🌿 Top-Down or Bottom-Up? Choosing the Right Mind-Body Therapy for Chronic Illness

When living with a complex condition like ME/CFS, fibromyalgia, Long COVID, or chronic pain, it can feel overwhelming to decide which therapeutic approach might actually help. You’ve probably heard of terms like Pain Reprocessing Therapy, Polyvagal Theory, or Amygdala Retraining. But what do these approaches actually do — and how might they work differently depending on your condition?

At the heart of these therapies lies one shared goal: calming a sensitized nervous system. But they get there through different pathways — some through the mind, others through the body.

Let’s explore three leading approaches — Pain Reprocessing Therapy (PRT), Amygdala & Insula Retraining (MAIR), and Polyvagal-Informed Therapy — and how their balance of top-down and bottom-up techniques can impact healing for different chronic conditions.

🧠 What Do “Top-Down” and “Bottom-Up” Mean?

• Top-down approaches work primarily through thoughts, beliefs, imagery, and awareness. They change how the mind interprets what the body is experiencing.

• Bottom-up approaches begin with the body — using movement, breath, sound, and sensation to shift the nervous system from survival mode into safety and rest.

Both have value. But for people with certain conditions, the degree of bottom-up involvement may matter more than we think.

🔄 Comparing Three Approaches

1. Pain Reprocessing Therapy (PRT)

PRT is a top-down neuroplasticity approach that teaches the brain to reframe chronic pain as a “false alarm” — a brain-generated signal that is safe to feel and can be unlearned. It works through awareness, somatic tracking, and reappraisal.

• Bottom-up involvement: Moderate
  Includes body awareness through “somatic tracking,” but the emphasis is on retraining thought pathways.

• Best fit for:
  Primary pain disorders (e.g. back pain, tension headaches) without significant fatigue or autonomic dysregulation.

2. Amygdala & Insula Retraining (MAIR / Gupta Program)

This method blends mindfulness, visualization, and emotional processing to calm the overactive threat response in the brain’s limbic system. It focuses on interrupting unconscious stress patterns.

• Bottom-up involvement: Low to moderate
  Uses breath and body awareness during mindfulness, but largely relies on visualizations and thought-shifting.

• Best fit for:
  Fibromyalgia, Long COVID, and anxiety-linked chronic illness, especially when mental hypervigilance is high.

3. Polyvagal-Informed Therapy (e.g., SSP, somatic therapy)

Grounded in Dr. Stephen Porges’ Polyvagal Theory, this approach focuses on directly regulating the autonomic nervous system. It works by engaging the vagus nerve — often through sound, movement, breath, and safe relational cues.

• Bottom-up involvement: High
  This is the most body-first of the three — aiming to restore a felt sense of safety through co-regulation and sensory experience.

• Best fit for:
  ME/CFS, dysautonomia, POTS, trauma, and conditions involving shutdown, fatigue, overstimulation, or emotional blunting.

Why Bottom-Up Support Matters More in Some Conditions

If you have a condition like ME/CFS, Long COVID, or fibromyalgia, you may already know what to think. You may be highly insightful, even spiritual or self-aware. But your body still feels stuck in a loop of crash, fatigue, or pain.

In these cases, purely top-down approaches can fall short. Why?

Because your autonomic nervous system (ANS) — the system that governs rest, digestion, heart rate, and energy — may be dysregulated at the level of the body itself. It needs felt safety, not just logical reassurance.

That’s where bottom-up therapies come in. They don’t ask your mind to convince your body it’s safe. They help your body experience safety through regulation, rhythm, and gentle sensory input.

So, Which Approach Should You Choose?

It depends on your starting point:

• If you feel stuck in fear around your symptoms, PRT or MAIR may help reframe and calm the brain's threat response.

• If you feel numb, dissociated, shut down, or crashing from minor stimuli, a polyvagal-informed or somatic approach may be more effective.

• For many people, the best path is layered: start with bottom-up safety, then introduce top-down retraining once the body can tolerate it.

At The Woods Counselling, We Can Use All Three

As a therapist with both clinical training and lived experience of chronic illness, I integrate PRT, limbic retraining, and somatic techniques into custom therapy plans. Whether you’re navigating ME/CFS, fibromyalgia, or post-viral fatigue, we’ll find the balance of top-down and bottom-up that your body and nervous system can actually use.

Because healing isn’t just about what you think.
It’s about what you feel — and what your body finally learns is safe again.

Curious about how this might apply to your own experience? Reach out for a consultation or explore our Weekly Support services for chronic illness.
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