History of Nia
AN INTERVIEW WITH DR. NADINE J. KASLOW (NJK),
DIRECTOR OF THE GRADY NIA PROJECT
AEE: What does Nia mean? Why name the program Nia?
NJK: Nia is a Kwanzaa principle that means purpose. It refers to making it our collective aim to develop and build our community in order to restore people to their traditional greatness. When we started our efforts we wanted a culturally relevant word to describe the program. We reviewed the Kwanzaa principles terms and our team, along with the women in the program, selected Nia because helping women find purpose and meaning in their lives is a central goal of the program.
AEE: When was Nia established, how did it start, and where has its funding come from?
NJK: Nia started in the early 1990’s purely as a program of research. We were fortunate to receive a grant from the Centers for Disease Control and Prevention (CDC) to examine factors that differentiated African American women who attempted suicide from those who had never attempted suicide. Our results revealed that intimate partner violence was one of the major predictors of a suicide attempt in this population. This finding led to our next study, which was also funded by CDC. In that study we compared risk and protective factors in African American women who had been abused and attempted suicide versus African American women who were abused but had never attempted suicide. The information we gleaned about risk and protective factors combined with input from focus groups of abused and suicidal African American women informed the development of our culturally-informed empowerment intervention that we still use today. Our intervention program is designed to reduce the risk factors and bolster the protective factors. Our first intervention study was funded by CDC and our second major intervention study was funded by the National Institutes of Mental Health (NIMH). This culturally competence empowerment based group intervention program has demonstrated some very positive effects and has been selected by the Agency for Healthcare Research and Quality (AHRQ). Over the years, in addition to our six grants from CDC and the grant from the NIMH, we have also received grants from the Emory Medical Care Foundation and Emory’s University Research Council that have allowed us to expand our programming and study compassion-based cognitive therapy and the value-addedness of our ReliefLink suicide prevention app. Of note, Relieflink was honored nationally for its promise as a suicide prevention app. Funding from the American Foundation for Suicide Prevention has enabled us to have a greater focus on providing effective care to families who have lost a loved one to death by suicide.
AEE: When and how did the intervention program start?
NJK: When we were engaged in the risk and protective factor study, which included lengthy one-time assessments, some women who were living in a shelter together discovered they had each participated in the study. They discussed with one another their desire to get help so they would no longer feel so hopeless and suicidal. So they came to Grady Hospital and knocked on my door and said: ‘Why do you just ask us these questions? When are you going to give us help?’. I inquired about the type of help they needed and they indicated that they wanted a group to talk about suicide and another group to talk about domestic violence. So we began building this group program, first with a weekly suicide support group. A few months later we started the domestic violence support group. So those are our two longest standing groups and they started in the mid-1990’s. Over the years, we have grown the group program from one or two groups per week to 20 weekly groups. It was with the initiation of our first two support groups that Nia really took off.
Currently we have a combination of support, skills-based, and process groups. In addition we conduct randomized controlled trials that examine the efficacy and effectiveness of both our culturally informed empowerment based intervention and a culturally adapted compassion meditation group intervention with and without the ReliefLink app.
AEE: There seems to be much passion and dedication behind the project. Can you share your reflections about that?
NJK: I agree with you that there is tremendous passion and dedication among the members of the Nia team. Initially, my personal interest emerged in response to both professional and personal experiences. I lost two female patients to suicide very early in my career and that had a huge impact on me. I also had a friend’s mother die by suicide when we were in high school and that had a huge effect on me as well. So I was very interested in suicidal behavior in women. The majority of people who work on the team have a personal connection to the work. Over the years, most of the team members have been interested in intimate partner violence as they had grown up in families where there was intimate partner violence, had been in an abusive partnership themselves, or someone they loved had been abused. So people often become associated with the project because something about the women resonates with their own life story or the life story of other people that they care about.
In addition, many team members, me included, share a deep commitment to social justice and the reduction of health disparities. We have a shared investment in providing quality and culturally relevant services and access to these services to low-income African American women who historically have been underserved and under privileged and have had limited access to such services.
Further, it is really important to me to integrate clinical work and research. I consider myself a scientist-practitioner, so integrating the two in the same program is a high priority for me. I believe that many people who work on the Nia Project team share this value and enjoy the opportunity to be part of a culture in which clinical work and research are equally valued and mutually informative.
AEE: Can you describe some of the common day-to-day struggles of the women who receive services through the Nia Project?
NJK: The women’s stories are both heart-warming and heartbreaking to me because in relation to their struggles their resilience is amazing. We have a lot of women at Nia who struggle just to survive with the basics of life. Many don’t have a secure place to live; about 43% of the people in the project consider themselves homeless. Many do not have enough food to eat or worry about paying their bills. Many of the women no longer have custody of their children, either due to violence in the home or because of their own difficulties taking care of their children. A lot of the women are still in or in-and-out of abusive partnerships. We do not require those to end to be part of Nia, which is different than a lot of projects. Rather, we try to empower women to lead more violence-free lives. In addition, many of the women struggle with mental health problems such as depression, anxiety, PTSD, substance misuse, personality disorders, and even psychosis. Despite all of these challenges, they women are remarkably strong, courageous, and resourceful.
AEE: Oftentimes people develop professionally based on the mentorship they have received. Is this applicable to you?
NJK: My graduate school advisor, who I definitely consider to be a mentor, Lynn Rehm, studied the efficacy of group interventions for depressed women. He was the person who exposed me to intervention research that was gender specific and that clearly had a huge impact on my career trajectory. My internship and post-doctoral mentor who is also unfortunately deceased, Alan Gurman, taught me to be an integrationist. There is no question that the Nia program is based upon an integrative model; we have groups that reflect different theoretical perspectives and the individual, group, and couple/family interventions conducted within the Nia Project are based upon an integration of multiple theoretical perspectives. In other words, we do not just offer CBT, or third-wave CBT, or interpersonal therapy, but we incorporate multiple models and always prioritize that are interventions are culturally sensitive and take into account biopsychosocial factors.
AEE: What services does the Nia Project offer?
NJK: Nia offers a range of services. We offer an on-call crisis intervention service 24/7/365. I handle these crises most of the time and/or patients can directly reach their therapists. We also do a comprehensive evaluation of each new woman that enters the program to understand their needs and help determine the optimal treatments for them to attend. As I mentioned previously, women can have access to a range of groups, some of which are drop-in and others are referral-based groups. If people attend three groups three weeks in-a-row then they are able to receive individual therapy through the program if that is of interest to them. We also provide couples and family therapy when appropriate. We have a parenting group that enables us to focus on parenting. The women in the program are able to receive psychiatric medications through Grady’s Adult Outpatient Program. In addition, if needed, women can be psychiatrically hospitalized to ensure their safety. We are an interdisciplinary team and ensure that the women in the program can access needed services throughout the hospital. Indeed, women are referred to Nia by staff in all services throughout the hospital, as well as from a variety of places in the community ranging from local colleges and universities and local women’s shelters.
AEE: What is unique about Nia? How is Nia different from other available services in the community?
NJK: In this day and age, behavioral health services for individuals without private insurance often are time limited and people often have to get on a waiting list to get these services. Nia is not time limited; people are welcome to come for as long as they want and drop in and out as they feel the need to do. We also offer many services under one roof and do not charge for services at this time. We provide resources for the women that most behavioral health programs don’t provide. For example, we help people pay for their transportation or MARTA. In addition, we take people into the community so they can participate in various activities. This past year, we had an outing with staff and patients to the botanical gardens. Our Community Advisory Board plans wellness programming for us. And we have an empowerment fund that supports our patients in pursuing their educational and vocational goals.
AEE: What does the Nia Project team do to be culturally competent?
NJK: From the outset, we have prioritized the cultural relevance of Nia. For example, in our research assessment protocols, we include measures that tap constructs relevant to low-income, African American women, such as the ‘strong Black woman’ construct, religious coping, and spiritual well-being. Components of our interventions focus on are on culturally relevant topics. For example, when we talk about building self-esteem, we have people think about African American heroines that can serve as models for them in this process. In addition, we have a wellness and nutrition group that focuses on healthy eating on a low budget. There is often diversity between the staff and the participants in Nia based on race/ethnicity, social class, and gender, as well as diversity within each of these groups. We attend to the potential impact of these differences in all that we do and do our best to be not only respectful of our differences but also to celebrate them. In addition, we strive to be mindful of our similarities. Nia is a family or a community, so once you are either a participant or a staff member of Nia, you are always on the team.
AEE: What has helped Nia survive and be successful throughout the years?
NJK: The secret behind the success is the team. Over the years, we have been fortunate to have a diverse team of people who are creative and thoughtful, take a lot of initiative, and really partner with the patients to hear what they want and need. They truly care about the work and have been innovative in figuring out how to move various endeavors forward in a way that is consistent with community-based participatory practice and research. Our programming and research are truly informed by the people we serve.
AEE: What human and environmental elements were the most influential and challenging in the life of Nia?
NJK: The human elements have been the compelling stories of the women and the impressive progress they have made. The commitment of many members of the team, over the years, has really made a difference as they have been instrumental in bolstering, spreading, and expanding the program. In terms of environmental elements, we have the invaluable support of both Emory and Grady. Grady provides the space and Emory supports many members of the team. We have had organizations like Rooms-to-Go that helped us decorate, or the Fulton-DeKalb Hospital Authority that helped us buy computers, books, and games for Nia’s patients. The biggest obstacle we have faced is money. It’s become harder to fund research like Nia and we need stronger philanthropic efforts. We are most grateful for the tremendous philanthropy we have received thus far.
AEE: What triumphs have you experienced running this project?
NJK: I think the successes are on multiple levels. There are small successes every week in having people’s lives improved, whether it’s somebody learning to read through the support of the Empowerment Fund or somebody reconnecting with their family, reentering the workplace, or being engaged in a healthy relationship. We have also had triumphs in terms of the accomplishments of the team members…what they’ve done in Nia and beyond has made a huge difference. We’ve been fortunate to have had my work with Nia and Nia itself honored, in multiple settings, and that has been very meaningful for us.
AEE: Please describe the Nia family to us, focusing on the staff.
NJK: Nia has two licensed and board certified psychologists on the team. We have 2-3 postdoctoral residents and 1-2 trauma-track interns who spend 50% of their time with Nia each year. Our general track interns rotate 4 months at Nia and some years we have neuropsychology interns as well. We have 10-12 practicum students from doctoral and masters’/MS programs in the Atlanta metropolitan area. We have undergraduate volunteers from Georgia State, Emory, Spelman, many of whom go on to be post-bac volunteers, and we have post-bacs from other places who want to volunteer for Nia. In addition, to all the psychology training, we often have medical students, psychiatry residents, and social work and public health students.
Trainees play different roles depending on their level of training from developing groups to serving as group helpers to co-leading groups and from supervising to doing individual therapy. Trainees often take leadership roles with our various initiatives and sometimes are the masterminds behind these initiatives. For example, in recent years, trainees have assumed leadership roles in creating our holiday talent show, organizing our botanical garden event, preparing our holiday meals and gift giving, and creating our Nia book of women’s stories.”
The culture I hope we have is one in which people feel nurtured to do their best to empower the women in the program, many of whom have very serious trauma histories, both historical and current. It can be challenging to hear their stories and we provide support so that team members don’t experience vicarious traumatization. Some of our patients have had very difficult lives, and they bring that to Nia in the form of interpersonal challenges. We work together as a team to develop a collaborative treatment plan so that there is a consistent approach to addressing these challenges. I really value collaboration, teamwork, and input. People often come to me for guidance, but often give me guidance as well and I definitely value that. We hold a weekly executive committee meeting of the team leaders in which we address strategies for handling complex situations that emerge in our daily work. We have a weekly team meeting that is designed to be educational and supportive. In these meetings, we try to find a balance of self-care and consultation, interview patients, talk about challenging patients, discuss research, and focus on community partnerships.
AEE: What paths have your trainees followed after their time of practicum, internship or post-doc with the Grady Nia Project?
NJK: My hope is that trainees pursue their passions. I care about that more than anything else—and that they go do that in an ethical way. Many of my trainees go on to do things relating to social justice effort, but others teach, create programs of research themselves, or go on to private practice. A lot of undergrads and post-bacs go on to graduate school, typically in behavioral health or medical fields. I have appreciated how many people have done Nia in one phase of their life, say as an undergrad and return as a practicum student or did Nia as a practicum student and come back for an internship or postdoctoral residency. When this happens, I am able to witness their tremendous growth. Others don’t want to leave and stay around for a long time. Dr. Sarah Dunn, for example, who is a Clinical Director, was a practicum student with Nia, then an intern, and then a post-doc, and has gone on to do other things, but has stayed connected throughout.
AEE: Do you have any favorite memories with the project? Any sad memories?
NJK: I have countless favorite memories with Nia, such as listening to women read their poems at our talent show (Nia’s Got Talent) and our fundraiser. It is truly amazing to see women, who when we first met them had such low self-esteem and felt so unsafe in the world, come into their own and share their thoughts in a powerful and courageous way. I really appreciate it when we have our annual fundraiser, and a Nia participant comes forward and tells her story. And some women have done a wonderful job sharing their healing and recovery story and the help they received from Nia along the way with these media. All of these are very special memories with Nia.
In terms of sad memories, we’ve lost some people in Nia. Fortunately, as far as I know, [we lost] no one to death by suicide, but to other physical causes, and we’ve done our best to have memorial services for them that included the staff and the patients. Those have been very touching and powerful, but also very sad. There have been sad times in which somebody has had a medical diagnosis at Nia. Some of our patients have had horrible trauma in their lives such as a loved one killing someone else or dying by suicide themselves. Those are very difficult situations.
AEE: What is your vision for the future of Nia?
NJK: I have prioritized creating Nia’s future with the team, rather than doing so by myself. We have a 10-year dream to have our own building, where we can house all our Nia services in one place and expand to include educational and vocational services and leisure activities. Ultimately, we would love to have, not a shelter, but a living community, because we want people to have a place to live of their own.
AEE: What are some of the lessons learned throughout the Nia experience that you would like to pass on to those in the field?
NJK: One lesson is the value of genuine collaboration and partnership with the team members and the community. Another one is don’t give up. There are countless barriers to doing the work that you want to do and I can understand why people just get burned out. But we must persevere and advocate for what we believe in so that we can provide quality care to people who are very much in need. A third lesson is that we all have dreams and things that really matter to us, and we need to stay focused on accomplishing our goals. I think that we have to start small and dream big. You have to take systematic steps and have a plan, but you also have to be flexible and adaptable as needs change and the climate changes. So it’s constantly a balancing act between “I have a plan, I’m going go this way” and “Oh! There is this other opportunity, let me check this out.” Finally, I also think you have to be willing to listen to and hear what people want, encourage and let to share their ideas, delegate as a leader so that others can spearhead new and exciting initiatives. If I had to do it over again, what would I do differently? I would have focused more systematically on fundraising and philanthropic outreach. I do not think Nia has done a good enough job addressing substance misuse issues in our patients. We have been fortunate that recently we have started a program evaluation related to these efforts and this has led to the creation of some new groups and some changes to existing groups. At times, we had a psychiatrist connected to Nia who specifically did medication management for our patients and I would like to have that again. It would be nice to have peer specialists supporting the people in Nia and hopefully Nia participants trained as peer specialists through the support of our Empowerment Fund can ultimately service as peer specialists on our team.