Articles
NEST: the Use of a Structured Group Programme in Training
Human Systems: The Journal of Therapy, Consultation and Training, 2008, Vol. 19, Issue 2, pp 129-141Human Systems Ágnes Kónya
Zoltán Kónya
AGAPE Life Care Foundation, Cluj, Romania Abstract: NEST (New Experience for Survivors of Trauma) is a structured group programme designed for persons who have experienced different types of trauma and loss. As the programme uses a broad definition of trauma and loss and emphasis is given to the acquisition of life skills, the programme can potentially benefit anybody motivated in learning and personal development. We have been adapting and using NEST as part of our training with the aim of promoting trainee self-reflexivity. Our paper includes feedback from trainees who participated in the group process and reflections from trainers. NEST as a therapeutic tool NEST (New Experience for Survivors of Trauma) is a therapeutic programme designed for adults who have experienced different types of trauma (e.g. abuse, witnessing violence), neglect or loss. The significant personal losses addressed by NEST include the loss of a reasonable childhood as a result of abuse or neglect and pregnancy losses such as miscarriage, abortion, stillbirth or early infant death. The aim of the programme is to help a person overcome emotional conflicts and relational difficulties associated with past experiences, as well as offer a context where one can learn adaptive ways of responding to stressful situations. NEST is also the name for an international network of European professionals, emerging out of the International Institute for Pregnancy Loss and Child Abuse Research and Recovery, an organisation founded by Philip Ney, a Canadian child psychiatrist and psychologist who first developed and taught this type of group treatment (Ney, 1995, Simon et al., 2006). As a result of an ongoing dialogue among these professionals, the NEST programme is continually evolving in light of feedback from clients and their therapists. The programme was initially called Hope Alive (1994-2002) and more recently NEST (since 2003) and has been applied in countries like Poland, Switzerland, Ireland, the Czech Republic and Romania. Based on post-treatment questionnaires and one-year follow-up sessions, it has been found useful by group leaders and group members alike. In an unpublished survey conducted in Ireland (2002), 24 of the 39 respondents (61%) considered that their participation in the group programme had greatly helped them, while 11 (28%) rated the helpfulness moderate. However, there is still a scarcity of research investigating the clinical effectiveness of NEST. Doherty (2003) employed a quantitative, repeated measures design involving 19 clients to determine if there was a decrease in symptoms connected with abuse experiences on treatment termination (Doherty, 2003). Highly significant decreases were found in guilt, suicidal thoughts, frustration, grief, feeling trapped, sadness, anger and fear. The study conducted by Simon et al. (2006) focused on the effect of the programme on partner relationships, concluding that “the integrative therapeutic programme of NEST, which utilizes, among others, the cognitive-behavioural and psychodynamic assumptions, proved effectiveness in attenuating the disadvantageous pair bonding in order to help the patients to get closer to the current partner. This seems to have been achieved by patients’ experience of the emotional-corrective influence of the therapeutic group as well as applying the specific technique of visual imagery.” In the authors’ view “even relatively healthy persons benefit from the procedure.”(Simon et al., 2006) The reason for seeking therapy is a combination of emotional problems and relational difficulties or psychosomatic complaints. The programme is recommended in case there appears to be a connection between present difficulties and past experiences of any type of trauma, deprivation or loss.
Groups represent the most widely used therapeutic context for using NEST, allowing for maximum opportunities of learning. The optimum size of the group varies between 5 and 7 members. Group sessions usually last for about two and a half - three hours. Most therapists use a 30-session format with one or two sessions per week and 3 follow-up sessions at 3, 6 and 12 months after the last group session. More recently, we have also been using NEST as a framework for individual therapy. The steps of the group process The therapeutic process unfolds in eight subsequent stages: 1. Joining. Each person introduces him/herself and shares his/her story of coming to the group. This phase involves informed consent to therapy from each participant and a commitment to the ground rules of group work. Ground rules include confidentiality, full participation, consideration for the needs of others and non-violence. 2. Dealing with traumatic experiences. Participants explore their family trees, discerning patterns and identifying themes. They also review their “time-line” (remembering two events per year, one happy and one painful or sad memory), looking for repetitions. Patterns across the timeline may reflect key-conflicts connected to early traumatic experiences. The remembering of such experiences and the expression of emotions connected with traumatic events are encouraged and facilitated. Participants are helped to make sense of and develop a coherent story about the past, learn to deal with anger, fear, confusion and guilt, and exercise alternative ways of responding to attack or manipulation: assertion, protest or flight when necessary. 3. Addressing existential questions. The central tasks at this stage are dealing with survivor guilt and fostering an inner sense of personal worth. This phase of therapy includes the experience of being welcomed, nurtured and protected by a symbolic womb formed by the group. 4. Defining the authentic person. The means for defining the authentic person are (1) identifying and discarding social masks and (2) grieving the loss of the person one could have been, had trauma and loss not interfered with one’s development. The definition of the self includes the person’s newly discovered strengths, vulnerabilities, values and real possibilities. The group at this stage acts as appreciative witnesses of the transformations experienced by each group member. 5. Dealing with significant personal losses. This is a time for grieving the loss of people who were not properly mourned at the time of their death (e.g. alienated parents, children lost through pregnancy loss). 6. Reconciliation. Reconciliation is encouraged between group members and people who hurt them and/or people whom they hurt. The recommended means for effecting reconciliation is the writing and sending of reconciliation letters. Very often the most significant letters are those addressed to one’s own parents. 7. Life skills training. These include negotiation, decision making and planning. 8. Ending therapy. Participants review and celebrate the progress they have made and say good-bye to one another. Throughout the therapeutic process the following aspects are facilitated:
· understanding past events and the connections between these and present day difficulties experienced by a person
· identifying, expressing and dealing with feelings of pain, fear, confusion and anger
· learning adaptive responses to trauma, like assertiveness and flight when necessary
· initiating or unblocking natural processes like grieving losses and forgiving hurts. The NEST programme combines ideas and concepts from a number of different approaches to therapy: psychoanalysis, attachment theory, existential analysis, cognitive restructuring, behaviour modification, transactional analysis, research on resilience, etc. Practices employed by NEST therapists include between-session tasks and personal reflections, exploration of dreams, role-playing, psychodrama, visual imagery, and therapeutic letter-writing. Training in NEST follows the general principles underlying any type of training in psychotherapy. Our training centre offers NEST as a specific therapeutic tool that experienced therapists can use in their practice with people presenting a particular set of problems, mainly emotional and relational difficulties connected with trauma or loss. Training and culture We would like to say a few words about Romania, the larger context of trainees’ lives and of the training. In December 1989, the communistic regime fell and was replaced with a democratic system. However, many years after this historical turning point many of the beliefs, practices and reflexes connected with the old system still live on. All of our trainees have in some way and for some time experienced dictatorship. The training offered them a space to think and talk about ways in which the bigger system impacted upon their lives and the life of their family. The use of the word “system” is most appropriate here, as this was the very term we used to refer to the subjugating communistic regime. Hearing this word may, in some of us, still trigger feelings of discomfort. As many participants remembered, the “system” promoted a style of education based on criticism. For many trainees it was a revelation to discover the effects that blame and criticism had on their lives, to learn about alternative attitudes and personally experience praise, appreciation and encouragement in the group (Kónya & Kónya, 2003). Also, open communication and assertive behaviour were discouraged during communism at all levels of the “system”. While the concept of assertiveness is commonplace in some parts of the world, the word itself, its meaning and the corresponding behaviour are completely new for many people living in our culture. Readers may notice the frequent reference to God in the section on trainee feedback. Discussions and exercises connected with various aspects of spirituality developed naturally and were welcomed in these training groups. Romania, according to recent surveys, is one of the countries with the highest proportion of people (97%) who declare they are believers (Hofmans, 2004). Also, these groups were special due to the presence of priests and pastors of four different denominations who were, at the same time, experienced counsellors. Exploring spirituality in the context of training is also in line with recent trends in family therapy (Carlson et al., 2003). Utilizing NEST in the context of training Up to this time we have used NEST as a tool for the personal and professional development of therapists in two training groups. The first group started in 2004 with 12 participants and the second group in 2005 with 9 participants. Trainees were generally young, their age ranging from 22 to 45 years, the average being 28.5 years. They came from various professional backgrounds: psychology (8), social work (7), theology (4) and nursing (2). Of the total of 21 trainees 17 were women and 4 men. The personal and professional development was offered in two blocks of five days each. We divided the large group in two small groups, each being led by one of the two trainers. The large group served as a context for discussing the small group experience and connecting it with relevant theory, but some of the experiential exercises (particularly role-plays, psychodrama and discussions about dreams) were also done in the large group. At the end of each day trainees received written tasks to reflect on during the evening, contributing to the intensive character of the training experience. Some of the ideas underlying this practice of exposing trainees to the group therapy experience were the following:
· trainees learn about themselves, particularly learn to see themselves through the eyes of others, about how they behave in relationship with others.
· having faced and dealt with certain essential life tasks (e.g. effecting reconciliation with others), they are in a better position to invite their clients to face the same tasks
· they personally experience the effects of a range of interventions
· they can closely observe an experienced group leader at work (modeling value).
The style of therapy was much the same as in the case of a real therapy group. However, in the context of training there was a constant oscillation between therapy level (usually in the small groups) and training level, where the therapy experience was discussed from a meta-position in the large group. Monitoring feedback from trainees was a constant feature of the process. There was a time set apart for voicing thoughts and feelings both at the start and at the end of each day. In addition, at the end of the programme trainees completed a questionnaire concerning their experience of the course. Finally, writing an essay with the title “Ways in which the training experience has influenced my beliefs and attitudes, both personal and professional” constituted part of the assessment process. The following section is a selection of feedback from course participants. While preparing it, we were particularly interested in how trainees saw the value of the programme for their personal and professional development, what was it like for them to participate in the group (including the level of discomfort involved) and accounts touching the issue of spirituality. Feedback from trainees NEST and personal development Some trainees describe a mix of personal and professional motifs for their enrollment in training: “[The course] seemed a good investment professionally, but what attracted me first of all was my personal need to heal my inner wounds.” “This course came as a response to my inner wish to benefit of a therapy of this kind.” There was a great variety of answers in response to the question “What did you find the most helpful about the programme?” A 26 year old woman, who had completed the full course of NEST group therapy a few years before she enrolled in the training, described her experience of the reconciliation process from the time of her personal therapy: “My greatest joy is that I succeeded to reconcile with my father, the main cause of my suffering in childhood. Now four years have passed and I am particularly grateful to God for guiding me in this direction because my father died. Had I not reconciled with him, I don’t know how could I have accepted his death and how could I have gone on with my life. It was not only the reconciliation that was special, but also the two years that followed. I felt that I recovered the many years that had been lost and emptied of his love.” Participation triggered changes in trainees’ relationship with themselves: “The NEST experience meant the beginning of my journey toward discovering and becoming my self.” “After these experiences I can say that I accept myself with joy and I love myself. (…) I found my way toward myself and toward others and now we can be together.” “It is an essential aspect that I reconsidered my expectations toward myself and toward others in a way that they better fit reality. This allows me to see things in a more flexible way.” One trainee describes the group format as a context that both expands and challenges personal perspectives:
“I am glad that I was offered the possibility to cultivate my fascination for the ‘stories’ told by others, for the life history of each participant, as the source of a perspective on life that is much richer and wider than my life history alone. In the same way, the debates and polemics in the large group, bringing up not only ideas but also life experiences, have helped me in leaving behind certain mental barriers connected with masculinity, femininity, Divinity and so on.” The professional side The next set of feedback concern the professional value of the participatory experience: “This way of training offers a possibility for experiencing the effectiveness of group therapy and to see the impact it can have on clients. It also helps you to really empathize with clients. This way you can have an idea about how they feel in the group, what inner conflicts may occur, the reticence or the resistance to opening up in the group and talk about the deepest and most intimate issues of the soul.”
“I learned ‘live’ about the characteristics of managing a group, which implies both observing rules and, at the same time, being flexible.”
“Unless you, as a therapist, do not acknowledge and resolve certain traumas, you can’t help others. Unless you reconsider your self image, accept yourself and learn from these experiences, you can’t help others.” “Before participating in NEST, I never used role-play in my practice. It was only there that I realized its importance and began using it. Also, I started to use visual imagery. The results came unexpectedly soon. I started to pay attention to body language much more than before. Before that I had been lost in the discussion with clients and thus I couldn’t perceive the messages sent by their body nor had I been aware of the messages my body was sending to them.” “[After the course] it has been easier for me to identify situations in which there is a connection between an ongoing problem and an early trauma.” Experience of the group process Several trainees described the personal development phase of the training as a tough one: “This probing of the past was anything but easy because there were many inner barriers. I often confronted states of anxiety and depression.” In the case of one trainee, the personal development phase of the training coincided with a difficult period in her life. The following is her account of this experience: “For me, this course came at a moment of crisis, when I already had some wounds of the past reactivated. I had no idea about how to get out of this situation. Even if I was very open toward what was about to happen, it was very difficult for me to fully participate, due to the almost unbearable mental suffering that was invading me. I had no intention to protect myself from the pain, yet I felt there was a limit to the extent to which my soul and body could resist. The too intense rhythm of the course did not benefit me personally.” Others made the therapeutic journey without any perceived need for a change in their own person or life: “To be honest, I had been happy with my self from before the group. Still, I consider my participation a useful experience.” Participants appreciated the learning value and the non-pathologising attitude of group work: “I have never before experienced being a trainee and a patient at the same time. I consider this an extraordinary method for having some information internalized and made alive in you.” “What I like about NEST is that no labels are used. The person is allowed to reflect on her own on her lived experience. There is some guidance, but done with particular care so that the freedom of the individual is not interfered with. Through this the person can make her own inner journey and reach inner maturity.” Spirituality There are several points during the NEST programme which offer participants a time and a space to think and talk about the place of spirituality in their life. The following idea was formulated by a 26-year old female social worker: “Both the varied, reliable, coherently presented and relevant information and the group interaction made me aware again of the fact that the main options of humans are between a trust in God’s love, generosity, wisdom and power, on one hand, and resignation, on the other; the latter as a sign of the conviction that abuse and neglect, in their more or less severe forms, have a destructive power much too important and won’t make any authentic and lasting recovery possible.” A feedback appreciating “depth” in the exploration of relationships: “I liked during the course the fact that we were open and honest and discussed deep issues, extending to our relationship with God and with those in the family - issues that are not usually discussed in other contexts.” One trainee’s personal spiritual commitment provided a resource to deal with the inner turmoil triggered by the group process: “I experienced a real inner crisis not long after the end of the first part of the course. My orientation toward God, who is love and endurance, meant for me an inner relief at that moment. I could understand that there is a certain course of issues for us which we may not understand but which has a meaning and finality.” The trainers’ perspective NEST as a resource for training From our perspective, some of the useful aspects of NEST as a training tool are the following:
· People are interested in applying any theory to self. NEST offers a range of theories, ideas, metaphors and practices that participants can “try on” their own person. They then have the possibility to experiment with these in their client work.
· The clear structure of the programme provided a sense of direction, safety and a degree of predictability for us, trainers, and, we assume, for trainees as well.
· The programme is experiential, including a number of role-plays and psychodrama exercises. This way of learning about self and relationships is both effective and exciting.
· The pre-determined sequence of themes and tasks makes sure that certain significant and meaningful issues are addressed, some of which are often neglected by training programmes or societal attention in general. These include the importance of child neglect, child blaming and criticism, the implications of pregnancy losses (including miscarriage, abortion, also stillbirth and early infant death) and the place of spirituality in people’s lives. Our first impression on reviewing trainee feedback is the obvious preponderance of positive remarks. Here we consider it important to balance enthusiasm with some degree of doubt. At the time of putting on paper their impressions participants had just finished the group programme. In the case of therapy we call the following couple of weeks, perhaps months, the “honeymoon” period, when group members leave the “NEST” full of enthusiasm about the changes they perceive in themselves, each other and their relationships. However, follow-up meetings demonstrate that the initial enthusiasm often subsides. Many former therapy group members request occasional consultations for new problems emerging in their lives. NEST is certainly not a miracle cure, but rather a context for safe learning, which works very well for some people, while others seem to benefit to a lesser degree. Training and trauma Another important question to reflect upon is: why use for the personal development of therapists a therapeutic programme originally designed to address the problems connected with trauma and loss?
For the purposes of NEST, when we say “trauma”, “loss”, “abuse” or “neglect”, we think of these phenomena as continuums. In other words we give a very broad definition to these concepts. Not everybody suffers big traumas but certainly all of us experience a number of small traumas in our lives. Also, loss is an inevitable aspect of family life. We focus not on the events or actions themselves but rather on the effect certain experiences have on the person and the meanings s/he attaches to them. It is not us, experts, defining or identifying abuse or loss, but the person who lived the experience. Thus it has been our general impression that even trainees who did not have a particularly difficult childhood could well connect their personal experience with the issues and tasks raised by their participation in this type of group. One example of a typical micro-trauma would be a situation where somebody, as a child, wanted to study the piano but her parents, for some reason, had her attend violin lessons. Many, growing up as the only child in a family, longed for a brother or sister. One person who was the youngest of five said she always wanted a younger sibling but never got one. Others remember that their parents never praised them or continually expressed dissatisfaction with them. In all of these situations the person remembering his/her childhood may feel that these experiences negatively impacted their development, even though they would not correspond to formal definitions of emotional abuse. Some people remember from their childhood being alone at home or left with various caretakers. Many adults still dread the specific smell reminding them of food cooked at the kindergarten. Again, in these cases neglect may not have reached a severity warranting intervention by the social services, yet the person considers it as something worth thinking and talking about. During initial interviews with potential trainees we emphasize that this is training, not therapy. If they need therapy, they first have to participate in personal therapy. However, spotting serious personal problems during the intake process is not always successful and later on in the training it turns out that many of the problems and traumas experienced by some trainees are quite “macro”. Accordingly, many trainees used in their feedback the expression of “personal healing”. Our experience of the severity and frequency of trauma and loss seen in the lives of our trainees may reflect the widespread character of child abuse and neglect in our society. It can also be a confirmation of the idea, that trauma survivors are attracted by the helping professions, as an unconscious attempt to sort out the emotional conflicts generated by the trauma they have experienced. The idea expressed by one trainee, a 35-year old social worker, is informed by this latter belief: “My participation in the group interaction has made me aware of the motivation behind my choice of profession. Some counsellors (and I am one of them) choose this profession so that they can work on their own problems.” Is this systemic? NEST is practiced by therapists trained in various schools of psychotherapy and their style of applying the programme is influenced by their basic orientation. Our way of using NEST is informed to a great extent by our systemic background, manifested, for example, in our interest in metaphors or in the way we think of the “authentic self” of the person. As post-modernism challenges the idea of normal developmental trajectories and the idea of the self (Hoffman, 1993), one of the potential risks of using such concepts in systemic family therapy training could be confusing trainees with conflicting messages.
While working with trauma survivors, we feel the need for a model of personal development that can be used as a frame of reference for describing the effects of trauma and loss. At the same time we should avoid imposing on people a model of normality that does not take account of the infinity of individual experiences. To meet these requirements and avoid confusing trainees, we made the following presuppositions: 1. For the purposes of the programme, we assume that there is a Plan for each person. As each person is unique, each person’s Plan is also unique. This assumption fits well with the observation that children, in most situations, seem to know with precision what they need and when they need it (e.g. with respect to the quality and quantity of food they are prepared to eat at a certain time), as if, being aware of their Plan, they were looking for the right materials to build the person they are becoming. The idea of the Plan, the building and the materials needed are presented as a metaphor. 2. Negative experiences can interfere with building/becoming in accordance with the Plan. Such interference has the significance of an important personal loss. 3. Each person is seen as the expert of his/her own life, Plan, needs, losses, resources and possibilities. Using the NEST group programme offers additional resources that trainees can utilize in their own practice, like becoming familiar with group processes and techniques like role-playing, letter-writing or guided imagery. The NEST theory contributes valuable ideas about trans-generational patterns, loss and reconciliation that therapists can use in their systemic work.
References: § Carlson, T. D., Erickson, M. J. (eds.) (2003) Spirituality and Family Therapy. Haworth Press.
§ Doherty, M. (2003) An Evaluation of Hope Alive Group Treatment Intervention. MSc Dissertation. Faculty of Social Sciences & Education University of Ulster
§ Hoffman, L. (1993) Exchanging voices. A collaborative approach to family therapy. London: Karnac Books.
§ Hofmans, M. (2004) Religion – a personal matter. Findings of the GfK survey on religious attitudes in Europe. http://www.gfk.hr/press_en/religion.htm
§ Kónya, Á., Kónya, Z. (2003) Getting from five to six... in the Ireland-Romania Family Therapy Training Project. Feedback, 3:26-28.
§ Ney, P. G. (1995) Ending the Cycle of Abuse. New York: Brunner/Mazel.
§ Simon, W., Gajowy, M., Sliwka, P. (2006) The effectiveness of attenuation of disadvantageous pair bonding from the past: a pilot study. Archives of Psychiatry and Psychotherapy, 3:65-84.
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