Positive Approaches Journal, Volume 13, Issue 1

Volume 13 ► Issue 1 ► June 2024

A Review of Top-Down and Bottom-Up Trauma Interventions

Julie Vayner & Kate Jakubovic

Abstract

The objective of this article is to review literature and modalities pertaining to positive approaches in treating trauma and posttraumatic stress disorder, with the use of expressive interventions in individuals with intellectual disabilities and/or mental health and behavioral challenges. 

Key Words: Posttraumatic stress disorder, trauma therapy, expressive therapy, top-down, bottom-up, cognitive, behavioral, somatic, mind-body connection.

It is not known exactly how much of the population has been exposed to a traumatic event, but it is estimated that most people in the United States will be exposed to at least one traumatic event in their lifetime.¹ While there is a specific set of criteria of symptoms one must endorse to be diagnosed with post-traumatic stress disorder (PTSD), the lasting effects of trauma can manifest in a variety of ways that may not be exclusive to PTSD. The effects of traumatic stress on the brain and physical body have been researched for over forty years. There is an increased understanding that traumatic experiences can cause short-term and long-term effects on various organs and systems in the body, due to the disruption in homeostasis.² As a result, interventions used to treat post-traumatic distress should consider adopting a holistic approach to target cognitive, behavioral, emotional, and physiological processes. It may be useful to combine elements from both, top-down (cognitive) and bottom-up (physiological) approaches based on the client’s individual needs. This literature review explores several top-down and bottom-up therapeutic interventions targeting post-traumatic distress.

Trauma therapies tend to fall into two very distinct categories: top-down or bottom-up. Top-down approaches include traditional talk-based, cognitive, and behavioral therapies. This approach works to resolve symptoms by working with the area of the brain known as the neocortex. The neocortex is responsible for logic and reason. Alternatively, bottom-up approaches, such as expressive and somatic ones, target the limbic system of the brain. This part of the brain focuses on feelings, automatic reflexes, and sensory receptors that run throughout the body. Both therapies have strengths, and therefore holistic approaches that include both, help better facilitate a mind-body connection, resolve unprocessed memories, and move the individual from a state of stress response to stabilization. Additionally, stages of trauma recovery typically involve three phases that include, 1) Safety and stabilization, 2) Remembering, mourning, and grieving, and 3) Integration and connection.³

To facilitate these phases, a diverse array of evidence-based modalities, which include expressive components, can be deployed. Both top-down and bottom-up approaches will be examined. Keep in mind, these modalities can be utilized on their own, simultaneously by the same practitioner, or adjectively by another practitioner working with the same client. Considering top-down modalities from Cognitive Behavior Therapy (CBT) developed by Aaron Beck in the 1960s, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was expanded by Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006, to assist children and adolescents in recovering from trauma. TF-CBT seen as a short-term (8-25 sessions) option and includes sessions with both the identified client and their caregiver or another trusted individual. The sessions are highly structured and cover psychoeducation, effective parenting skills (relating to the caregiver’s personal distress about the client’s experience), relaxation skills, affective modulation, cognitive coping and processing, trauma narration, in vivo mastery, conjoint parent-child sessions, and enhancing safety in the client’s natural ecology.⁴ The primary intervention focuses on trauma narration and processing, which can be assisted through writing, storytelling, drawing, and even music. For example, clients can select songs or music that help express their experiences, which are otherwise difficult to verbalize. It was initially developed to address the needs of children who experienced sexual abuse but has expanded and adapted to treat other populations and age groups across developmental levels and cultures.⁵

Alternatively, prolonged exposure (PE) developed by Edna Foa, Ph.D. in 1991, is another cognitive behavioral or top-down approach, which is based on emotional processing theory, and focuses on assisting clients in emotionally processing their traumatic experience (s). It is intended to be a short-term intervention consisting of approximately 15, 90-minute sessions. The sessions are also highly structured and involve psychoeducation, breathing retraining, imaginal exposure, cognitive and emotional processing, and homework review. Outside of session, the client practices imaginal exposure as well as in vivo exposure. The intervention targets fear and avoidance by focusing on the client repeatedly exposing themselves to the trauma memory in a variety of ways, until habituation occurs and the memory becomes less distressing. While a person may want to avoid reminders of their trauma and other trauma related stimuli due to the unpleasant feelings they trigger, avoidance serves to maintain post-traumatic distress. Decreasing avoidance through repeated exposure to the trauma memory and emotional processing, allows the client to build tolerance to the trauma related stimuli and experience less distress overall.⁶

Bottom-up approaches include interventions that focus on physiological and somatic processing. Expressive therapies are a group of interventions that target the expression of thoughts and feelings through nonverbal and alternative means of communication. Through this process clients can regain a sense of control. Some examples of expressive therapies may include but are not limited to visual arts therapy, music engagement, movement based creative expression, and expressive writing.^7,8 These approaches are centered around creative arts and are considered non-traditional. Existing research on expressive therapies contains limitations that affect generalizability across populations; however, preliminary research demonstrates that creative and artistic approaches may have an impact on decreasing post-traumatic distress and improving overall physical health.^7,8 Visual arts therapies involve clients using an artistic medium (e.g., painting, drawing, sculpting) to represent their emotions related to the trauma. Music engagement teaches clients to self-regulate through playing musical instruments and form interpersonal connections through playing with others. Movement based creative expression promotes release of tension and stress through dance and body movement (e.g., yoga). Expressive writing promotes emotional expression using language and creative writing. Due to the limitations in research on expressive therapies, it may not be appropriate to rely exclusively on them as the primary source of trauma treatment. However, employing expressive therapeutic techniques in conjunction with other interventions, can help the client adopt a variety of outlets for emotional expression and coping.

Speaking of bottom-up approaches, Eye Movement Desensitization and Reprocessing (EMDR), established by Francine Shapiro in the 1980s, has become highly popularized in recent years. The goal of this therapy is to target distressing memories, themes, and uncomfortable body sensations while installing more adaptive outlooks utilizing eye movements or bilateral body exercises, such as self-tapping, tactile buzzers, and auditory music. Expressive takes on this modality can also incorporate drumming, coloring/scribbling back and forth, acting/role-playing (psychodrama), walking/marching, and dancing, which is notably useful in addressing preverbal and communication deficit needs.⁹ This modality is based on the premise that unhealed traumatic memories become stored maladaptively and lead to maladaptive responses. It is particularly beneficial in reducing risk for flooding and re-traumatization through less intense desensitization practices, wherein the client simply imagines the stimuli versus direct exposure as is conducted with other therapies.¹⁰ EMDR includes an eight-phase protocol, consisting of 1) History taking and treatment formulation, 2) Resourcing, preparation, and coping strategies, which is an ongoing process in the treatment, 3) Assessment, 4) Desensitization, 5) Installation, 6) Body Scan, 7) Closure, and 8) Re-evaluation. Through this process, the client can work on a singular event or cumulating patterns and themes causing them distress.

From EMDR, a more somatic-based approach, Brainspotting, was adapted by David Grand in the early 2000s. It was initially discovered through work pertaining to creativity and performance enhancement, and therefore has been opted for by athletes and artists alike. Brainspotting is used to locate points in the client’s visual field to facilitate the accessing of unprocessed trauma in the subcortical region of the brain.¹¹ This part of the brain targets cognitive, affective, and emotional functioning. When memories aren’t properly processed (i.e. moved into long-term storage), they remain stuck in this region. Brain spots can be located in a variety of ways, including the client organically coming upon or the clinician noticing a particular focal point as the client looks about the room (Gazespotting), or the client and clinician working together to detect a spot of activation or grounding in the client’s visual field using a pointer. Clients can elect to work on a topic from a brain spot that is more activating or less activating (grounding). This type of approach allows for deeper access and reprocessing. It seeks to connect emotional, mental, and physical responses to trauma and releases stress held in each domain. Another benefit of this approach is that the client does not need to “relive” a traumatic event, which can be especially accommodating for clients with high dissociation. 

Holistic approaches to treating post-traumatic distress are gaining popularity as more research emerges supporting the connection between the effects of traumatic stress on the mind and physical body. In this literature review, we highlighted several therapeutic interventions from both top-down and bottom-up approaches. Trauma treatment does not fall into a one size fits all category. It is recommended to consider an individual’s strengths and limitations when selecting therapeutic interventions. For instance, a high functioning, neurotypical individual may benefit from cognitive behavioral therapies (top-down) with expressive components, whereas a lower functioning, neurodivergent individual may benefit from bottom-up approaches, focusing more on expressive and creative means of communicating than cognitive components.¹²