There are numerous approaches to psychotherapy. I’ve studied many. Because there is never a one-size-fits-all approach, I integrate many therapeutic approaches into my work with clients. One thing I can say for sure is that, in my experience, a bottom-up approach to therapy works better in trauma-informed care. In my experience, it is the best all-encompassing approach to help create healing, and lasting change in a person’s ability to think, feel, and find healthier ways to live after trauma.
It’s important for those who have and treat trauma to know the differences between a bottom-up and top-down approach. Here’s why I believe a bottom-up approach is so valuable, especially for trauma survivors.
What Does Top-Down and Bottom-Up Therapy Refer To?
The terms top-down and bottom-up refer to the general areas of the brain and where you start in therapy (from the top or the bottom). Different parts of the brain work together to help us use information to survive and thrive in the world.
When we talk about a top-down approach, we’re focused on starting therapy with the parts of the brain we associate with thinking, speaking, and current emotional awareness. These are the topmost areas of the brain, and include the neocortex, frontal lobes and prefrontal lobes.
When we talk about the bottom-up approach, we’re talking about starting therapy with the parts of the brain located toward the base. These are the brain stem areas responsible for reflexes, memories, and automatic survival responses. This area also has a role in learning.
What is a Top-Down Approach?
A top-down approach in psychotherapy starts with looking at how the mind is interpreting information. The therapeutic interventions are all about changing your thoughts. If you think “right”, you’ll be able to make healthier choices, and everything will be okay. A top-down approach may involve the use of Cognitive Behavioral Therapy (CBT). As the Mayo Clinic defines it, “CBT helps you become aware of inaccurate or negative thinking so you can view challenging situations more clearly and respond to them in a more effective way.”
Limits of the Top-Down Approach
In my view, the top-down approach questions the client’s thoughts in therapy. It begs the question: What is wrong with your thinking, and how do we fix it?
The primary focus on thinking undermines our job of building a client’s trust in himself or herself. It’s like saying: What happened doesn’t really matter—only changing your thoughts does. Pay no attention to how your body feels or the memories left living inside of it. Let’s just think about it differently. Let’s think ourselves out of it.
The issue I have with a top-down approach in trauma therapy is that it focuses first on the cognitive, frontal lobes. The higher brain is the place where logic lives. A logic-first approach can be less effective because, if your brain has experienced trauma, the trauma response de-activates the thinking areas, and activates the lower areas of brain.
Trauma diverts energy to the more primal part of your brain that developed first. For those without a trauma history, or who do not first mobilize a fight-flight-freeze response (that is, those who can experience stress without a hyper or hypo—aroused amygdala), CBT can work well. But for those with trauma, thinking as an initial intervention, cannot override the response from the primal brain. The body’s memories of danger, supercharged by the amygdala, take precedence over the ability to calmly think things through.
What is a Bottom-Up Approach?
The bottom-up approach begins with information acquired from the body’s sensations. The bottom-up approach accepts that feelings or even body sensations happen first. The body’s automatic responses or feelings happen, feelings that one is unsafe. The life-saving stress response that has people looking and acting dysregulated is noticed. Trauma-informed therapy creates healing relationships in which it is safe to begin to look at the reasons why a person feels unsafe (and unable to control thoughts and feelings when triggered), without being overwhelmed. The healing relationships include the therapist-client relationship, and the client’s own relationship with himself or herself.
The best modalities for bottom-up therapy incorporate dual awareness —thinking and feeling —that is necessary for healing. In order to heal, feeling safe and learning how to have regulated responses in both the body and the brain need to develop,. Bottom-up therapy integrates the whole brain: left, right, top and bottom. Integration is key to healthy regulation.
Strengths of the Bottom-Up Approach
In bottom-up therapy, we don’t just focus on the primal part of the brain. Simply feeling one’s trauma-charged feelings – that is actually not enough to heal the injuries to the nervous system. It can actually be re-traumatizing to just feel the feelings and not do anything with them. Trauma informed therapy with a bottom-up approach allows a person to explore the dysregulated feelings after safety and stabilization are built and felt. Safety and stability allows a person to have one foot in feelings (right side of the brain or the bottom) and one foot in the logic, the here and now, the present, the frontal lobe (left side or top).
Using both sensation and thinking to process trauma helps a person realize that the danger they are responding to is actually old. Clients can begin to develop awareness that puts the danger in the past.…They can experience feeling safe now. They can develop dual awareness that they are able to keep themselves safe in the current situation, and look back on what has happened in the past.
This healing process allows a sense of safety in the present day to nurture a sense of safety for the younger parts of the self that otherwise only know danger as ever-present. The frontal lobe needs to be on board — to integrate with the lower parts of the brain — to make sense of the feelings.
In my view, a bottom-up approach is asking: Why are you doing this behavior? There must be a reason. What happened to you?
It’s saying: What is the root cause, so we can address and resolve it?
As we detail on our website, using a strengths-based trauma-informed model of care, our approach:
…accepts a person as-is. It recognizes the desperation and extreme states of emotion that unhealed trauma creates, and affirms their need for care and resources. This perspective:
- Does NOT ask: “What is wrong with you?”
- Asks: “What happened to you and how did you survive?”
- Affirms: “Your behavior makes sense, given what has happened to you.”
“Emotions can be and, in fact, probably are mostly processed at an unconscious level. We become conscious and aware of all this after the fact,” says researcher Joseph LeDoux about emotional regulation taking place from the bottom-up, in Anxious: Using the Brain to Understand and Treat Fear and Anxiety.
According to Stephen Porges’ Polyvagal Theory, the state of the nervous system influences healthy (or unhealthy) social behavior. The theory links:
…the evolution of the mammalian autonomic nervous system to social behavior and emphasizes the importance of physiological state in the expression of behavioral problems and psychiatric disorders. The theory is leading to innovative treatments based on insights into the mechanisms mediating symptoms observed in several behavioral, psychiatric, and physical disorders.
Bottom-Up Therapy Addresses the Trauma Response in the Body
As I mentioned in my recent article, the body remembers trauma. Sometimes a trauma survivor may be exhibiting body sensations or reactions to trauma without being able to name the trauma. Sometimes a situation triggers a person’s trauma response without them being aware of it. The individual just feels a threat to their safety. They then begin to find ways to cope with those feelings. These become usually deeply ingrained coping mechanisms that were developed long ago when the trauma first happened in their life.
Perhaps the person is using a coping mechanism (binging, smoking, self-harm, or using drugs or alcohol) because they don’t want to feel what they’re feeling. With a bottom-up approach to therapy, we help that person find new skills so that feelings feel more manageable. Until a person can learn to be present and in their body and feel their feelings safely, it’s impossible to truly process trauma.
Why We Use Bottom-Up Therapy First
First the body reacts; then the mind thinks. It can be hard to know you’re safe when the amygdala (the smoke alarm in your brain) is blaring.
The part of the brain that develops earliest in life is the primitive brain, the brain stem. It is the part of the brain that is responsible for keeping us safe. It is where fight, flight, and freeze exist. The primitive part of the brain does not suddenly just turn off when it’s had longstanding danger. After trauma, especially complex or developmental trauma, the brain gets stuck in this mode and remains prepared for danger all the time.
The higher brain regions (the limbic system, responsible for attachment and emotional development, and the cortical brain, responsible for thinking, learning and inhibiting) do not develop as-needed, nor can they work well if the lower part of the brain, the part responsible for sensory motor functions and survival are not functioning well.
In my experience, you cannot change your thoughts long term about anything without first noticing the feeling that triggers the thought, and working to address it from the primal part of your brain—the limbic system—where the trauma is stored.
How Clients Experience the Bottom-Up Approach
Once you begin to understand how you feel about something, you can start to change the way you think about it.
Is this an easy fix? No.
Does it work? Absolutely.
We at Brickel and Associates use a bottom-up approach to therapy because it works better, is more long lasting, and attends to underlying issues. It does not just attempt to change the belief around a behavior.
If you change what you tell yourself about an issue, without addressing the underlying cause, you are simply creating a game of Whack-A-Mole.
You may get rid of one behavior (or as I like to say, one coping skill). But if you are still feeling badly inside, another coping skill will pop up. And if you are still feeling badly on the inside, it may be hard to come up with healthy coping skills. A person can go from one way of coping, say, hair pulling, to another self-harming behavior. For example, a person may try using food, controlled eating, drugs or alcohol instead. Healing is not about continuing to look for something to dull the pain and help you feel less badly. You may hit the mole in one place, but it will inevitably pop up somewhere else.
That’s not to say self-talk is ineffective. Ideas learned through CBT are an important component of bottom-up therapy. CBT just needs to work in conjunction with the feelings and the bottom or the right side of the brain.
How to Integrate Therapeutic Approaches
After safety and stabilization has been achieved —where the person can learn to tolerate their feelings and be in their body—then a multi-faceted approach can be useful. Integrating bottom-up approaches and top-down therapy helps people progress toward healing.
We use many modalities of treatment in our practice including EMDR therapy, Sensorimotor psychotherapy, Ego State Psychotherapy, Mindfulness, etc to help the individual progress towards recovery. Bottom-up helps to process the trauma that lives in the body. Top-down can help with grounding skills (I’m having a flashback but I know that I’m safe because I’m sitting in my therapist’s office).
My colleague and EMDRIA approved consultant, Tracy Ryan Kidd, LCSW and I were talking about the different engines that make bottom-up therapy run.
Bottom-up approaches and examples that allow for and work with dual awareness include:
- Somatic Therapies use mindfulness for the top side and noticing body sensations for the bottom.
- Ego State Psychotherapy uses the adult self being able to empathize or nurture the child self.
- EMDR uses Bilateral Stimulation and the protocol to go left and right, bottom and top.
Bottom-up is an integrated understanding of trauma!
How to Find a Therapist Who Takes a Bottom-up Approach
Perhaps you’ve tried a top-down approach to therapy, and it hasn’t worked long term. I believe this is because top-down therapy doesn’t address the root of the trauma—where the trauma lives in the body. There is hope for true recovery; it comes from a bottom-up approach. If you’re in the D.C. area, contact us.
- 9 signs you may be a trauma survivor
- A mind-body approach to trauma recovery
- Why You Need a Trauma-Informed Therapist, Even if You Don’t Think You Have TRAUMA