“Top-Down” or“Bottom-Up” Therapy:What’s the difference?
As much as we all wish therapy could be as simple as telling someone your problems and them telling you what to do to solve them; there are many elements necessary for a healing and revitalizing therapeutic experience. Part of the reason you may feel like you’re not getting that full experience with your therapy is because you might not be using the best approach for your journey.
There are hundreds of approaches to choose from and, while that sounds daunting, there is a way to simplify the process and that is by understanding what bottom-up and top-down therapy is.
In this post, we’re going to be breaking down what they are, who they are best suited for, examples of approaches that fall under these two types and the way to make sure you’re getting the right therapy for you.
What Does “Top-Down” Therapy Mean?
Therapeutic approaches are categorized based on their entry point - meaning, where and how they begin processing your experiences. Top-down therapy starts with your thinking brain, so you process your experiences through thoughts, words, and make meaning through the narrative you’re able to create. It focuses more on understanding your thought patterns and finding ways to shift your experiences. It can help you change what emotion you associate with certain situations or how you react to them. It
For instance, if you often feel shame about how you react in certain situations, a top-down approach would help you examine the thoughts and beliefs fueling that shame (“I shouldn’t feel this way,” or “I’m weak for reacting like that”). Through techniques like reframing, cognitive restructuring, or challenging unhelpful narratives, you learn to shift how you interpret your reaction.
Examples of top-down therapy:
Exposure therapy
Narrative therapy
Acceptance and Commitment Therapy (ACT)
Psychodynamic therapy
When a Top-Down Approach May Help More?
Depression (negative thinking patterns, hopelessness)
OCD (intrusive thoughts + compulsions)
Perfectionism & self-criticism
Overthinking
What Does “Bottom-Up” Therapy Mean?
Bottom-up therapy has the opposite entry point - the body. Instead of starting with thoughts, beliefs, or stories,the nervous system, automatic responses, sensations, and physical cues that shape how we feel and behave. It comes from the framework that we register sensations prior to our cognitive awareness of what we’re feeling. Therefore by increasing awareness and comfort with our sensations, we can begin to process our experiences and meet our needs.
This might include practices that bring awareness to breath, heart rate, muscle tension, or gut sensations, which is the body’s language for safety and danger. By noticing and gently shifting these physical states, you can gradually access and process deeper emotions, memories, and patterns that may not be available through cognitive processing alone.
This is really useful for people who have experienced trauma, over-intellectualize their emotions or feel disconnected from themselves. It focuses on your body’s reactions and teaches you to regulate yourself by helping you soothe your triggered nervous system.
It’s a body-based therapy, so, if you find it tricky to actually know or trust what you’re feeling or what made you feel a certain way, this therapy is going to have you acknowledge how your body reacts and then help you manage that reaction.
Examples of Bottom-up therapy:
Dance/movement therapy
Somatic Experiencing (part of Somatic Therapy)
When a Bottom-Up Approach May Help More?
Difficulty verbalizing your experiences
Dissociation
Blended approach: Top-Down+Bottom-Up
While top-down and bottom-up therapy might sound like complete opposites, it is important to note that therapy is a unique experience for everyone so therapists – especially our therapists here at TCC – might use a blended approach to best cater to your needs.
Some therapies make use of both bottom-up approaches and top-down approaches. These therapies explore both what the body feels as well as how the mind processes.
Examples of blended (integrative) approach therapies:
Mindfulness-Based Cognitive Therapies (MBCT)
| Top-Down Approaches | Bottom-Up Approach | Blended/Integrative |
|---|---|---|
| Cognitive Behavioral Therapy (CBT) | Somatic Experiencing | Internal Family Systems (IFS) |
| Narrative Therapy | Eye Movement Desensitization and Reprocessing (EMDR) | Dialectical Behavior Therapy (DBT) *can be top-down depending on practitioner* |
| Acceptance and Commitment Therapy (ACT) | Accelerated Resolution Therapy (ART) | Emotion-Focused Therapy (EFT) |
| Exposure Therapy | Brainspotting | Sensorimotor Psychotherapy |
| Trauma Focused Cognitive Behavioral Therapy (TF-CBT) | Dance/Movement Therapy | Mindfulness-Based Cognitive Therapy (MBCT) |
| Psychodynamic Therapy | Hakomi | Visual & Expressive Art Therapy |
| Cognitive Processing Therapy (CPT) | Depth Hypnosis |
Things that may affect the effectiveness of top-down and bottom-up approaches:
Figuring out the best approach for you is an excellent starting point but it is still only a starting point. There are a couple elements that may limit the impact of these approaches on your therapeutic journey. For instance:
Your therapist’s knowledge of bottom-up versus top-down approaches: While your therapist should know about bottom-up and top-down approaches, they may not always prioritize choosing their approach based off which approach would be most compatible for you.
Your therapist's access to these approaches: There is much less research on bottom up and blended approaches which may limit what approaches your therapist is able to employ.
Your therapeutic relationship: The effectiveness of therapy depends strongly on the trust you have in your therapist to guide you. Without a strong therapeutic relationship, the effectiveness of any therapeutic approach becomes incredibly limited.
Your willingness to open up: Therapy requires vulnerability and, especially when it comes to top-down therapy, you must be willing to dig deep and be open. Without this, your therapist cannot properly address the root cause of issues, and you may find yourself unable to progress in therapy.
Here at TCC, our therapists ensure that they remain knowledgeable and up to date, catering their approaches and pacing towards the individual needs of their clients. If you’re interested in learning what approach may work best for you, you can book a free 15 minute consult with one of the trauma-informed and culturally-responsive therapists within our team.
TLDR:
Bottom-up therapy involves processing your feelings through your body, connecting your emotions with your body’s reactions and learning to soothe yourself.
Top-down therapy involves restructuring how you view your emotions, reactions and situations.
While there is no objectively better therapy, there will be a way that is best suited for your therapeutic needs.
At TCC, we offer consultations with our therapists to give you and them the ability to best assess what form of therapy would work best for you.
Resources:
https://khironclinics.com/blog/the-power-of-the-bottom-up-approach-transforming-trauma-recovery/
