Integration of neuroscience in social work education

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TOWARD THE INTEGRATION OF

NEUROSCIENCE AND CLINICAL SOCIAL

WORK

This article reviews recent findings in neuroscience in light of the history of social work, the

scientific support for clinical social work interventions and the challenges of integrating

neuroscience into academic and practice settings. Illustrations of several critical

neurophysiological underpinnings of important clinical phenomena are described, including

disorders of personality, defense mechanisms, attachment styles and the close relationship

between ego functions and right hemisphere functions.

Keywords neuroscience; social work; attachment; personality disorders;

defense mechanisms; autonomic nervous system

Neuroscience and social work: a new appreciation

Over the years, social work has had an uneasy relationship with neuroscience. The past

five decades have seen the clinical field (led primarily by psychologists) highlighting

those left hemisphere cognitive techniques, strategies and interventions that could be

measured by left hemisphere cognitive functions, such as memory, verbal self-report,

pencil-and-paper checklists and the like, and behavioral changes over short periods of

time. As the measurement of right hemisphere affective/emotional function was not

technologically feasible until the past two decades or so, therapeutic progress was

generally a matter of clinician and/or client subjective report.

At this juncture, the clinical community has the benefit of not only certain

evidence-based measurements of clinical outcomes but also incorporating the findings

from the field of neuroscience into social work practice. Thanks to the knowledge

gained from brain imaging technology and other scientific means, it is no longer a

speculation that the brain itself may be changed at the level of neuronal structure and

function by psychological/social/affective relationship interaction (Schore, 1994,

2003a, 2003b; Cozolino, 2002). This brief essay will address the beginning integration

of findings from neuroscience into psychodynamic social work. I will discuss the recent

embracing of neuroscience, examples of concepts shared between psychodynamically

informed interventions and neuroscience research, examples of integrating social work

practice and neuroscience, and some of the challenges we face in using neuroscience in

our clinical practices.

q 2013 GAPS

Journal of Social Work Practice, 2013

Vol. 27, No. 3, 333–339, http://dx.doi.org/10.1080/02650533.2013.818947

The ‘Decade of the Brain’

We are now beyond the 1990 –1999 ‘Decade of the Brain’ as declared by the US

Library of Congress and the National Institute of Mental Health that sponsored public

awareness of the benefits of brain research (http://www.loc.gov/loc/brain/).

President Obama recently announced the Brain Research through Advancing

Innovative Neurotechnologies (BRAIN) initiative. This 2013 effort aims at producing a

‘revolutionary new dynamic picture of the brain, that, for the first time, shows how

individual cells and complex neural circuits interact in both time and space ... with

the aim to treat, cure, and even prevent brain disorders’ both neurological (e.g.,

Parkinson’s or Alzheimer’s disease) and psychiatric (e.g., depression or schizophrenia)

(http://www.nih.gov/science/brain/index.htm).

The current impressive mapping of neural connections is stimulating imagining and

planning for a near-future generation of technological innovations to increasingly

sensitively record brain signals. Though this seems far from Sigmund Freud’s work, in

fact his early interest and contributions in neurology (from 1876 to 1896) set the stage

for connecting the understanding of the nervous system and brain with symptoms of

observed clinical phenomenon (Freud, 1957; originally first published in 1914). Over

the years, attempts to do so have had to rely on such efforts as associating a symptom

(e.g., loss of speech) and damage with certain areas of the brain (e.g., Broca’s area for

speaking). Technological advances such as the use of electroencephalographs. Today,

new brain imaging technologies (e.g., positron emission tomography scans) are

revolutionizing our ability to understand brain function underlying psychiatric

symptoms, much as Freud hypothesized.

Illustrations of the relationship between psychodynamic

concepts and findings from neuroscience

What follows are four illustrations of the contribution of neuroscience discoveries to

clinical practice. Three of the examples integrate the relationship between an

important arousal system in the brain and body, the autonomic nervous system (ANS),

and the phenomena often the focus of clinical interventions such as disorders of

personality, defense mechanisms and attachment styles. The fourth illustration

addresses the implications for clinical work of unconscious arousal strategies. The last

illustration makes the connection between ego functions and right hemisphere

function. Implicit in these examples is the interface between the well-developed brain

function of the clinician and the positive impact that repeated interpersonal encounters

may have on the client’s brain function due, in part, to brain plasticity (Cozolino,

2002, 2006).

The ANS and personality disorders

Much attention is now being paid to what is considered a central risk factor in a wide

range of psychosocial difficulties – the dysregulation of affect. Regulation of affect is a

psychophysiological phenomenon involving an important arousal system in the brain

334 JOURNAL OF SOCIAL WORK PRACTICE

and the body called the autonomic nervous system or the ANS. The ANS is divided into

sympathetic branch that activates arousal and the parasympathetic branch that inhibits

arousal (Schore, 1994, 2003a, 2003b, 2012; Applegate & Shapiro, 2005, p. xi).

One important example of the connection between arousal difficulties and

psychopathology is personality disorders. Personality disorders can be organized into

those that unconsciously attempt to sustain low levels of arousal (e.g., schizoid

personality disorder or avoidant personality disorder) or those that attempt to maintain

higher levels of arousal (e.g., paranoid personality disorder, antisocial personality

disorder, histrionic personality disorder or dependent personality disorder)

(Montgomery, 2013). This is critical information for many reasons, not the least of

which is that the arousal system of the clinician is often co-opted into the regulation of

these problematic arousal strategies, often by doing the opposite, for example, for the

schizoid personality organization, trying to elevate the affect and mood (use of

sympathetic branch of clinician’s ANS) or for the histrionic personality organization, the

clinician’s arousal system will likely intuitively attempt to lower the affect (use of the

parasympathetic branch of clinician’s ANS) (Schore, 2003a, 2002b, 2012; Montgomery,

2013).

The ANS and defense mechanisms

Scientific support has been found for the unconscious nature of defense mechanisms.

For instance, Berlin and Koch (2009) designed an experimental technique using the

functional magnetic resonance imaging procedure, ‘backward stimulus masking,’

which examines the brain’s capacity to process affective information outside of normal

conscious awareness (Killgore & Yugelun-Todd, 2010). Linking the reflexive and

unconscious function of the ANS, described briefly in the above paragraphs, to the

unconscious processing of information, they demonstrated that in less than optimal life

circumstances, defense mechanisms are unconsciously sorting out threatening

information and have, in difficult circumstances, learned to manage the threats via

use of the over- or under-arousal. Accordingly, parasympathetically driven defenses

(e.g., asceticism, blocking, denial, dissociation or inhibition) will favor the low arousal

state while other sympathetically driven defenses (e.g., acting out, regression,

externalization, projection, mania) will seek the opposite state, that is, higher arousal

(Montgomery, 2013). Adaptive defenses (e.g., affiliation, altruism, anticipation, self-

assertion, suppression) do not preferentially utilize either branch of the ANS, but

rather are flexible in the expression of arousal, as called for by the context of the

situation. Interestingly, the more adaptive defenses have conscious control, not a

hallmark of the maladaptive and less- or not-conscious defenses (Vaillant, 1997).

The ANS and attachment

Another way that clinicians may use information about the functioning of the arousal

system is elucidated by Schore (2003a, 2003b) and elaborated upon by Montgomery

(2013). The secure and insecure attachment styles of both childhood and adulthood are the

result of the unconscious use of the ANS in predictable ways. The secure attachment of

childhood and adulthood is similar to the adaptive defenses, in the sense that the activating

or inhibiting ANS branches work in concert and in a smooth and effortless manner to

INTEGRATION OF NEUROSCIENCE AND SOCIAL WORK 335

manifest generally socially acceptable behaviors in context-appropriate ways. However,

two of the insecure attachment styles, avoidant and ambivalent, are not flexible in response

to the situation, and for individuals with these styles, primarily one branch of ANS will be

employed to manage behavior. The avoidant individual strives for low arousal, while the

ambivalent individual strives for high arousal. Individuals with the third insecure

attachment style, disorganized/disoriented, react erratically and unpredictably with

excitable or very low arousal in ways that are inappropriate to the situation (Main &

Goldwyn, 1991; Kaslow, 1996; Siegel, 1999; Montgomery, 2013).

Implications of unconscious arousal strategies on clinical work

The over-use or erratic use of the branches of the ANS responsible for arousal means that

the under-utilized branch needs to be coaxed into use in order for the plasticity of the

neural systemto grow connections withinthe brain and to use both branches appropriately.

This cannot be done without another mature and functional person’s brain with which to

interact. The insecure attachment styles of childhood have come about becausethe children

have no interactive regulation of arousal from a caretaker and have to rely on their own

immature coping strategies. Without intervention, the arousal management strategies of

childhood will persist in adulthood. The clinical experience can provide a rewiring of the

brain and correct developmental insults and consequent arrests (Cozolino, 2002;

Applegate & Shapiro, 2005; Badenoch, 2008; Miehls, 2011), which can result in an‘earned

secure attachment’ (Pearson et al., 1994).

The ego and the right hemisphere

There is growing evidence that many of the ego functions identified in ego psychology have

substrates in the brain (Schore as cited in Montgomery, 2013). For example, the right

hemisphere has been found to regulate impulse control, self-esteem, processing of self and

other related material, as well as social and moral judgment – all well-known ego functions

(Schore, 1994, 2003a, 2003b; Schamess, 1996; Siegel, 1999; Cozolino, 2002). As much

psychological distress and dysfunction are reflected in poor right hemispheric function (and

often structure), it seems clear that it is critical to identify interventions targeting this area

of the brain. As is well documented, the right hemisphere is the seat of emotional

functioning and is implicated in almost all psychiatric diagnoses (Schore, 2003b). The road

to repair of the right hemisphere function is contained within old-fashioned interventions,

including, but not limited to, all the elements of the treatment alliance, the ability of the

therapist to withstand and manage the inevitable transferences, the encouragement of

improvement in ego function and availability for affect regulation. Our new ability to link

these methods of treatment to current neuroscience findings offers us an increased

understanding and appreciation of the effectiveness of psychodynamic treatment.

Challenges to the integration of neuroscience into social

work practice

Without question, interpersonal neuroscience plays a significant and growing role in

our understanding human development and behavior. However, social work has been

336 JOURNAL OF SOCIAL WORK PRACTICE

rather slow to incorporate these findings into its curriculum and practice. In part, the

profession has been plagued with numerous splits [i.e., hard vs. soft science, mind vs.

body (Schore, 1994, 2003a, 2004b), psyche vs. social, biology vs. environment

(Germain, 1996), direct practice vs. social change (Goldstein, 1996) and

psychodynamic vs. ecological perspectives (Goldstein, 1996)]. Consequently,

neurobiological knowledge could easily be construed as accentuating many of these

ongoing splits into science versus time-honored practice interventions. However,

interpersonal neurobiology resonates with social work practice and its emphasis on

emotional relationships – the power to both causes problematic, intrapsychic and

interpersonal issues as well as has a positive effect on them (Schore, 1994; Sroufe et al.,

2000). Nonetheless, the questions of what to teach and how to teach this curriculum in

an integrative fashion present a considerable challenge for social work instructors, as

well as the question of how findings from neuroscience may be incorporated in practice

settings.

Beyond the substantive issues of what, how and where to teach neurobiological

knowledge, there are other constraints and barriers to its inclusion. For instance, many

older tenured faculty as well as practitioners were educated or trained at a time when

neuroscience did not factor significantly in practice (Gabbard as cited in Kerr, 1992).

The lack of biology, particularly neuroscience, in his or her own educational

background presents a formidable obstacle to teaching this content with confidence.

It is highly likely that if one studied neuroscience, the focus would be on the left

hemisphere, the seat of cognition, rather than the right hemisphere, generally

described as the seat of emotional and relationship experiences (Schore, 1994). The

mastery of medical and scientific findings is especially hampered by the ‘imposition of

the language of neuroscience’ as well as the lack of obvious relevance to clinical

practice (Baylis, 2006). Many who have spent their university lives in social science

classrooms can be easily intimidated with brain science, which is itself in a constant

state of flux. New neurobiological breakthroughs are occurring daily, some of which

are not necessarily meant to have a bearing on the clinical work done by non-medical

professionals (Badenoch, 2008). Furthermore, once having mastered this content area,

it can be an overwhelming task to stay current with this burgeoning field.

Final thoughts

Though there are impediments to integrating neuroscience into the social work field, a

major advantage is that, as discussed above, certain tried-and-true approaches or

techniques for interventions are supported by recent findings from the neurosciences

(Applegate & Shapiro, 2005, p. xvii). What has been labeled ‘practice wisdom’ and has

often been dismissed as not enjoying scientific support, currently finds much validation.

The challenge is to translate that information from the unfamiliar vernacular of

neuroscience into usable explanations of familiar clinical phenomenon. By integrating

basic information about the structure and function of the brain and the mind into

clinical social work curriculum and practice, evidence-based practice can continue to

expand. Many social work educators have contributed to this integration of

neurobiology and social work, including J. R. Schore in Applegate and Shapiro (2005),

INTEGRATION OF NEUROSCIENCE AND SOCIAL WORK 337

Baylis (2006), Badenoch (2008), Schore and Schore (2008), Farmer (2009), Miehls

(2011), and Montgomery (2013).

There are risks to taking ‘shortcuts to enlightenment’ (Quart, 2012), which

include being seduced by stretching scientific findings to support cherished theories

and/or techniques, not properly representing the function of brain structures or

generally being undisciplined in applying scientific facts to a variety of mental health

issues. In addition, there is a danger of suspending one’s own critical thinking when

‘science’ is quoted to support a conclusion, particularly when the person is naive about

science (Weisberg et al., 2008). However, these foibles notwithstanding, I have the

conviction that the integration of neuroscience into psychodynamic practice is not just a

passing fad. The mind –brain –body split seems to be melting around the edges as the

neurobiological findings have the potential to validate many of the practices, such as

the focus on the relationship, that we see as central to our work.

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Arlene Montgomery, Ph.D., LCSW, has taught clinical courses since 1993 at the

University of Texas, Austin, Texas. She has had a private psychotherapy practice since

1978. Address: University of Texas, Austin, TX, USA. [E-mail: yerzaborzoi@aol.com]

INTEGRATION OF NEUROSCIENCE AND SOCIAL WORK 339

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