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Comparing Top-Down vs. Bottom-Up Therapy for Complex Trauma

Top-Down vs. Bottom-Up Therapy for Trauma: Which is better?

I learned about the concept of top-down versus bottom-up therapy about a year into my own therapy journey. At that point, I had been doing some general, sporadic talk therapy, but I was beginning to realize that my symptoms originated in unhealed past traumas.

Here, I’m going to offer a brief comparison of top-down and bottom-up therapy modalities, and I will link to some awesome resources for furthering listening!

Top-Down, Cognitive, and/or Talk Therapies

With top-down, cognitive, and/or talk therapies, you will engage the more cognitive parts of your brain in changing your thoughts to help improve your emotional well-being and behaviors.

Top-Down therapy modalities include:

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

Bottom-Up Therapy Modalities

With bottom-up therapy modalities, you will go to the deeper, older parts of your brain. The limbic system stores trauma, emotions, memories and instincts. The ultimate goal here is to start with the root of your symptoms.

Bottom-Up therapy modalities include:

  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Internal Family Systems (IFS)
  • Somatic Experiencing
  • Sensorimotor Psychotherapy
  • Brainspotting
  • Yoga Therapy
  • Sand Tray Therapy

Is a Top-Down or Bottom-Up Approach Better for Healing Trauma?

Top-down or cognitive therapies can be very helpful in the short-term. Many trauma therapists agree that it isn’t necessarily possible to think your way out of trauma responses, so a bottom-up approach is the way to go. For lasting impact, bottom-up therapies better address the root source of your symptoms. Many therapists and clients find that a combination of top-down and bottom-up therapies provide a comprehensive treatment plan for unhealed posttraumatic stress.

In his book The Body Keeps the Score, Dr. Bessel van der Kolk says, “Sadly, our educational system as well as many of the methods that profess to treat trauma tend to bypass this emotional engagement system and focus instead on recruiting the cognitive capacities of the mind. Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain before trying to promote new ways of thinking.“

To explore more about this topic, I would recommend the following books and podcasts:

Books: Top-Down vs. Bottom-Up Therapy for Trauma

  • The Body Keeps the Score: Dr. Bessel van der Kolk literally wrote THE book about trauma. His personal stories are fascinating and include neuroscience research, in addition to chapters on brain-body connections, survival strategies, attachment, developmental trauma, EMDR, yoga, neurofeedback, and healing.
  • What My Bones Know: In her memoir, Stephanie Foo outlines her own journey from complex trauma, to talk therapy, to bottom-up modalities for healing. She says, “At the same time, in my readings, I discovered some evidence that traditional talk therapy might not actually be particularly effective for C-PTSD. In The Body Keeps the Score, van der Kolk writes about how talk therapy can be useless for those whom ‘traumatic events are almost impossible to put into words.’ Some people are too dissociated and distanced from these traumatic experiences for talk therapy to work well. They might not be able to access their feelings, let alone convey them. For others, they’re in such an activated state that they have a hard time reaching into difficult memories, and the very act of recalling them could be retraumatizing.”
  • Complex PTSD: From Surviving to Thriving: Pete Walker’s book provides so much insight into the nuances of healing from C-PTSD. He says, “Thus, while it may be fairly easy to like yourself when feelings of love or happiness or serenity are present, deeper psychological health is seen only when you can maintain a posture of self-love and self-respect in the times of emotional hurt that accompany life’s inevitable contingencies of loss, loneliness, confusion, uncontrollable unfairness, and accidental mistake. The human feeling experience, much like the weather, is often unpredictably changeable. No ‘positive’ feeling can be induced to persist as a permanent experience, no matter what Cognitive-Behavioral Therapy tells us…Similarly, effective recovery is unwinding the natural potential you were born with out of your unconscious. This is your innate potential which may be, as yet, unrealized because of your childhood trauma.”

Recommended Books: Bottom-Up Approaches for PTSD and C-PTSD

Internal Family Systems (IFS)

EMDR

Somatic Experiencing

Workbooks

Podcasts: Top-Down vs. Bottom-Up Therapy for Trauma

  • On Being Well with Forrest Hanson and Dr. Rick Hanson, they discuss CBT, developmental trauma, individualized treatment, and bottom-up therapy in Childhood Trauma, Self-Sabotage, and Therapy. Don’t miss Dr. Hanson’s deeply meaningful gardening analogy at minute 23:00.
  • The Complex Trauma Recovery podcast focuses on C-PTSD and bottom-up therapy modalities. She is a therapist who is recovering from C-PTSD herself and has so much personal experience to share.

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Dissociation, Depression, Freeze, and Shutdown: Dorsal Vagal Responses to Trauma

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