Top-Down vs Bottom-Up Therapy: What’s the difference?
When people begin therapy, they’re often surprised to learn that there are a number of approaches or modalities that a therapist may incorporate. Some approaches start with thoughts and behaviour. Others begin with the body, emotions, or past life experiences. Neither is “better”—but understanding the difference can help you choose a form of therapy that truly supports how you process and heal.
What Does “Top-Down” Therapy Mean?
Top-down therapy focuses on the cognitive brain (prefrontal cortex) and relates to how the mind processes thoughts. The idea that changing your thought patterns can help manage/impact your emotions and behaviour. This approach focuses on insight, awareness, language, and conscious reflection as pathways to change.
This approach is helpful for:
Understanding patterns
Naming thoughts and beliefs
Building coping skills
Creating structure and clarity
Cognitive Behavioural Therapy (CBT) – A Top-Down Approach
What it focuses on:
CBT works with the relationship between thoughts, emotions, and behaviours. The idea is that by identifying and shifting unhelpful thought patterns, emotional distress can decrease.
Art therapy lens:
CBT is often language-based, but in art therapy, thoughts and beliefs can be explored visually—what’s the story you are telling yourself? When discussing the meaning of artwork, aspects of CBT may be explored.
What Are Bottom-Up Approaches?
Bottom-up therapy focuses on the lower brain (limbic system and brainstem) and relates to physical sensations of the body. The idea that the body needs to feel regulated and safe before shifting to higher order processing through language and reason.
Art therapy is considered a bottom-up approach. By working with materials that help regulate the nervous system, safety and containment is established. When the body feels safe, things naturally emerge through the art instead of consciously trying to “figure out” what’s going on.
This approach is helpful for people who:
Feel overwhelmed by talking
Have trauma or chronic stress
Are highly intuitive or embodied
Know why they struggle but still feel stuck
Other bottom-up approaches include: somatic experiencing, mindfulness and yoga
Humanistic Approach:What it focuses on:
Humanistic therapy emphasizes self-awareness, current feelings, personal meaning, authenticity, and the therapeutic relationship. It trusts that individuals have an innate desire for personal growth.
Art therapy lens:
The artwork becomes a way to explore identity, values, and inner truth without forcing insight. The client leads the understanding of meaning behind symbols and the creative process.
Therapy Examples: Person-Centered (Client-centered), Gestalt Therapy, Narrative Therapy, Existential Therapy, Transpersonal Therapy
Psychodynamic Approach: What it focuses on:
Psychodynamic therapy explores unconscious thoughts, early childhood relationships, internal conflicts, and recurring emotional themes that influence present-day experiences. This approach is often misinterpreted with Psychoanalytic therapy developed by Freud that falls under this umbrella as a sub category.
Art therapy lens:
Art has a way of building a bridge to the unconscious through images, symbols, and metaphors. By providing distance, art can explore internal dynamics to bring a greater sense of clarity without the influence of the conscious rational brain.
Therapy Examples: Psychoanalysis (Freud), Object Relations Theory, Attachment Theory, IFS (Internal Family Systems)
Evidence-Based Approaches: What it focuses on:
Scientific evidence and research that supports treatment.
Art therapy lens:
There is a growing amount of research that supports the intersection between neuroscience and art therapy. Engaging in art can help support neuroplasticity (creating new neural pathways). Creative expression has also been shown to improve mood and reduce stress.
Therapy Examples: Cognitive Behavioural Therapy, Dialectical Behavioural Therapy, Acceptance and Commitment Therapy, Eye Movement Desensitization and Reprocessing
Where Art Therapy Fits:
Art therapy is often considered a bottom-up approach, though it can integrate top-down reflection once safety and regulation are established.
From an art therapy perspective:
The body processes through creative expression, and sensory engagement
Meaning and connections are observed after the experience
Talking supports awareness and understanding
Emotions move and flow through the body
The nervous system is supported
Inner parts to be externalized and witnessed
Choosing the Right Approach for You
Therapy is not a one-size fits all. Many therapists draw on multiple approaches—and art therapy can support a different perspective. The therapeutic “alliance” between you and your therapist is the most valuable and important aspect in the therapy space. It takes time to build trust, and if you don’t feel comfortable it can be difficult to open up.
✨ If you’re interested in exploring therapy through an intuitive, art-based lens, I invite you to connect or book a consultation.This is not a comprehensive list, there may be other available approaches not mentioned.