Are We Getting It All Wrong? Rethinking Top-Down Approaches in Behavioral Health

For decades, cognitive-behavioral therapy (CBT) has dominated the landscape of behavioral health care. With its structured, goal-oriented nature and emphasis on identifying and changing thoughts to influence behavior, CBT has become a go-to method for clinicians and insurance companies alike. But what if our clinical compass is calibrated too heavily toward the mind, and not enough toward the body?

Having worked extensively in substance use disorder (SUD) treatment settings, I’ve seen firsthand how this top-down emphasis—starting with the brain and thoughts—often falls short, especially for those grappling with deep trauma, chronic dysregulation, or long-standing patterns of disconnection from their own bodies.

Here’s the reality: Before we can think clearly, we must feel safe.

Top-Down vs. Bottom-Up: What’s the Difference?

• Top-Down approaches (like CBT, DBT, REBT) start with the cognitive system: change your thoughts, and you can change your behaviors and emotions.

• Bottom-Up approaches (like somatic experiencing, sensorimotor psychotherapy, polyvagal-informed interventions) start with the body: regulate the nervous system and increase safety signals, and only then can cognitive processing truly take root.

In trauma-informed or SUD recovery contexts, asking clients to challenge maladaptive thinking without first establishing nervous system safety is like trying to install new software on a computer that’s overheating. The system simply isn’t ready.

Why This Matters in Real-Life Recovery

Many clients I’ve worked with are light years away from being ready for cognitive restructuring. When someone is stuck in fight-or-flight—or worse, in the frozen grip of collapse—accessing their "thinking brain" is neurologically difficult, if not impossible.

What these clients often need first isn’t a worksheet or a thought log.
What they need is:

• A safe relational space.

• Permission to feel.

• Tools to anchor back into their bodies.

Only when the body feels it’s safe to explore, process, and trust can the mind follow.

The Problem with the “Fix Your Thinking” Model

The overemphasis on CBT-style interventions often places the burden of change solely on the client’s ability to "control" or "redirect" thoughts. This unintentionally reinforces shame in those whose nervous systems simply aren't yet regulated enough to comply.

Clients then internalize failure—not because they lack motivation or insight, but because the intervention wasn’t right-sized for their nervous system's readiness.

What If Safety Is the Starting Point?

In my practice, I approach healing with the belief that co-regulation precedes self-regulation. Honoring that:

• Some clients need touchpoints for grounding long before they can challenge negative thoughts.

• Some need nervous system literacy to understand their trauma responses before they’re asked to analyze them.

• Some need safe, embodied presence—not strategies and homework—as their first steps toward healing.

We are not abandoning CBT; rather, we are recalibrating our priorities. We are saying: Let’s build the foundation before we decorate the house.

Bottom-Up First, Then Build Up

True empowerment begins when people feel seen, safe, and stable in their bodies.
From that place, top-down tools become much more effective—and less threatening.

It’s not either/or. It’s both/and.
But maybe we’ve been starting at the wrong end.

Final Thought:

Healing is not linear, and it’s certainly not one-size-fits-all. I believe that slowing down to help clients feel safe enough to begin can lead to far deeper, more sustainable outcomes than jumping straight into cognitive interventions.

Let’s start by meeting the body where it is.
The mind will follow.

Interested in a trauma-informed, bottom-up approach to behavioral health? Here’s Where to Start.

If you're curious about how bottom-up, body-first methods can transform behavioral health outcomes, you’re not alone—and you’re in the right place. Whether you're a client seeking a new path to healing or a clinician exploring new ways to support others, the journey starts with understanding why these approaches matter and how to apply them safely.

🔍 Learn the Foundations:

Start by deepening your understanding of nervous system regulation and trauma physiology. These concepts lay the groundwork for any effective bottom-up intervention.

• Recommended Reading:

  • The Body Keeps the Score by Bessel van der Kolk, M.D.

  • Waking the Tiger by Peter Levine, Ph.D.

  • Polyvagal Theory by Stephen Porges, Ph.D.

🛠 Explore Bottom-Up Modalities:

These approaches work with the body to create a foundation of safety and emotional regulation:

• Somatic Experiencing (SE) – Founded by Peter Levine, SE focuses on resolving trauma through tuning into bodily sensations.

• Sensorimotor Psychotherapy – Combines talk therapy with body awareness to process trauma stored in the nervous system.

• EMDR (Eye Movement Desensitization and Reprocessing) – Uses bilateral stimulation to help process traumatic memories.

• Internal Family Systems (IFS) – While not strictly bottom-up, IFS incorporates deep internal awareness that often integrates well with somatic work.

• Polyvagal-Informed Practices – Based on Porges’ theory, focuses on restoring nervous system flexibility and safety cues through breathwork, vocal toning, movement, and relational safety.

📚 Pursue Evidence-Based Training:

If you're a clinician, these programs can equip you with the tools to integrate body-first care into your work:

• Somatic Experiencing

• Sensorimotor Psychotherapy

• EMDR Trainings

• Havening

• IFS Training

• Polyvagal Applications

👣 Take Your First Step:

Explore the blend of evidence-based modalities with trauma-informed presence, always starting with safety and nervous system readiness. Whether you're a provider or someone seeking care, we believe healing begins where you are—grounded, safe, and supported.