Path to Recovery: Top-Down, Bottom-Up, or Through the Side Door?

Introduction

Trauma therapies are often fall into one of two distinct categories: top-down or bottom-up. These terms refer to the emphasis of a given treatment model in targeting two distinct brain regions.

However, limitations of both treatment approaches, and the false binary they presume, suggest there may in fact be a third pathway toward recovery from trauma. Hiding in plain sight, this side door of the brain may be accessible through use of integrative mind-body techniques, expressive arts-based therapies, and other innovative forms of intervention.

Top-Down Processing

Traditional talk-based psychotherapy, and most cognitively-oriented trauma-focused therapies, are viewed as taking a top-down approach to treatment. Most often this involves efforts to resolve trauma symptoms by working with the dorsolateral prefrontal cortex, the area of the brain most responsible for logic and reason.

Top-down processing presumes that something similar to a boss-employee relationship exists between the prefrontal cortex and the limbic system: namely, the thinking centers of the brain can activate cognitive controls adjusting the feeling centers of the brain.

Following this logic, enhanced cognitive regulation would enable a person to alter the relevance of current environmental “stimuli”, things like:

• perceived and actual threats,
• trauma triggers and reminders,
• conflict, and
• stressors.

Over time, this would reshape a person’s physiological and emotional responses to these experiences in the present.

Limitations of Top-Down Processing

Experimental research has demonstrated, however, that the brain’s ability to regulate arousal through cognition becomes compromised, and can even by deactivated, by acute stress.

Researchers like Dr. Joseph LeDoux have theorized that information entering the brain through its primary cognitive processing center--the dorsolateral prefrontal cortex--typically remains stuck in the prefrontal cortex and cannot not reach the emotion regulating centers of the brain. Otherwise helpful cognitive capacities like perspective taking, reason, problem-solving and decision-making, and the capacity for impulse control routinely falter in the face of trauma.

When the body’s physiological alarm system is activated, the areas of the brain responsible for these higher order executive functions go dark. When this occurs, our distinctively human cognitive controls stop working and cannot be recruited to shut down our more primitive “fight or flight” response or the many associated sensorimotor survival-driven action patterns that we have learned during past experiences of danger. These get reactivated in the face of perceived threat, even and increasingly when the current trigger, while perhaps frustrating, is hardly life threatening and ultimately a false alarm.

Healing the Body from the Bottom-Up

Other, more somatically-driven and body-based interventions adopt what has been characterized as a bottom-up approach to trauma therapy. These interventions endeavor to undo trauma’s imprint on the body by directly accessing the limbic system, the feeling center of the brain, and by directly targeting sensory receptors located throughout the body.

Bottom-up treatment interventions are believed by a growing number of complex trauma practitioners to regulate and adjust the visceral responses associated with complex trauma. This happens by resetting trauma-related emotional and sensory states stored within the limbic system and peripheral nervous system. To activate this bottom-up process, the following activities could be used:

• exercise,
• rhythmic movement,
• deep, relaxed (diaphragmatic) breathing, and
• synchrony between breathing and heart rate

Nevertheless, other professionals in the traumatic stress field are highly skeptical of this approach. Proponents of traditional cognitive-processing based treatment models insist that interventions that engage the body but do not explore traumatic memories directly cannot resolve symptoms of posttraumatic stress.

Compelling findings from well-designed studies of bottom-up interventions -- including trauma-sensitive yoga and clinical neurofeedback -- for adults with long histories of limited response to traditional trauma therapies suggest otherwise.

Through the Side Door

Some visionary thinkers in the traumatic stress field, foremost among them Bessel van der Kolk, M.D., believe contemporary mind-body interventions actually engineer change by forging communication and restoring balance between the rational and emotional brain systems through a third pathway: the medial prefrontal cortex. This is what Dr. Joseph Spinazzola refers to as the brain’s secret side door.

Neuroscience research findings based on advanced technology such as functional magnetic resonance imaging (fMRI) suggest that the limbic system can be consciously accessed through interoceptive awareness.

Interoceptive awareness is a person’s awareness and perception of the internal experience. It allows humans to integrate body sensations, thoughts and feelings. This phenomenon relies upon the medial prefrontal cortex, the side door of the brain.

Side Door Approaches to Healing from Complex Trauma

Mind-body practices, such as trauma-sensitive yoga, meditation, biofeedback, and some therapies focused on sensory motor regulation or integration, may expand interoceptive awareness through proprioception.

A frequently overlooked sense of the human body, proprioception involves our awareness of our body’s position in space, and is activated by the flexing of muscles and stretching of tendons.

Participation in expressive-arts based interventions such as theater, storytelling and the visual arts, also seem to reach the medial prefrontal cortex through their drawing upon powerful cultural healing rituals and symbolism deeply rooted in the human experience which resonates with the human mind and spirit in a way transcending or at least circumventing the limits of logical thinking.

These side door interventions appear to possess the potential to help guide complexly traumatized individuals towards a more integrated awareness and processing of unresolved trauma symptoms and reactions, helping to reset the thinking and feelings centers of the brain and to release the stranglehold of complex trauma on the body.