Neurosequential Model of Therapeutics (NMT)

Written By Jehan Ganachaud

Introduction

One of the most helpful framework I have been trained in to understand and conceptualise the impact of trauma and neglect is the Neurosequential Model of Therapeutics, which is a mouthful, so I will just call it NMT for now.

It was thanks to FamilyForward that I was trained in that framework, and I am forever grateful to have worked with them.

NMT was created and developed by Dr. Bruce Perry, who trained as a child psychiatrist and neuroscientist in the late 80s. He quickly found out that his standard training could not make sense of what he was seeing in his practice with children who had experienced developmental trauma, and thanks to the insight his lab research on rats was providing him about the nervous system and the brain, he created a new framework. His book “The Boy Who Was raised as a dog” nicely puts together how he came about this framework through specific clinical examples (here are more books he has written).

I must say; I am still surprised that Bruce Perry is not part of the Big Names in the field of trauma therapy (e.g. van der Kolk, Siegel, Porges, Fisher, Ogden, etc.), although he has had interactions with Gabor Maté (link to an article about Bruce and Gabor discussing ACEs).

I have not found much information about NMT, so I will attempt to share what I have learned and found so helpful in my practice. For me personally, it has helped me develop a better understanding of how trauma and neglect impact the nervous system, while also given me broad strategies to promote nervous system’s regulation. Additionally, as a framework, it has helped guide me when thinking about interventions.

I am mindful of time people have these days to read and digest information, so I will break it down into several articles.

NMT is often used to compile and create a specific report that families and professionals have, in my experience, found helpful. However, you do have to pay for the training along with additional fees each year to have access to a specific website to create said report.

First and foremost, NMT has four basic tenets:

  1. the brain is important (for basically all our functions, although I think heart cells can beat on their own)

  2. the brain develops in a sequential way (the brain develops from the inside out and if you like at someone’s profile; the brain develops diagonally from the bottom of the nape -where the cerebellum is- diagonally to the forehead -where the prefrontal cortex sits)

  3. if a system changes rapidly, then an event in that system will have more impact on that system (it’s called biological relativity)

  4. relational health has a buffering effect on adverse events

Second, Bruce Perry developed his own model of the brain. Now, I know this is not fully neuroscientifically accurate, as brain functions and networks are spread across the brain and require many different areas to be interconnected, but it makes a lot of sense within the NMT framework, so bear with me.

Here below, before I jump into the model, are other NMT - Bruce Perry’s concepts I, and families I have worked with, have found useful:

Bruce Perry’s Model of the Brain

If you watch a video with Bruce Perry, you are more than likely to have him show his brain model and it also appears in his books. It’s also important to keep in mind when looking at some of the other NMT concepts to make sense of them.

I like visuals, so I will show the picture first and then comment on it. The image comes from one of the many videos Bruce Perry has made available to the world (link here).

Bruce Perry’s Model of the Brain

As you can see, Bruce Perry’s model of the brain focuses on 4 major areas: the brainstem and cerebellum, the diencephalon, the limbic system (I know, I know, the limbic system is neuroscientifically not meaningful anymore, but this is a model and all models have limitations), and the cortex.

The way NMT works is that each of those areas have been given specific functions of the brain (the full brain map I talk about in another post has 32 different brain functions). For instance, the brainstem - cerebellum areas will have functions such heart beat, respiration, metabolism, blood pressure, and other functions linked to the autonomic nervous system.

In a very basic way, the lower you are in the brain, the more basic the functions are, while the higher you go, the more complex they become. You can see some examples of those functions on the right side of the model on the picture.

Now, you may be thinking: “Jehan, this is not very neuroscientifically accurate, so how is this helpful?”.

Well, the way it helps is that when you use this model to map out where someone’s nervous is developmentally, you can then think about ways to support this person with interventions designed for that specific area.

For instance, Trauma-Focused CBT is a very cognitive way of working. Yet, it is often prescribed as a go-to intervention for children with developmental trauma. However, because the brain develops in a sequential way, until the lower parts of the brain systems have been supported, TF-CBT will have very limited impacted.

In a more direct way of talking: if the child is constantly hypervigilant and any noise and light is activating his fight or flight system, there is no way he will be learning anything that doesn’t have to do with survival.

So instead of TF-CBT, you will first want to ensure the child has routines and rituals in place that create predictability, you will want him to have an attune adult around him that provides those rituals and routines. Finally, you will want to think about a lot of sensory and rhythmic activities to support soothe and regulate the child’s nervous system.


Jehan Ganachaud
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