Bottom-Up vs. Top-Down Therapy for Trauma: A Brain-Based Approach to Healing
Trauma therapy has evolved significantly over time, shaped by both psychological theory and advancements in neuroscience. Traditional talk therapy and psychoanalysis, which are top-down approaches, have long been used to help individuals make sense of their trauma through verbal processing. We talk about what happened, we analyze its effects, and make progress through understanding the experience more. However, research has shown that trauma is not just a cognitive experience—it is a full-body event that affects the nervous system, often beyond the reach of rational thought.
Bottom-up therapies work from this understanding, focusing on the body’s response first, rather than relying solely on cognitive processing. Many therapists, myself included, find that blending both top-down and bottom-up techniques creates the most effective healing process.
The Brain Under Trauma: When the Thinking Brain Shuts Down
One big reason cognitive-based therapies sometimes fall short is that trauma literally rewires the brain, making it hard to think clearly when you're in distress. Normally, information enters the brain through the dorsolateral prefrontal cortex (DLPFC), the part of the brain responsible for perspective-taking, problem-solving, decision-making, and impulse control—all the things that help us reflect rationally. But when trauma is triggered, those higher-level functions go offline.
Instead, the brain shifts into more primal survival mode, and thinking becomes way harder. When a traumatic memory or trigger pops up—whether it's from the past or in the present—your body reacts first, and your mind thinks later. As trauma expert Peter Levine puts it, you can't properly process thoughts when your body is telling you that you're standing in front of a tiger.
When trauma activates the body, the amygdala (the brain’s fear center) goes into overdrive, and the autonomic nervous system shifts into fight, flight, freeze, or fawn mode. This means:
The prefrontal cortex (our thinking brain) gets suppressed.
The amygdala (our brain’s alarm system) takes control, making fear and panic stronger.
The limbic system (emotional brain) dominates, leading to intense emotional and physical reactions.
In the aftermath of trauma, this experience is stored both in our memory and in our body, particularly in sensorimotor patterns—stuff like chronic tension, dissociation, or hypervigilance. This is why sometimes trauma survivors find it hard to control their emotions, feel safe, or think clearly, even when they know they aren’t in danger anymore.
Top-Down Therapy: The Role of Talk Therapy in Trauma Healing
Many of the people I work with want to talk about their trauma. They want to analyze it and understand its impact on them. To be able to move from the sometimes paralyzing impact of trauma to being able to talk about it freely, from a position of strength, is what feels like true trauma recovery for many.
Traditional top-down therapies, such as Cognitive Behavioral Therapy (CBT), Trauma-Focused CBT (TF-CBT), Psychoanalysis or Narrative Therapy & Written Exposure Therapy can be extremely useful for trauma survivors. These therapies help individuals gain insight, reframe distorted thoughts, and find meaning in their experiences.
These are some of the ways in which these type of therapies work -
Understanding the Trauma: Top-down approaches typically start by helping the person understand what happened, how it impacts their thinking, and how their perception of the traumatic event may be shaping their current experiences.
Understanding and Managing Intense Emotions: Trauma often leads to overwhelming emotions, including fear, anger, sadness, or shame. Top-down approaches aim to help individuals identify and process these emotions in a healthy way. This may involve techniques like emotion labeling, mindfulness, and self-compassion.
Cognitive Restructuring and Cognitive Behavioural Skillbuilding: One of the core components is challenging distorted or unhelpful thoughts that may have developed after trauma (e.g., feelings of guilt, shame, or worthlessness). We can teach specific skills to deal with triggers, stress, and trauma-related thoughts. Techniques like relaxation training, problem-solving, and thought-stopping help people manage their reactions when they are confronted with memories or stressors related to the trauma.
Exploring Beliefs and Identity: For many trauma survivors, their identity and worldview are altered by their experiences. Top-down treatments help clients process how their sense of self, relationships, and beliefs about the world may have been affected. This can involve exploring themes like trust, safety, power, and self-worth.
Reframing and Making Meaning of the Trauma: The ultimate goal is often to help create a new narrative around trauma. This means not just acknowledging the pain but also recognizing the strength, resilience, and the ways in which they have learned or grown from the experience. We move the trauma from being the whole story to becoming just part of a person’s life story.
The risk with top-down therapy is that it can sometimes end up as an avoidance strategy instead of a true healing process. Talking about trauma without connecting to the body can create a sense of distance, allowing people to analyze their experiences without fully feeling them. This can lead to emotional detachment, where people focus on understanding the trauma intellectually but avoid facing the deeper pain, fear, or anger that’s still stored in their bodies. By separating the mind from the emotions, the person might discuss the trauma without truly experiencing it. While this can offer clarity, it also prevents the emotional processing needed for real healing, leaving the individual feeling numb or disconnected. Without fully engaging with the emotions involved, the trauma can stay unresolved, hindering true recovery.
Bottom-Up Therapy: Engaging the Body to Heal Trauma
Bottom-up therapies focus on the body's sensations, movement, and nervous system regulation before diving into cognitive processing. These approaches understand that trauma is often stored in the body, particularly in non-verbal, implicit memories that don’t always surface through traditional talking therapies.
Some of the most effective bottom-up therapies include Somatic Experiencing (SE), which helps individuals release trauma by tuning into the body’s awareness and movement; Eye Movement Desensitization and Reprocessing (EMDR), which uses bilateral stimulation to help the brain reprocess traumatic memories while staying connected to the body; Sensorimotor Psychotherapy, which incorporates body movement and posture into the healing process; and Polyvagal Therapy, which focuses on the autonomic nervous system to restore a sense of safety and connection.
By working from the bottom up, these therapies help regulate the nervous system first, creating a safe foundation that allows the brain to process trauma in a more grounded, logical way.
The Power of Combining EMDR with Talk Therapy
While bottom-up therapies are essential for deep trauma healing, they do not replace the need for cognitive integration. This is why I often combine EMDR with talk therapy:
Talk therapy helps process trauma verbally, gain perspective, and understand patterns.
EMDR and somatic work help release trauma stored in the nervous system.
However, what’s most important when starting therapy, is to go with what feels most natural. Every person’s trauma response is unique—and this means we may start in different places. Some people may feel ready to dive straight into EMDR, and we might very well end up with deep analysis along the way. Conversely, others may start with traditional talking therapy, only to discover as they progress that talking is only getting them so far, and they want to explore EMDR or other somatic therapies to release it. There’s no "right" order, and therapy doesn’t have to be rigid.
Finding the Right Approach for You
Here are some questions to consider before embarking on therapy for trauma -
When I imagine a successful therapy session, what is happening?
Do I want or feel the need to talk about happening? Would that feel like a relief?
Have I, in the past, analyzed or intellectualized my experiences to avoid feeling?
Do I notice any physical symptoms of trauma, such as tension, disassociation or panic? Are there any hidden symptoms?
Have I felt stuck in talk therapy before, like its just not working?
The key is to work with a therapist who listens deeply to your needs, assesses your comfort level, and supports you through the process. A skilled therapist will know when to gently push you outside your comfort zone, but they will always maintain a sense of safety. I believe therapy should sometimes be a little hard, because that’s where the healing happens. But that challenge needs to occur within a trusting, sensitive relationship that has a strong foundation of safety and mutual respect. Therapy should feel like a partnership, not something that feels fixed or trapped. The goal is to find a path that works best for you and to honor where you’re at in your healing journey.
We can discuss this further and you can see if we are a good fit for therapy by scheduling a free consultation here.
If you would like to learn more about how I like to integrate EMDR and talk therapy you can read more here.
Healing is not just about understanding trauma—it’s about experiencing safety again, in both the brain and body.