Watering Can
by Christie Mason, Ph.D.
Knowledge of how specific systems in the brain affect and are affected by traumatic events has grown substantially over the past two decades of social work practice. Many clinicians are familiar with basic concepts of neurobiology, such as the importance of neurotransmitters in regulating mood; the activation of the hypothalamic pituitary (HPA) axis in response to stress; and the necessity of the frontal cortex for functions that include impulse control, judgment, logic, planning, attention, and empathy. However, most social workers have yet to learn a coherent model for using knowledge about the brain to inform their selection and implementation of interventions with clients.
A number of neuroscientists and psychologists have translated principles of neuroscience into language that can be understood and applied by helping professionals. Examples of books in translational neuroscience include Dan Siegel’s (2015) The Developing Mind, Bessel van der Kolk’s (2014) The Body Keeps the Score, Louis Cozolino’s (2017) The Neuroscience of Psychotherapy, Bruce Perry’s (2017) The Boy Who Was Raised as a Dog, Allan Schore’s (2012) The Science of the Art of Psychotherapy, and Stephen Porges’ (2011) The Polyvagal Theory. The readability of these works ranges, with some being appropriate to a general audience and others reading more like complex textbooks that will take the average social worker serious discipline to complete.
All of these works have interesting and valuable information to offer new clinicians. One stands out, though, in terms of its compatibility with social work practice and the clarity of its application to work with clients—The Boy Who Was Raised as a Dog by Dr. Bruce Perry. In it, Perry offers an informal description of the Neurosequential Model of Therapeutics™ (NMT), developed by Perry and colleagues at the ChildTrauma Academy. I’m admittedly biased, because I’ve been trained in this model and not the others, but I’ve also had the opportunity to teach the model to MSW students, and I can tell you that they’ve found it to be accessible, valuable in helping clients, and consistent with the person-in-environment and strengths perspectives that permeate social work practice. Their primary frustration has been lack of awareness of the model by other clinicians, a challenge I hope to partially address with this article.
NMT was developed out of Dr. Perry’s and his team’s work with children who had experienced trauma, especially those involved in the child welfare system. Although the model was initially developed to be used with children, it is applicable to anyone who has endured trauma while the brain is still developing, including adults with histories of abuse, neglect, and other adversity.
Unlike many other approaches, NMT is not an intervention model but a decision-making tool. In other words, it helps clinicians choose from existing interventions, rather than proposing a method that is unique to NMT. The interventions are selected based on an estimate of the client’s neurodevelopmental functioning—basically, how well various parts of the brain are working. Areas that are underdeveloped or that show disorganization are selected for intervention using methods that are most likely to affect specific brain areas.
For example, when someone has dysregulation in his or her brainstem—an area of the brain that mediates functions such as heart rate and metabolism—interventions will be most effective if they are rhythmic and sensory, because that’s the kind of input that regulates that part of the brain. If, however, someone’s main difficulty is dealing with self-blame for trauma he or she has experienced, then that would suggest the cortex is the part of the brain most likely to benefit from intervention, pointing toward a more verbal method of treatment.
To determine which parts of the brain are most in need of intervention, the social worker using the NMT completes a “brain map,” estimating how well developed various brain functions are relative to same-age peers. Questions in this mapping process cover functions that range from sleep, eating, sensory processing, and arousal to attachment, delay of gratification, communication, and reasoning. One of the outputs clinicians receive from the brain mapping process is a score estimating the ability of the highest area of the brain—the cortex—to manage impulses from lower brain areas, such as the brainstem and limbic systems.
Called the Cortical Modulation Ratio (CMR), this score offers an estimate of a client’s developmental age, which can be useful in helping caregivers, educators, or others establish developmentally appropriate expectations for a client. It also helps the worker determine whether a client is likely to benefit from verbally-based or insight-oriented interventions (e.g., cognitive, psychodynamic, or narrative therapies), something that’s advised only when the cortex is judged to be at least twice as strong as lower brain areas.
In addition to the CMR, the NMT brain mapping process also provides scores for four areas of client functioning that are mediated by specific regions of the brain. Those areas are sensory-integration, self-regulation, relational functioning, and cognitive functioning. A key tenet of NMT is that these functions develop in a certain order, just as the areas of the brain that mediate them do. A closely related idea is that these functions build upon one another, meaning earlier functions have to be present before later ones can fully develop. The implication of these principles is that intervention should first focus on the earliest developing area of the brain with significant disruption (as indicated by a score of less than 65% of age-typical development) and build from there. Thus, if a client has significant difficulties with self-regulation, a social worker would design a treatment plan focused on that domain prior to engaging the client in interventions targeting later developing functions, such as relationships and cognition.
Another NMT principle is that the brain requires sufficiently frequent, patterned, repetitive activation for change to occur. This is true of any skill—you don’t learn to ski well if you only do it once a year, and you can’t learn Spanish by practicing a few words every Thursday. Many of us know intuitively that this is true of therapy, as well. An hour of time with a client each week is simply insufficient to create meaningful change in our most vulnerable clients; at best, progress is very slow. In recognition of this, NMT asks that the clinician shift from primarily being a provider of services to coordinating therapeutic activities so that they occur outside of session with the necessary frequency, pattern, and repetition for the brain to be altered.
Let’s say a child client is having significant problems in relationships, even though his sensory integration and self-regulation skills are intact, and needs therefore to have brief but frequent non-threatening human interactions to improve his brain’s capacity for relational functioning. The social worker might ask that a parent look for several opportunities throughout the day to engage in side-by-side activities with the child, like brushing teeth together in front of the mirror each morning, singing along to favorite music in the car on the way to school, standing adjacent to one another making a salad to go with dinner, and reading a book before bed. This repetition of positive relational experiences in small bursts throughout the day is precisely the kind of input the child’s brain needs to develop or reorganize most efficiently.
Some clinicians in related fields may find the shift from being the primary provider of services to being a coordinator to be a difficult adjustment. However, I think social workers are able to naturally assume this role because of our understanding of case management and our appreciation of the importance of clients’ environments in influencing their functioning. Many of the recommended interventions in NMT, especially those that target lower brain areas, involve allied fields (e.g., occupational therapy, massage therapy, animal-assisted therapy). This, too, is a natural fit for social workers, who have long recognized the value of cross-disciplinary collaboration.
The final ways I see NMT as fitting with social work are in its emphasis on client strengths and its insistence that clients have adequate relational support before expecting significant individual growth. Every NMT staffing I’ve listened to begins with a description of the client’s strengths, setting the expectation this individual is to be regarded positively and seen as more than the sum of his or her difficulties. Every assessment process includes a measure of the client’s current relational health. When it’s judged to be insufficient, the focus becomes how to improve the client’s supports by bringing in extended family, coaches, mentors, or people from the client’s culture or community of faith. It’s understood that clients cannot make progress without these connections. This recognition of the importance of the relational environment fits well with the person-in-environment perspective that characterizes social work practice.
As I noted at the beginning of this article, a number of good models of translational neuroscience are available. As one of them, NMT offers a specific tool for assessing the neurodevelopmental functioning of clients with trauma histories in order to select treatments that will best meet clients’ needs. In addition, it does this in ways that are consistent with principles of social work intervention, including a person-in-environment assessment process, integration of case management, encouragement for cross-disciplinary collaboration, and emphasis on client strengths.
For more information on NMT, see the resources listed below or visit http://childtrauma.org.
Resources
Perry, B. D. (2006) The neurosequential model of therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children. In N.B. Webb (Ed.) Working with traumatized youth in child welfare (pp. 27-52). New York, NY: The Guilford Press.
Perry, B. D., & Dobson, C. L. (2013). The neurosequential model of therapeutics. In J. D. Ford and C. Courtois (Eds.) Treating complex traumatic stress disorders in children and adolescents (pp. 249-260). New York, NY: The Guilford Press.
Perry, B. D., & Szalavitz, M. (2017). The boy who was raised as a dog: And other stories from a child psychiatrist’s notebook. New York, NY: Basic Books.
Christie Mason, Ph.D., is a clinical assistant professor of social work at Loyola University Chicago, where she teaches classes on human development, practice with children and adolescents, and trauma and neurodevelopment. Christie also works with clients of all ages in a group clinical practice, specializing in adoption, attachment, and trauma.