Trauma Therapy: What Sets EMDR Therapy and Other Bottom-Up Approaches to Trauma Apart

If you have been looking into trauma therapy at all, you may notice there is a lot of talk about “bottom up approaches”. But what does “bottom up” really mean and have these approaches become the new gold star standard for trauma work in the field?

Bottom Up Vs. Top Down

Bottom up modalities start with sensory information first when processing, which eventually informs perceptions and more cognitive processes. Top down modalities start with knowledge, ideas and more cognitive input to inform sensory or body-based experiences. I want you to think of “start with the body” or “start with the mind”.

Due to trauma experiences being held in the nervous system and being more so remembered by the body, bottom-up approaches can intervene in a way that bypasses some of the unhelpful beliefs that trauma can create and instead address nervous system regulation first. Once the body and brain have had a chance to process what is inherently instinctual to survival and protection, change in the “cognitive stuff” such as beliefs, ways of perceiving the trauma, ways of perceiving yourself and the world can more easily shift.

When the “amygdala” or the security guard part of the brain is activated, it essentially hijacks the rest of the brain including the neo-cortex. The neo-cortex is where higher order and logical thinking exist. Trying to change thinking and perspectives that come from trauma can be an uphill battle without addressing the sensory, somatic and autonomic processes first.

Of course (and as always), there are differing opinions in the field. Many clinicians consider CPT or “Cognitive Processing Therapy” to be the most evidence-based treatment for trauma which is a cognitive heavy modality that includes prolonged exposure and repeated recall and re-storying of the trauma experience. You are likely to see this modality being utilized in places like outpatient hospital programs or other medical spaces.

What Does Evidence Based Mean?

Evidence is talking about peer-reviewed scientific studies that look at outcomes and do so in an ethical and unbiased way. Looking to evidence for health based decisions is a good thing and encouraged. However, when it comes to mental health care specifically, so much of the outcome is based on the client’s specific presentation, their preferences and what they connect with.

Additionally, just because a modality or approach does not have the most evidence doesn’t mean it couldn’t have the most evidence if studies were funded and conducted. Bottom-up approaches can be longer-term and tend to be based on client readiness to move to different phases of the approach versus a short-term scripted protocol. From a fiscal perspective, this is not attractive to government bodies and funding sources who want data that shows the most improvement in the shortest (and therefore cheapest) way possible. This, can impact what studies are funded and what studies are not.

Despite all of this, evidence continues to build in favour of bottom-up approaches. EMDR, Internal Family Systems and Somatic Experiencing as examples have compounding evidence for their efficacy. EMDR has over 30 published randomized controlled trials (RCTs), systematic reviews, and analyses of its effectiveness in treating Posttraumatic Stress Disorder (PTSD). International organizations like the World Health Organization (WHO), the American Psychological Association (APA), and government agencies such as the U.S. Department of Veterans Affairs recognize it as a recommended treatment for trauma (EMDRIA). 

Approaches to healing that are grounded in the body are not new to Western psychology. Indigenous methods to healing have always been connected to the body and sensory and somatic processes. As someone with Indigenous ancestry, I think about ways in which dancing, drumming, singing, sensory-rich medicines and ceremony have been and continue to be healing. It has been amazing to pair what I’ve come to know through cultural experiences and education with what I’ve come to know through my education about trauma and neuroscience. I always say that therapy is only one way to engage in healing work. Sometimes people need a different approach or multiple approaches. The wisdom of how emotional and spiritual hurts rest within our bones and tissues is nothing new. The evidence is in the wisest and oldest traditions. Indigenous knowledge is its own kind of research and evidence-based information, but equally (or even more so) credible and sophisticated.

So Should I Choose a Therapist Who Provides a Bottom Up Approach?

Trauma processing is deeply personal, and the approach used will need to be tailored to what type of trauma you are looking to treat, how it shows up for you in your daily life, what approach you prefer and what training your clinician has. One thing I can say for sure is that any clinician treating trauma needs to have formal and direct training in treating trauma. Favourably, they will be able to show credentials in the form of documented training, certifications or even designations to show clients that they are equipped to work with trauma. For example, I am currently waiting for my application for “Certified EMDR Therapist” to be approved. This is something that required a basic amount of post grad experience, a certain amount of EMDR client hours, EMDR consultation hours, additional specialized training in EMDR, and recommendation letters.

A major red flag is a clinician who is too new to the therapy field and says they are an expert in trauma. Trauma work can be so healing but can also be destabilizing for the client if done by someone not trained and experienced enough. Newer clinicians should be seeking out ongoing and regular supervision in this area if they wish to grow a specialization in it. New clinicians should always be honest about their education, experience and lack their of and never embellish these things in order to retain a client. Client care should always go above “business”. Another red flag is unregulated practitioners that claim to do trauma work. You may notice people that do unregulated mental health care under the guise of “coach” or “healer” (*without any actual Indigenous ancestry or merit) using pseudo-therapy lingo to gain followers and clients. To be blunt, this is dangerous. Hiring a licensed clinician that attended a legitimate university should provide you with a baseline of responsible and ethical care. Registered Social Workers or Registered Psychotherapists who have graduated from a publicly funded university are trusted providers. Nothing can match years of experience in the field, so a clinician with more relevant experience, the better.

Take Aways

Trauma work is deeply personal and deeply specialized. Trauma focused work can look inherently different from talk therapy and tends to be structured with safety and efficacy in mind. Bottom-up approaches have the ability to move stuck points that cannot be moved as easily through top down approaches and tend to be better suited for complex presentations. More importantly, finding a licensed, ethical and trained provider that helps you to feel safe enough to move forward with this work is essential. Trauma focused work, when responsibly applied, can be life changing and sacred.

Brittany Vincze, MSW, RSW.