Bottom-Up vs. Top-Down Therapy: What It Is and Why It Matters
When I was a baby therapist...
(And yes, this is a loving term we use in the mental health community for those newer to the field.)
I was all about therapy with worksheets, protocols, and building skills to help people manage the struggles that come with being human.
And honestly? There is absolutely nothing wrong with that.
Skills are valuable. Learning tools to regulate emotions, challenge unhelpful thoughts, communicate effectively, and navigate life more successfully can be incredibly helpful. I know I helped many clients over the years using these approaches, and I still believe there is an important place for skills-based work.
This is where many top-down therapy modalities tend to live.
Top-down approaches work primarily through the thinking brain. They often involve identifying thoughts, learning skills, practicing strategies between sessions, and using cognitive awareness to create change.
Examples of top-down approaches include Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Exposure and Response Prevention (ERP).
However, as I have grown into the therapist I am today, I have found that skills-building is sometimes not enough. At a certain point, many clients reach a place where they know what to do—but still feel stuck.
And honestly? I experienced this in my own life too.
I lovingly describe this barrier as:
"Knowing..."
(points at head)
vs
"Knowing..."
(points at heart)
Because there is a difference.
I have clients who come to me and they know what their negative cognition is. They know what skill they could use. They know that self-compassion is important.
They know all the "right" things.
But then there is the deeper, felt sense of knowing.
Knowing that you are worthy.
Knowing that the past is truly in the past.
Knowing that the negative belief you've carried about yourself isn't actually true at the deepest level of your being.
That is where bottom-up processing comes in.
In very basic terms, bottom-up approaches work with the body, nervous system, emotions, and deeper implicit memories rather than relying primarily on conscious thought and analysis.
Top-down approaches engage the thinking brain—the prefrontal cortex, which is involved in planning, problem-solving, perspective-taking, and (let's be honest) sometimes a whole lot of overthinking.
Bottom-up approaches work with the systems underneath that thinking process, including emotional and body-based experiences that may be difficult to shift through insight alone.
Because sometimes we can understand something intellectually and still not feel it.
We can know we are safe, but our body still reacts as if we are not.
We can know we are worthy, but still carry the felt experience of not being enough.
We can know the past is over, but still feel stuck in the emotions connected to it.
This is where bottom-up therapies can be especially helpful.
Examples of bottom-up approaches that I utilize include Brainspotting and Internal Family Systems (IFS). These approaches incorporate more somatic and experiential elements to support deeper processing and help clients move beyond simply knowing change is possible into actually experiencing that change.
Both top-down and bottom-up approaches have value. Many people benefit from a combination of both: building practical skills while also addressing the deeper emotional and nervous system patterns that keep us feeling stuck.
If this article resonates with you and your therapy journey, and you are interested in exploring a deeper, experiential approach to therapy, I invite you to learn more about my Therapy Intensives.
Please note: This article is intended for educational purposes and is not a substitute for individualized mental health care. Reading this blog does not establish a therapeutic relationship. If you need personalized support, please reach out to a licensed mental health professional.
