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Understanding Processing in the Treatment of Trauma

What is Top Down Vs Bottom Up Processing in the Treatment of Trauma?

Mary-Lauren O’Crowley, NCC, LPC

Trauma is a loaded term that often elicits a strong response from those who hear it uttered. It covers all aspects of insult to a human body including physical injury and psychological disturbance; however, most tend to think of trauma as an injury to the mind or the nervous system as a result of something overwhelming, indescribable, or terrifying happening. While physical trauma can cause damage to any organ or part of the body, psychological trauma can result from various factors including emotional distress, burnout, rejection, abandonment, death, war, neglect, and abuse, among others. Psychological trauma can occur at any age to any person of any gender, class, or occupation. Adolescents are usually more prone to psychological trauma, however, given that their brains and bodies are at a crucial point in development. Treatment of trauma depends upon the severity of symptoms. Both psychotherapy and pharmacotherapy are used to hasten recovery in more severe cases. Top-down and bottom-up are two approaches involved in somatic and cognitive therapy. These are known as multimodal or integrated type treatments which help in the relief of traumatic symptoms.

Top-down approach

Top-down processing aims to treat the symptoms of trauma and post-traumatic stress beginning with higher mental functions to lower ones. Put more simply, it utilizes logic and reason, which are both sustained by the prefrontal cortex. The top down approach is compensatory in nature and results in the enhancement of existing patterns of thinking and coping. This approach can help by first identifying maladaptive or negative thoughts pertaining to the trauma (“I am worthless,” “I could have stopped it,” “I deserved it”) and modifying them to be more reasonable, accurate, and rooted in evidence. This helps the brain to internalize healthier and more accurate beliefs and perceptions of our external environment and lived experience (“This was not my fault,” “I could not have changed the outcome,” “I did not deserve this”). Psychotherapy, namely cognitive behavioral therapy and trauma focused-CBT, is also cost-effective and effective at treating acute psychological trauma. It has been shown to increase the patient’s daily functioning. 

Bottom-up approach

The bottom up approach to trauma treatment aims to start from the roots of the brain- the areas that control memory, reflexes, and automatic survival instincts- to the higher thought processor (prefrontal cortex, logic, and reason). The bottom-up approach utilizes sensations and feelings from the body as “messengers.” When the body’s stress responses are activated as a result of something traumatic, the body then becomes dysregulated, causing the individual to feel any number of distressing sensations including increased heart rate, flushed skin, difficulty breathing/hyperventilation, among others. This same process can be enacted when the individual feels unsafe or encounters a reminder of the traumatic experience. The goal of bottom-up processing, then, is to help the patient familiarize themselves with what is occurring in the body and how to regulate these processes. Some of the most effective methods for managing difficult sensations and regulating the nervous system and the fight-flight freeze responses include meditation, deep diaphragmatic breathing, and visualization. 


Top-down involves the ‘perception ‘while bottom-up involves ‘sensation’. The sensation is the sensory stimuli from environment while perception is how your brain interpret that stimuli. Bottom-up is practically more preferred as it is easy to change sensation as compared to ‘perception’. The treatment approach depends upon the severity of trauma either and whether it is acute or chronic. These therapies require consistency in order to obtain positive outcomes. It can also be time-consuming and thus, requires patience and cooperation.

If you or someone you know is interested in exploring trauma treatment, please reach out to the intake specialists at Symmetry Counseling today!  


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