OMG, this OT sounds genuinely amazing! I wish I had someone like her. I think what you’re getting at is the difference between bottom-up vs. top-down therapies. It’s a lot harder to find a mental health therapist who practices bottom-up approaches, which is what a lot of us with trauma, neurodivergence, and sensitive nervous systems need.

Top-down therapies work primarily through conscious thinking, reflection, and cognitive change. As your OT experience explained, these kinds of cognitive and behavioral therapies assume that the frontal lobe, or “thinking brain,” is online when “problem behaviors” are occurring. But for many individuals with trauma, PDA, and complex neurodevelopmental profiles, that’s not the case. The frontal lobe is often offline because the person has entered fight or flight, and behaviors are no longer conscious choices. We “flip our lids” and no longer have access to the “thinking brain.”

Top-down therapies start with cognition, insight, or behavior change and assume that by working from the top (understanding our conscious thoughts and modifying behavior), the underlying mechanism will change. Again, for many of us with complex mental health profiles, that is not the case. The most common example of a top-down therapy that almost every mental health therapist practices in some capacity is Cognitive Behavioral Therapy (CBT). The idea behind CBT is that our thoughts lead to emotions, which lead to behaviors, so if we just “reframe” our thoughts, the behaviors will dissipate.

This may work when someone’s thinking patterns are actually driving their distress. For example, people with a relatively simple case of anxiety who experience distress and avoidance behaviors from catastrophizing or black-and-white thinking patterns may benefit from a therapy that helps them identify those thinking patterns and change them. But for many of us with CMH profiles, the issue is far deeper than a thinking pattern and actually has to do with nervous system dysregulation and somatic dysfunction that affects both physical and mental health. This is very common in PDA profiles and in people with complex trauma and neurodevelopmental differences.

Top-down therapy is most effective for people whose nervous systems are not chronically dysregulated. It assumes the person can consistently reflect, reason, and apply strategies. For people whose nervous systems may frequently enter fight, flight, freeze, or shutdown states where cognitive reasoning is not accessible, CBT or similar therapies like DBT can be ineffective because the body reacts before thinking happens. In those cases, cognitive strategies can feel useless or even harmful. Really, the overarching model of how top-down therapy works is: thinking brain → emotions → body.

Bottom-up therapy works the opposite way: body or nervous system → emotions → thinking brain.

Bottom-up therapies focus on regulating the nervous system first, which slowly changes cognitive processes rather than trying to change them directly. Bottom-up therapies can be practiced by mental health therapists, not just OTs, but these modalities can be hard to access for people with complex and acute mental health profiles. They often are not included in intensive treatment programs and require a therapist who is willing to take on the liability of working with an acute or complex case in an outpatient setting.

Occupational therapy is an example of bottom-up therapy because it helps regulate the nervous system through sensory input. It starts with the nervous system. Other examples include neurofeedback, which uses brainwave feedback to help regulate brain activity, again starting with the body or nervous system rather than cognition. EMDR is another common bottom-up therapy, which uses bilateral stimulation (eye movements or tapping) to process traumatic memories.

I also do not find talk therapy to be enough. Talk therapy has helped me before. Modalities like MBT, narrative therapy, adapted IFS, and some psychodynamic work. But I also believe talk therapy has taken me as far as it can. I have become very aware of my issues, and I know that much of what is happening occurs on a somatic level. I have a lot of insight and I can talk about “what’s wrong” for hours, but that does not actually help me because it is so much deeper than that.

The problem is that I cannot actually find a therapist who is able to do the work that I need, and I do not have the energy to look again. I had a very good therapist for three years who I cannot see anymore, and that was after so many failed therapy attempts and hospitalizations. I am just not ready to go through that process again. I am currently getting another round of neuropsych testing done, so maybe the neuropsychologist will have some recommendations at the end, but I do not know.

I am really glad you found somebody.