What does it mean to do therapy from the top-down or from the bottom-up?

When a person goes into therapy they are generally looking to feel better, or have an outlet. As a therapist I am always assessing my clients, “Do they need a higher level of care”, “Am I the best fit for the client”, “What approach is going to work for my clients”. These are just a few of the thoughts that go through my head. There are many different ways to work with clients today, I will be looking at two approaches, Top-down, and Bottom-up.

Top-Down Approach

When I think of doing therapy from a top-down approach I am working with clients in more of a cognitive approach. This would be your therapy done through talk, and challenging the negative beliefs that a client has. I look for logical steps to help a person relate to their world that would be less stressful, and ultimately allow them to gain a sense of peace, and contentment. How can we work together to change the negative thought patterns to help change the behaviors and feelings one is having. This is a great approach when a client is regulated, and able to think from their logical brain.

Bottom-up Approach

Bottom-up approach is used when we are helping clients process memories, feelings, or thoughts that aren’t as logical, or are more emotionally charged. When a client is in a state of panic, or shock, or feeling extremely depressed, and unable to process through traditional talk therapy. I might suggest that we do some more bottom-up work that would be: breathing exercises, yoga, meditation, EMDR if the client is appropriate, How can I best help the client to cope with their experiences, and move through the pain in a way that is more experiential.

Both top-down and bottom-up have pros and cons to them, and depending on where the client is, and the goals of therapy both can be appropriate for clients to use at different parts of treatment. As a therapist I really borrow from both approaches working with CBT, DBT, mindfulness, and EMDR to help guide clients out of the trenches and back onto solid ground.

Written by: Bethany Juran, LPC