Top Down vs Bottom Up Therapy. What’s the Difference?
When people begin therapy, they’re often surprised to learn that there are very different ways of working with emotional distress, trauma, anxiety, and long‑standing patterns of behaviour. One of the most helpful distinctions is between top‑down and bottom‑up approaches to therapy.
Understanding this difference can help you make sense of why certain therapies feel more “talk‑based,” while others focus more on the body, sensations, or nervous system regulation—and why many modern therapists integrate both.
What Do Top Down and Bottom Up Mean?
The terms come from neuroscience and describe where change is initiated in the brain and nervous system.
Top down therapy starts with the thinking brain (the cortex). Change happens through insight, reflection, meaning‑making, and conscious choice.
Bottom up therapy starts with the body and nervous system (the brainstem and limbic system). Change happens through sensation, movement, emotional processing, and regulation—often before words.
Neither approach is better or worse. They simply work on different levels of human experience.
Top Down Therapy Explained
Top down therapies focus on thoughts, beliefs, interpretations, and narratives. The idea is that by understanding and reshaping how we think, we can change how we feel and behave.
Common Top Down Approaches
- Cognitive Behaviour Therapy (CBT)
- Acceptance and Commitment Therapy (ACT)
- Cognitive Processing Therapy (CPT)
- Schema Therapy (cognitive components)
- Traditional talk therapy
How Top Down Therapy Works
In a top down approach, you might:
Identify unhelpful thinking patterns
- Explore core beliefs and assumptions
- Reframe interpretations of events
- Develop coping strategies and skills
- Make sense of past experiences through insight
Strengths of Top Down Therapy
- Helps people understand why they feel the way they do
- Builds cognitive clarity and self‑awareness
- Effective for anxiety, depression, stress, and problem‑solving
- Structured and goal‑oriented
- Often time‑limited and practical
Limitations of Top Down Therapy
- May feel ineffective when emotions feel overwhelming or “out of control”
- Can struggle to reach deeply stored trauma
- Insight doesn’t always translate into emotional or bodily change
- Clients may say: “I know this logically, but I still feel the same.”
Bottom Up Therapy Explained
Bottom‑up therapies focus on the body, emotions, and nervous system responses. Instead of starting with thoughts, they work with what is happening below conscious reasoning.
Common Bottom Up Approaches
- Somatic Experiencing (SE)
- EMDR (Eye Movement Desensitisation and Reprocessing)
- Sensorimotor Psychotherapy
- Internal Family Systems (IFS)
- Trauma‑informed yoga and movement therapies
- Breathwork and mindfulness‑based somatic practices
How Bottom Up Therapy Works
In a bottom‑up approach, you might:
- Notice bodily sensations and impulses
- Work with emotions as physical experiences
- Regulate the nervous system
- Process traumatic memories without detailed verbal recounting
- Develop safety and stability in the body
Strengths of Bottom Up Therapy
- Highly effective for trauma and complex trauma
- Helps regulate fight‑flight‑freeze responses
- Accesses implicit memory stored in the body
- Useful when words are hard to find
- Supports deep emotional processing and integration
Limitations of Bottom Up Therapy
- Can feel unfamiliar or confusing at first
- May take longer to articulate insights verbally
- Less structured than cognitive approaches
- Some clients prefer clear explanations and strategies
A Simple Comparison
Top Down Therapy Bottom Up Therapy
Starts with thinking Starts with sensation
Focuses on thoughts and beliefs Focuses on body and emotions
Uses language and insight Uses experience and regulation
Conscious processing Implicit processing
“Understanding” leads change “Feeling” leads change
Why Trauma Often Needs a Bottom Up Approach
Trauma is stored largely in the nervous system, not just in memory or thought. During threat, the thinking brain often goes offline while the survival brain takes over.
This is why someone can:
- Understand they are safe
- Know an event is in the past
- Believe their thoughts are irrational
…and still experience panic, shutdown, or emotional flooding.
Bottom up therapies help the nervous system learn safety again, rather than trying to think its way out of survival responses.
Do You Have to Choose One?
In practice, the most effective therapy often integrates both.
A skilled therapist may:
- Use bottom up techniques to stabilise and regulate
- Use top down approaches to build meaning and insight
- Move flexibly depending on what the client needs in the moment
For example, therapy might involve grounding and somatic awareness first, followed by cognitive reflection once the nervous system is settled.
Which Approach Is Right for You?
You may benefit more from:
Top Down Therapy if you:
- Enjoy reflection and discussion
- Want practical tools and strategies
- Are dealing with stress, anxiety, or mild‑to‑moderate depression
- Feel emotionally regulated most of the time
Bottom Up Therapy if you:
- Have experienced trauma or chronic stress
- Feel emotionally overwhelmed or shut down
- Experience strong bodily reactions
- Struggle to “think your way” out of distress
Many people benefit from both, at different stages of therapy.
Top Down vs Bottom Up Therapy – Final Thoughts
Top‑down and bottom‑up therapies aren’t opposing camps—they’re complementary ways of understanding human healing. True change often happens when insight and embodied experience come together.
If therapy hasn’t worked for you in the past, it may not be because therapy doesn’t work—but because the approach didn’t match what your nervous system needed at the time.
