Top-down and bottom-up approaches
Talking therapies are considered to be top-down approaches, which means they involve thinking, talking, answering questions, retelling and potentially reliving events. These methodologies include psychiatry, psychotherapy, counselling, cognitive behavioural therapy and narrative therapy. There are many different talking therapies available.
In the UK, psychiatrists are medically qualified doctors who can assess, diagnose and treat PTSD and a range of mental health conditions (NHS, 2022). They can prescribe medication and recommend the provision of local mental health services, psychological support and other treatments to patients who have long-term issues. Of the client case studies in Joanna Harper’s book – The Trauma-Informed Coach, only Pandora had seen a psychiatrist for a formal diagnosis or referral for specialist treatment; she had been diagnosed with anorexia but did not mention PTSD on her intake form.
For some people, medication and talking therapies are highly beneficial. Having someone to talk to about ‘what happened’ and how they feel about it is validating and important. This may be their first experience of being heard, witnessed and believed non-judgementally by anyone. It can offer a sense of relief and unburdening. However, not everyone wants to talk about what happened, particularly to someone they don’t know or who they think won’t understand. Others can’t recall much or anything of what happened or simply can’t put it into words.
Many clients believe there is a stigma associated with seeing a therapist compared to seeing a coach. Marcus resisted engagement with any talk therapy; he mistrusted professionals and felt nobody would understand him. Group talking therapy sessions offer the opportunity to have a shared experience with people who understand and are beneficial to some. For others, such sessions can be challenging and emotionally demanding: Sharon said she would have been too anxious to attend group sessions. Eventually, Marcus felt ready to engage in a group setting that he chose for himself. Group sessions risk exposure to other people’s stories (secondary or vicarious trauma), which can be triggering, dysregulating and counterproductive. Some clients have told multiple professionals and therapists what happened. They are in search of another way; trauma-informed coaches can offer a focus on solutions without hearing their client’s stories.
Due to limited NHS resources and long waiting lists for talking therapists in the UK, well-being apps have been developed to support clients. These are not designed for those who have experienced trauma, but the calming and soothing techniques offered may be beneficial to some users. Pandora’s needs are complex; she was unable to engage in regulating techniques, and the impact of the pandemic interrupted her medical care, resulting in more challenges to her emotional and physical well-being during lockdown and isolation. She did not appear regulated or to feel safe in her body, in her home or on the screen.
Bottom-up approaches
Mind-body therapeutic approaches that focus primarily on the body, autonomic nervous system (ANS) and state regulation are considered bottom-up therapies. These may include Breath-Body-Mind™, trauma release exercises, qigong, martial arts, acupuncture, sacro-cranial osteopathy and somatic repatterning techniques. Some bottom-up and state regulation methodologies don’t include any narrative, while others take a blended approach.
Top-down and bottom-up emergent techniques
These can be used as a client-centred, whole-person approach focusing on the person, not their issue or symptoms. They include Advanced NLP, IEMT and Core Transformation.
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