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  • Writer's pictureAnnabelle Mebane

Understanding Different Approaches to Therapy

By Annabelle Mebane, MA, AMFT & Jodi Staszak, LMFT

When it comes to seeking out therapy, there are many modalities and approaches to choose from. Understanding the different orientations can help you decide what type of therapy may be the right one for you. One way to look at the different modalities is to consider whether it falls under a Top Down approach or a Bottom Up approach. What does this mean?

To understand Bottom Up versus Top Down, first we need to talk about basic brain structure.

Our brains are structured in three major systems. At the very bottom is the brainstem: the part of the brain that was the first to evolve and regulates most of our major automatic bodily processes, like our breathing, our heart rate, and our digestion.

The next layer is what is known as the limbic system, which generally controls our emotions and instinctual behaviors. This system is responsible for the fight/flight/freeze/fawn response, hunger, mating and sexual arousal, as well as some aspects of memory.

And finally, the top layer of the brain is known as the cortex. The prefrontal cortex is responsible for our executive functioning, including thinking, learning, reasoning, and planning.

Top Down approaches address the top structures first and foremost.

With this basic understanding of brain anatomy in place, a Top Down approach to therapy is going to focus more on those processes controlled by the cortex: thinking, reasoning, planning and problem solving. Cognitive approaches like CBT often approach things in a top down fashion, examining how one’s thoughts may impact their feelings and behaviors, and work to change behavior in order to correct faulty predictions or assumptions and likely also shift emotional experiences.

Bottom Up approaches address the deeper structures first.

A Bottom Up approach, like Accelerated Experiential Dynamic Psychotherapy (AEDP), Emotionally Focused Therapy (EFT) or Internal Family Systems Therapy (IFS), is more likely to start with the brain stem and the limbic system – those automatic, instinctual, emotional responses that show up in the body before they are even registered by the cortex. Bottom Up approaches tend to focus on the body and its experience of emotions in the form of physical sensations first.

AEDP specifically aims to help clients to face – in the context of a safe, secure, compassionate therapeutic relationship – emotions that have previously been deemed too overwhelming to approach. In allowing for the emotion to be experienced fully in the body, this allows for our inherent ability to take adaptive action and to identify important information held within our emotions to kick in.

The experience of Top Down versus Bottom Up modalities is likely to be pretty different.

A CBT therapist may be more likely to identify specific behavioral goals with you, and focus on helping you to change behavior as a means to intervene in an unworkable cycle of unhelpful thoughts and accompanying painful feelings. An AEDP therapist may focus more on exploring past experiences, as well as identifying defenses against painful feelings, and helping you to identify physiological cues connected with different emotional experiences. A specific goal in AEDP is to “undo aloneness” for clients, and to help them feel seen and understood in what has previously been an overwhelming and lonely emotional experience.

It's not always quite as simple as just Top Down or Bottom Up.

However, a more traditionally Top Down approach like CBT also often includes some elements of experiencing overwhelming emotions in the body, and a more traditionally Bottom Up Approach like AEDP is likely to include some elements of integrating our emotional experiences with our prefrontal cortex and thinking patterns. Both approaches can help facilitate the integration of feelings and thoughts, creating new neural connections in our minds, and changing how we relate and respond to painful feelings.

So why choose a Bottom Up approach?

We know that, as neuropsychologist Donald Hebb once said, “neurons that fire together, wire together,” so proponents of a Bottom Up approach would assert that only when we are feeling emotions, particularly viscerally in the body, are we actually able lay down new neural pathways. When this has been achieved “there is a distinct physical sensation of change, which you recognize once you experienced it…When people have this even once, they no longer helplessly wonder for years whether they are changing or not. Now they can be their own judge of that.” (Gendlin, 1981. Pg 7).

Who can benefit from a Bottom Up approach?

While this approach can be broadly beneficial, here are some indications a Bottom Up approach might be particularly helpful:

· If you get stuck in guilt, shame or anxiety,

· If you struggle to identify or process your emotions,

· If you've experienced any kind of trauma,

· If your emotions seem to be running interference in your relationships,

· If you keep repeating patterns that are causing harm, but you feel stuck,

· If you struggle with feeling your anger or feel your anger takes over

If you or someone you love might benefit from therapy for codependency, anxiety, low-self esteem, trauma or depression, please contact Jodi Staszak, LMFT. Jodi offers Accelerated Experiential Dynamic Psychotherapy (AEDP) for individuals, and Emotionally Focused Therapy (EFT) for couples, in addition to Overcoming Codependency groups for individuals struggling with codependence. Jodi can be reached at 619-818-0375 or


Gendlin, E. T. (1981). Focusing. New York, NY: Bantam Dell.

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