Top-down and Bottom-up Pathways to Developing Psychological Interventions

Abstract

The development of psychological interventions follows 2 possible pathways (Table ). The top-down pathway centers on individual founders as "bricoleurs" building on a diversity of sources, including case observations, cultural or religious notions, selected psychological theories, and empirical findings, to formulate assumptions about processes that cause or maintain symptoms. A treatment manual with strategies to address the conjectured processes is further developed. The bottom-up pathway aims to alter the mechanisms presumably subtending symptoms. In this mechanistic 1 approach, a potentially modifiable target process is identified from extant theories of etiologic or maintaining factors. Experimental studies are conducted to ascertain whether manipulation of the target leads to symptom change. Studies often initially use analogue samples, 1 ie, healthy participants experimentally induced with a transient symptom-like manifestation. Experimental manipulations that effectively impact symptoms or behaviors are then translated into intervention strategies for use on symptomatic individuals. Crucially, independently from the development pathway, psychological treatments require randomized clinical trials of patients to be established as effective.Historically, most psychological interventions were developed using the top-down pathway, with notable exceptions such as exposure therapies. This approach is not systematic or reproducible because rules for selecting, combining, and weighing the evidence used to derive both target processes and treatments strategies are entirely subjective. Moreover, it is deeply embedded in the founder's unique sociocultural context, values, and views. Consequently, even when interventions developed this way are effective, their mechanisms of action remain largely elusive. 2 The problem is further compounded by the operationalization and measurement of key constructs, usually by self-report. For example, in cognitive behavioral therapy (CBT), dysfunctional schemas presumed to cause or maintain symptoms are measured with self-report instruments, often created in collaboration with the founders. 2 This circular search for mechanisms is limited in elucidating how the often broad and ill-defined core constructs of top-down approaches effectively affect patients within and outside of therapy.Conversely, in starting from mechanisms, the bottom-up approach necessitates valid theories of symptoms from which to select targets for experimental manipulations. Concomitantly, the reliable measurement of targets is fundamental, ranging from the experimental stimuli and tasks to the indexes computed to capture task-relevant behavior. In practice, unknown or limited reliability are major obstacles toward developing treat-VIEWPOINT

The Biopsychosocial Impact and Syndemic Effect of COVID-19 on Youth Living with HIV in Kenya

“…While individual and community level categories provided support for bottom up strategies to minimize the long-term impact of COVID-19 on YLWH in Kenya, healthcare and government categories provided support for top down strategies. The importance of both top down and bottom up strategies in healthcare has been established; for example, the existing literature includes descriptions of the benefits of top down and bottom up approaches for social mobilization in health communication, 27 developing psychological interventions, 28 and improving healthcare quality. 29 …”

Treatment Approaches for Functional Neurological Disorders in Children

“…Psychotherapy with the child included a broad range of approaches. Bottom-up approaches [ 48 , 49 , 60 ] were used to help the child regulate the body’s neurophysiological state [ 34 •]. Top-down approaches such as CBT or talking therapy were used to help with maladaptive thoughts or to work through unresolved grief or other interpersonal issues, respectively [ 48 , 49 , 60 ].…”

“…Bottom-up approaches [ 48 , 49 , 60 ] were used to help the child regulate the body’s neurophysiological state [ 34 •]. Top-down approaches such as CBT or talking therapy were used to help with maladaptive thoughts or to work through unresolved grief or other interpersonal issues, respectively [ 48 , 49 , 60 ]. If required, trauma-specific interventions such as Eye Movement Desensitization and Reprocessing (EMDR), radical exposure tapping, or trauma-focused CBT were also used [ 48 , 49 , 60 ].…”

Splitting Things Apart to Put Them Back Together Again: A Targeted Review and Analysis of Psychological Therapy RCTs Addressing Recovery From Negative Symptoms

“…Currently the negative symptom treatment literature is dominated by multicomponent treatments, some elements of which are offshoots of experimental studies, but the specification of mechanistic targets is often incomplete. Next generation psychological treatment studies for negative symptoms are likely to benefit from a more explicit bottom-up development approach ( 37 ).…”