“Psychologists usually try to help people use insight and understanding to manage their behavior. However, neuroscience research shows that very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention. When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it.”
― Bessel A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Carrie was familiar with the long-felt painful emotions that arose from a nagging belief: “I’m not good enough”. This belief was embedded into her as a child through years of emotional abuse from her parents. After years of talk therapy, she rationally understood the error of this belief as she worked to debunk it. However, this persistent narrative always crept into every encounter. She was fired from numerous jobs and her relationships were suffering. She could not move past these self-sabotaging behaviors. Her child-self was still dictating her present-day behavior.

Carrie’s situation is common for those experiencing trauma-based, chronic mental health conditions such as Depression, Anxiety, and PTSD. Long-time sufferers have often been through the gamut of Top-Down therapy approaches such as Cognitive Behavioral Therapy (CBT) …Dialectical Behavioral Therapy (DBT), or Psychodynamic Therapy.

Numerous studies on trauma have found Bottom-Up approaches that incorporate the body and mind connection have been necessary to pair with Top-Down approaches for treatment. These could include Somatic Experiencing, Yoga, Equine Therapy, Drama Therapy, Biofeedback, and others.

Understanding the differences between these approaches requires a comprehension of the functions of the parts of the brain. Simply put, the upper brain is associated with cognition. The younger part of the brain is responsible for newly developed traits such as time management, understanding how things work, and accomplishing goals. In contrast, the older part of the brain is known as the reptilian brain. This part of the brain includes the lower brain centers and the limbic system. Essential bodily functions such as digestion, heart rate, hormone production and release, and immune system functioning are controlled here.

What is a Top-Down approach in mental health treatment?

A Top-Down approach involves the upper brain centers, including the hippocampus and the prefrontal cortex. These are associated with the analytical mind, including reflection, cognition, and narration. The brain is a “meaning-seeking machine” that likes to tell stories. This approach addresses the “rational” side of the brain.
A top-down approach assumes that strengthening a patient’s cognition resources can determine the logic of potential threats, conflict, and stressors and ascertain whether they are perceived or actual.

Practicing mindfulness, identifying distorted patterns, and adjusting underlying beliefs and narratives are a few techniques used in top-down processing.

What is a Bottom-Up approach to mental health treatment?

A “Bottom-up” approach is associated with the feeling center of the brain and sensory receptors of the peripheral nervous system. Bottom-up treatment regulates and adjusts the bodily responses by resetting focus on body sensations, emotional awareness, and movement impulses to release energy that has gotten stuck in a traumatic “freeze” response or has stayed hypervigilant in fight or flight. As a result of this shutdown or hyperarousal, basic functions such as sleep, appetite, touch, and digestion have been affected. This theory supports the body/connection, aided through “Bottom-up” interventions such as rhythmic movement and emotional and body awareness.

Why do Top-Down approaches “miss the mark” in recovery?

When the brain has been through traumatic changes resulting in PTSD, anxiety, depression, or other mood disorders, top-down approaches are often not wholly effective. As trauma-altering beliefs have affected informational systems, prompting a patient to use a “rational approach” is often unsuccessful. In depression, anxiety, PTSD, OCD, and other mental disorders, there is a fixation from the rational side of the brain to “figure out” problems. Combating these overthinking tendencies with more thinking is counterproductive, as overthinking is a symptom, not the cause of distress.

Those who have experienced trauma are often stuck in a shutdown from a freeze response of the autonomic nervous system and an overactive amygdala. As our memory is a faulty storyteller, trauma survivors often flash through fragmented, distressing images, sounds, and emotions that don’t register as “in the past.” The amygdala has no sense of time. Shutdown or overactivation has become chronic and plays a part in a distressed person’s ability to feel sensations or emotions or feel safe in their body. Dysregulation often results in hypo-or hyperarousal of the autonomic nervous system. Stress hormones wreak havoc on the body with their bombardment.

Brain parts that have been the most affected by trauma are the oldest portions of the brain. These house traumatic memories that have often occurred before age five and exist in the unconscious, and are associated with primitive/ preverbal functions. They are not related to rational thought, dialogue, and reasoning.

As a result, top-down therapy is ineffective for these early trauma stores, as it “speaks a different language”.

Bottom-up processing invites individuals experiencing trauma to reconnect with the mind-body starting first with the basic “housekeeping” functions, necessary to provide an environment of homeostasis so that the rational brain can “come back online.”

“If we want to change the posttraumatic reactions, we have to access the emotional brain and do “limbic system therapy”: repairing faulty alarm systems and restoring the emotional brain to its ordinary job of being a quiet background presence that takes care of the housekeeping of the body, ensuring that you eat, sleep, connect with intimate partners, protect your children and defend against danger.”
― Bessel A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma 

How Accelerated Resolution Therapy combines both Top-down and Bottom-up approaches:

Accelerated Resolution Therapy (ART) uses bilateral eye movements and bodily awareness, which are shown to be highly effective in bottom-up processing. Both methods address the parts of the brain associated with emotion and bodily regulations.

Bilateral eye movements work both the emotional and rational sides of the brain while stimulating the parasympathetic (rest and digest) system. As a client focuses on a distressing image, the side-to-side eye movement relaxes the brain while imitating what happens in REM sleep cycles, allowing the memory to be processed and integrated with other memories on an unconscious level. This process is said to be happening “in the background” on a level that does not require the degree of rational thought used by talk therapy and other “top-down” approaches.

While the client is directed to focus on a specific memory or a montage of related traumatic memories, they are asked to become aware of the related sensations in the body: “What is the feeling that comes up?” “Where in the body is this feeling located?” “Does the feeling shift, move, or change at all?” “How intense is this feeling?” Creating awareness around emotional and physical sensations allows the client to experience the feeling of being “in the body”. During a chronic freeze state of trauma, these connections are not as easily accessible. A safe, therapeutic setting combined with soothing, bilateral allows emotions to be processed, felt, and moved through the body.

ART has been shown to be especially successful in its approach through its use of Voluntary Image Replacement and rescripting, through which the client is guided in eliminating their recurring distressing images and replacing them with positive images. Top-down therapy approaches from Cognitive Behavior Therapy help guide the triggered response. The combination of top-down and bottom-up approaches has been demonstrated as quicker and more constructive than talk therapy alone.

“The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and emotional brains, so that you can feel in charge of how you respond to and conduct your life. “
― Bessel A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma


The Truth About Anxiety and How To Heal It: Tools for Anxiety From a Neuroscientist MD How to Rewire Your Traumatized Brain

The Bottom-Up Processing Protocol | Springer Publishing

How Bottom-Up Treatment Can Address Trauma | Psychology Today

The Trauma Resiliency Model: A “Bottom-Up” Intervention for Trauma Psychotherapy

The Body Keeps The Score | Bessel van der Kolk, MD.


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