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need to know that you are human. I don’t think it works for everybody, but
self-disclosure, I think for our community is appreciated.

Their suggestions create additional guidelines for the effective use of ritual in groupwork

with these subpopulations of African American women.

Attention to Use of Language

Throughout the interviews, groupworkers advised exercising caution with

language. Word-choice can help to bridge differences in education between facilitators

and their clients. Natalie (personal communication, April 9, 2012) stresses, “Really being

conscious of the language you use is important, use something familiar. If you use

something clinical that’s a real big turn off . . . because it makes it seem like you aren’t

really speaking to them.” Kate (personal communication, April 13, 2012) reiterates this

same concept, saying, “Other advice is to watch your language. With my women—and I

know it slips through with me—but you have got to make a determined effort to not

sound like an educated White woman.” These observations highlight that facilitators are

most accessible when their communication style does not reflect privilege.

Facilitators also reflected on the importance of using language specifically as it

respects the religious beliefs of the client. Sophia (personal communication, April 5,

2012) consciously uses different language when she guides the same rituals in a yoga

studio as compared to the hospital setting where she works as a counselor. She reflects,

“What I choose to talk about with my clients and with students in a yoga studio is very

different. . . . With my clients at work I use language that I feel will appeal to them so I

talk in physical terms. I say anatomy, because that’s really relevant to them.” Amy
 60

(personal communication, April 16, 2012) speaks to the importance of using the client’s

language out of respect for their worldview:

I think it’s always important to incorporate the clients’ language—

whatever it is. Not all of my clients [believe in] God and the Devil but if
they use that language, or if they say it to me, as a therapist I am going to
reflect back what they said and not alter it and change it.

The facilitator can use clients’ word preferences in order to work with them on their

terms.

Response of Agencies to Use of Ritual

Fortunately, the majority of agencies represented show support for the use of

ritual in groups. Natalie (personal communication, April 9, 2012) says, “This place is

pretty supportive of what we do with the clients.” Sophia (personal communication, April

5, 2012) has the same affirming experience in her agency. She remarks, “I have gotten a

very positive response from everybody, which is really nice. . . . My boss happens to be

really awesome and he’s just into that stuff and he sees and he is very good at

acknowledging how it is affecting the population and it doesn’t cost a lot of money.” In

both cases, importance is placed on the impact that ritual has on clients. Furthermore, if

the rituals used are feasible and do not require additional resources, then this a valued

way of providing innovative treatment options.

A couple of the groupworkers critiqued their agencies approach to ritual. Kristen

(personal communication, April 5, 2012) expresses concern that fellow staff members

tend to dismiss her efforts to affect positive change in the lives of clients. This is reflected

in their response to her use of ritual:

Something that is always interesting is the way that other people in the
agency respond to seeing ritual or groups approached in this way. . . . I
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have a set of politics where I refuse to be punitive with clients. . . . When I

can I bend to get around rules and get them what they need. That’s been
interesting and one co-worker said, “If clients start walking around here all
empowered, people are going to be pissed. This is why we have to do this
and in this way and too bad for them.”

Rituals that lead to strong client outcomes threaten the stability of existing agency

operations. Alana (personal communication, April 27, 2012) sees the limitations of an

agency in which groups are run by students doing one-year internships. The group

facilitators have diminished ability to influence agency operations. At her organization,

even groups that establish effective rituals are short-lived under these circumstances:

There used to be a group called a Can of Milk Club. . . . They would

always make tea, so that was kind of a ritual they had: making the tea
every single week. That’s gone now and mood management took its
place. The fact is that Can of Milk Club was relaxing, but now there is no
tea-making going on. . . . If no one comes in and wants to start that group,
that group will die out.

Alana pointed out additional aspects of agency operations that are not conducive to

establishing rituals. Since all groups are open and ongoing, with very little consistency,

retaining members is difficult. In this case, the existing agency structure undermines

client services, and rituals are made nearly impossible due to issues of administration.
 CHAPTER SEVEN

ASSESSMENT AND CONCLUSIONS

Limitations of the Study

Numerous limitations of the study are explored in depth throughout the paper and

only briefly summarized in this section. The sample presented several limitations to the

study. The sample size is too small to be generalizable to broader populations.

Furthermore, the selection of interviewed groupworkers was not randomized.

Consequently, group members described in this paper do not accurately reflect the

African American community as a whole. Instead, the study represents African American

women participating in groups facilitated at social service agencies in a large,

Midwestern city. The subpopulations included are women transitioning out of

homelessness, survivors of incest and other sexual violence, women receiving out-patient

care for severe mental illness, and mandated perpetrators of domestic violence. Although

African American women are disproportionately poor and the homeless, the study

nevertheless over-represents both poor and homeless women.

There were additional systemic barriers to conducting interviews. On the part of

groupworkers and their affiliated agencies, barriers included communication, location,

and agency issues of being understaffed and underfunded. These factors limited the

extent to which facilitators were able to contribute to the research project. There were

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also challenges regarding the scope of the study. The interview process consisted of just

one meeting with each facilitator, which presented an obstacle to developing a rapport

between the researcher and interviewees. It would be optimal to conduct a series of

interviews with each interviewee allowing for a more full investigation of sensitive

topics.

Recommendations for Clinical Practice

Several key recommendations for ritual therapy in social work were generated by

the research. A client-centered approach during processes of selection and

implementation enhances therapeutic outcomes. It is of utmost importance that clinicians

respect their clients’ preferences when using ritual therapy, due to its sensitive nature.

One area for clinical focus is use of accessible language when describing or

implementing ritual. Additionally, groupworkers are responsible for preventing unethical

appropriations of ritual from marginalized cultures in accordance with the profession’s

commitment to social justice.

Social work practice would benefit from increased dialogue about groupwork

along with role of spirituality and religion in clinical services. It is in the interest of

mental healthcare that practitioners advocate for quality in groupwork practice, through

education and training, and by supporting innovation in research and implementation. It

is also in client interest that providers further explore the relevance of spiritual and

religion beliefs to clinical practice. In particular, there is a call for groupworkers to

develop strategies for bridging differences in beliefs between themselves and their group

members. This component of cultural competency is often overlooked.

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Group facilitators can continue to develop cultural competency by identifying and

communicating the needs of clients who are marginalized due to systemic racism.

Specifically, it is important to recognize the unique cultural experiences of clients with

intersecting oppressed identities. For instance, the experiences of African American

women cannot be presumed to be some combination of research about the needs of

“African Americans” (which often implicitly refers to men) paired with research about

the needs of “women” (which most often implicitly refers to White women). Research

narrowly focused on African American women will best foster cultural competency in the

treatment of this demographic.

Conclusions

The study suggests that ritual is utilized as a form of clinical treatment more often

in practice than is reflected by the literature. Although ritual therapy holds practical

relevance within the mental healthcare profession it is underrepresented in scholarship.

Without a strong theoretical foundation, the potential of ritual therapy cannot be

harnessed to its fullest capacity within the field of mental healthcare. Ritual is

underutilized in therapeutic practice including, but not limited to, the context of social

work with groups. This underutilization arguably leads to repercussions for African

American women clients, who benefit from a spiritual orientation and from approaching

feeling as a way of knowing. In the interest of developing more culturally competent

treatment options for African American women, this study suggests that further research

on ritual in groupwork with African American women is warranted.

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 VITA

Kathryn K. Berg was born and raised in Chicago, Illinois. Before attending

Loyola University Chicago, she attended Hollins University in Roanoke, Virgina, where

she earned a Bachelor of Arts in Women’s Studies, with Departmental Honors, in 2005.

While at Loyola, Kathryn did her first level field placement at Loyola University

Chicago’s Department for Students Diversity and Multicultural Affairs, where she

developed and implemented a seven-session group psycho-educational training on White

anti-racism identity development. She did her second level field placement as a counselor

at Truman College, one of the City Colleges of Chicago, where she facilitated individual

counseling sessions. Kathryn also won second place in the distinguished program

category in 2011 at the ACJU (Association for Jesuit Colleges and Universities)

Conference on Multicultural Affairs for her curricular model entitled White Identity

Development and Anti-Racism Training: A Psycho-Educational for White European

Americans.

Currently, Kathryn is focused on earning her clinical license before pursuing a

doctorate in social work. She lives in Chicago, IL.

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