What do “bottom-up” and “top-down” mean in therapy?

In my previous blog post, I shared my thoughts on Accelerated Experiential Dynamic Psychotherapy, or AEDP, and explained that it's considered a "bottom-up" therapeutic approach. But what do "bottom-up" and "top-down mean" in therapy? In this post, I hope to help you understand the differences between these two approaches and see which one might be best suited for you.

Top-down processing: learning through information

Top-down and bottom-up are just two ways in which humans learn and process information. To understand how they work, it can be helpful to use the "triune brain" model, proposed by Paul D. MacLean in the 1960s. It's important to note, though, that this is a comparative model between species that is considered outdated as subsequent findings on evolution and neuroanatomy have been made. However, it can still help us visualize the human brain in a simplified way.

According to the triune brain model, we have three areas within the brain:

• The "reptilian" complex: it's the basal ganglia, derived from the floor of the forebrain. It operates on instinct, so it's responsible for the functions of our body that help us survive.
• The "mammalian" or paleomammalian complex: includes the septum, amygdalae, hypothalamus, hippocampal complex, and cingulate cortex, and it's also known as a whole as the limbic system. This area is responsible for processing our emotional and relational experience.
  
• The "neomammalian" complex: or simply called the neocortex, this is the topmost and greater area of the brain. This is where thinking happens; it's responsible for our ability for reasoning, language, abstraction, planning, self-awareness, and perception.
  

If we think of this model, top-down means that processing happens in the neocortex, to exercise change in the lower areas of the brain. In top-down processing, we rely on forming new insights and cognitive understandings in order to shift how we feel. Here, it's the change in thinking that begins the process and leads to a change in emotions and body responses.

Top-down processing is cognitive—we learn through information. One way to easily remember how it works is this: top-down processing is reading about how to ride a bike.

Examples of top-down therapy:

• Cognitive-Behavioral Therapy (CBT)
• Trauma-Focused CBT (TF-CBT)
  
• Dialectical Behavior Therapy (DBT)
• Cognitive Processing Therapy (CPT)
• Prolonged Exposure Therapy (PE)
• Psychoanalysis
• Solution-Focused Brief Therapy (SFBT)
• Psychodynamic Therapy

Bottom-up processing: learning by doing

In bottom-up processing, we rely on having new felt experiences in the body, which in turn impacts how we feel and think. It uses felt experiences of safety, connection, and regulation and a change in our body state to alter how we see ourselves and the world.

Bottom-up processing is experiential—information moves from the lower brain to the neocortex. To continue the previous example, bottom-up processing occurs when we learn to ride a bike by taking our bike out and trying to do it.

Examples of bottom-up therapy:

• Yoga
• Somatic Experiencing
  
• Eye Movement Desensitization Reprocessing (EMDR)
• Accelerated Experiential Dynamic Psychotherapy (AEDP)
  
• Sensorimotor Psychotherapy
• Brainspotting
• Focusing
  
• Hakomi Method
  
• Art Therapy
• Drama Therapy
• Dance/Movement Therapy
• Play Therapy
• Sand Tray Therapy
• Equine-Assisted Psychotherapy

Which one is more effective at treating trauma?

I have many clients who come into the therapy room knowing, from a cognitive perspective, that rest is a good thing, that people should have rest, that overworking is related to capitalism, etc. And yet, on a body level they still feel uncomfortable resting. In those cases, the cognitive insight is there, but their felt sense of resting is still "it's not safe". This is when we would work with the body and use a bottom-up approach to help them actually feel safe with rest. 

On the other hand, I've also had clients who've found a new way of thinking about things. For example, the idea that rest can help us to do the things we want to do actually makes them feel safer, because they'd never considered that perspective. In this case, the new way of thinking leads to actually feeling different—this would be top-down processing.

When we discuss trauma, we need to understand that it is stored in the body: it triggers physical responses and shuts down the rational parts of our brain. For this reason, top-down processing may result in changes of behavior and emotional reactivity over time. However, people with trauma have impaired capacity to integrate new information, because their bodies (or: the lower parts of their brains) react before the neocortex can process what's happening when they're triggered.

Bottom-up processing is emotional and sensorimotor: it starts with the body. A bottom-up therapeutic approach engages the body in the healing process so that it can become a safe place, and it results in new, adaptive cognitions and meaning for people with trauma. This doesn't mean that top-down processing isn't good for treating trauma: it means that it's most effective when it's combined with a bottom-up approach.

If you’ve tried a top-down therapy and it didn’t work for you as much as you hoped or you feel like you’d like to try something different, it might be a good idea to try bottom-up, or an integrated approach!