There Isn't Just One Way to Heal: Top-Down vs. Bottom-Up Approaches to Trauma Therapy

You’ve probably heard the phrase “Trauma affects us on every level”. When it comes to therapy, there are two key approaches that can holistically address trauma, anxiety and other concerns: top-down and bottom-up. I believe both can be incredibly effective in their own way. If you’ve done therapy, you might have experienced both types, sometimes without even realizing it. So, what are these two approaches and what do they mean? And more importantly, which one might be most beneficial for you in your healing journey?

Let’s explore the distinctions between top-down and bottom-up processing in therapy, and how understanding these can help you navigate your healing in a way that’s best suited to you.

Top-Down Processing: Healing Through the Mind

When we talk about "top-down" processing, we’re referring to an approach that primarily engages the mind and relies on high brain functions such as the prefrontal cortex which is responsible for reasoning, planning and decision-making. This method focuses on the cognitive aspects of trauma — the thoughts, beliefs, and narratives that have been shaped by your experiences. Essentially, it’s about thinking through and understanding the trauma you’ve experienced, often with the help of talk therapy.

Top-down therapy is rooted in the idea that our thoughts and beliefs influence how we feel and behave. If you’ve been to traditional talk therapy, you’ve probably used this method. One, of many, forms of top-down processing is Cognitive Behavioral Therapy (CBT). It encourages identifying negative thought patterns and replacing them with healthier, more realistic perspectives. In the context of trauma, top-down approaches aim to help you make sense of your trauma, change how you perceive it, and shift the negative beliefs that may have developed because of it.

One of the major benefits of top-down therapy is that it can help you regain a sense of control over your thoughts and emotions. Trauma often leads to a sense of chaos and helplessness, and top-down approaches can be empowering because they allow you to reframe your narrative and challenge unhelpful patterns. It’s incredibly valuable for people who are more verbally oriented, and who can process and articulate their trauma in a logical or reflective way.

That being said, there are limitations to this approach — trauma is not just stored in our thoughts. It is also stored in the body and the nervous system. Sometimes, we do not have the words to think our way through trauma or the holistic and somatic symptoms of trauma are not addressed as well. That’s where bottom-up processing comes in.

Bottom-Up Processing: Healing Through the Body

While top-down therapy focuses on changing thought patterns, bottom-up processing centres on the body’s responses and subconscious processing of trauma. It is largely rooted in the brain stem and limbic system, which govern automatic, instinctive reactions like fear, fight or flight responses and emotional regulation. The basic idea behind bottom-up therapy is that trauma is stored in our bodies and our minds in our nervous system, physical sensations, movements, and postures. These are often unconscious and happen outside of our awareness, but they significantly affect how we feel, how we interact with others, and even how we interpret our thoughts.

One of my favourite bottom-up approaches is EMDR (Eye Movement Desensitization and Reprocessing). EMDR is a specialized form of therapy that helps you process and integrate traumatic memories by stimulating both sides of the brain. This form of stimulation is thought to mimic the brain’s natural processing during REM (Rapid Eye Movement) sleep, which is associated with the brain’s ability to process and integrate memories. It works by engaging the body’s natural healing mechanisms, using bilateral stimulation (such as side-to-side eye movements, tapping, or sounds) while focusing on distressing memories. This helps desensitize the emotional charge tied to those memories, allowing the trauma to be processed in a more balanced way.

Why does this work? Trauma can cause your nervous system to get "stuck" in a heightened state of arousal (fight or flight) or shutdown (freeze). In these states, the body feels the trauma long after the traumatic event has passed, affecting your ability to stay grounded or safe in your present life. By focusing on the body and how it reacts to trauma, bottom-up therapies like EMDR aim to release that stored trauma, allowing your nervous system to return to a more balanced state.

Many people find bottom-up approaches especially helpful when cognitive processing feels inaccessible or overwhelming. For example, someone who has experienced complex trauma might find it difficult to express their experiences with words, but they may feel the effects of trauma in their body—like tension, dysregulation, constant stress, anxiety, hypervigilance, or exhaustion. Bottom-up therapy, especially EMDR, addresses these sensations directly, helping individuals regulate their nervous system and heal through reprocessing at cognitive and physiological levels.

Integrating Both Approaches for Comprehensive Healing

When combined, top-down and bottom-up processing are a pair to be reckoned with.

• Holistic Brain Healing: Top-down approaches help address trauma cognitively, while bottom-up approaches work with the body to release emotions and tension. Together, they help both the thinking mind and the feeling body process trauma in a more balanced way.

• Dual Activation of Brain Networks: Top-down processing activates higher brain centres involved in reasoning, while bottom-up engages lower brain centres related to emotion and physical sensation. Activating both helps the brain integrate different aspects of trauma (cognitive, emotional, and physiological), fostering deeper healing.

• Stabilization and Rewiring: When top-down therapy teaches cognitive strategies and bottom-up therapy helps stabilize emotional and physical responses, the brain rewires itself to handle stress and trauma more effectively. Both systems work to create new neural pathways that support healthier, more adaptive coping mechanisms in daily life.

Best Practices for Trauma Therapy: Integrating Top-Down and Bottom-Up Approaches

Now that we understand the differences between top-down and bottom-up approaches, how do we put this into practice? In my experience, the most effective trauma therapy doesn’t rely solely on one or the other but rather integrates both top-down and bottom-up techniques.

1. Seek a Therapist Who Uses an Integrative Approach

If you’ve been doing therapy and feel like something’s missing, it might be time to look for a therapist who uses an integrative approach. This means they combine talk therapy (top-down) with EMDR or body-based approaches (bottom-up), allowing you to address trauma from all angles. If you’re not sure whether your therapist is using both approaches, it’s okay to ask. A skilled therapist will be able to help you explore both the cognitive and somatic aspects of your trauma.

2. Use Mindfulness and Grounding Techniques

Mindfulness is a tool that bridges the gap between top-down and bottom-up approaches. It encourages you to be aware of your thoughts without judgment, which can help you process trauma in a gentle, compassionate way. At the same time, mindfulness also encourages you to pay attention to your body—your breath, your posture, and any sensations that arise. Grounding exercises, like focusing on your feet on the floor or engaging in deep breathing, can help bring you back to your body and the present moment, especially when you’re feeling triggered.

3. Be Patient with Your Healing Process

Healing from trauma is rarely a linear process. Sometimes you’ll feel more cognitively aware of your trauma, and other times your body will reveal sensations that you need to attend to. Be patient with yourself as you navigate the complexity of trauma recovery. Whether you’re working from the top down or bottom up, remember that you’re on a journey of self-discovery and healing.

Final Thoughts: The Power of Healing from All Angles

Whether you find comfort in processing your trauma through your mind or your body, the key is finding an approach that works for you. Top-down and bottom-up approaches offer different, yet complementary, ways to heal. If you’ve done therapy before and felt like something wasn’t quite clicking, it could be that one approach is more suitable for you than the other—or maybe it’s time to explore a more integrated method. Healing from trauma is about understanding that there are multiple layers to our experiences, and addressing all those layers is the path to true recovery.

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