Why a Bottom-Up Approach Works for Autistic People

Autistic clients begin therapy for all kinds of reasons, from wanting to untangle a specific issue to figuring out how to exist in a world that sometimes feels like it was designed by a committee of sleep-deprived neurotypicals. Therapists, in turn, adapt and mix approaches to meet each client’s individual needs—because no one fits neatly into a one-size-fits-all model. For instance, a trauma-informed lens can blend seamlessly with gender-affirming care or a holistic perspective. In this blog, we’ll dive into the why and how of using a bottom-up approach, specifically for Autistic individuals in therapy.

(Consider this your fair warning that I am an Autistic individual who suffers (/j¹) from the infliction of excessive use of parentheses.) 

What is a Bottom-Up Approach?

A bottom-up² approach is essentially a way of solving problems, making plans, or implementing strategies that starts with smaller, detailed elements and builds up toward a broader idea or solution. In therapy, this means working with body sensations first, based on the understanding that sensations in the body come before conscious thought.

Treatment using this approach starts with focusing on the body and its sensations, building awareness of those sensations (interoception), and responding to them to create a sense of safety in the present moment.

A felt sense of safety in one’s body is absolutely essential to the therapeutic process. After all, who’s going to make meaningful progress if their body doesn’t feel safe during sessions?

Very few people, I’d bet.

When Autistic clients come to therapy, I’ve noticed that many say they’re very self-aware but still find themselves struggling. I, too, have gone to therapy claiming I was too self-aware, only to discover (plot twist) I actually had pretty poor insight (cue teardrop emoji). While this isn’t the case for everyone, it can be a clue about which therapeutic approaches might be most helpful.

People who consider themselves highly self-aware often end up intellectualizing their feelings. In other words, we (including myself) focus more on logic and reasoning than on feeling, expressing, and processing emotions. This leads to suppressing emotions and avoiding the discomfort they bring. And as we all may or may not know, suppressing emotions creates all sorts of problems that keep us stuck—in situations, mindsets, and sometimes even physically—in ways that don’t really help us move forward.

The Stress Responses: Fight, Flight, Freeze, Fawn

When people reach the point of realizing that suppressing emotions is causing them problems, resistance often comes up. And you know what? That’s not just okay—it’s part of the process. Going from constantly pushing emotions down to even considering the idea of ~feeling~ them can feel like a threat. And I mean that literally. Emotions can trigger our stress response, which is the body’s way of gearing up to survive a perceived threat.

The stress response involves four automatic reactions controlled by our nervous system. These reactions can be split into active responses—fight and flight—and passive responses—freeze and fawn. Breaking down each of these with specific examples can help clients understand what they might look like in real life. These responses can show up as the urge to hit or push, the need to run away, feeling compelled to appease and avoid conflict, or shutting down to cope with overwhelming situations or stimuli.

I find it helpful to remember that Autistic individuals are more prone to the fawn response.

Fawning—appeasing others to avoid conflict—is a part of masking. For Autistic individuals who may already find social cues and expectations confusing and overwhelming, fawning can become a default behavior.

This can look like excessive politeness, offering constant reassurance, and accommodating others’ wishes, even at the expense of their own well-being.

The Role of Psychoeducation

Psychoeducation is key to getting buy-in from clients. Not only is it an essential part of informed consent and the collaborative nature of therapy, but it’s especially important for Autistic individuals to understand the “why” behind their behaviors and how they’re connected to their needs. It’s also crucial for them to understand why certain therapeutic approaches and interventions are being used.

When I’m explaining a bottom-up approach to clients, this is usually the point where I either pull out a sticky note to draw a shape that kind of looks like a brain, or I just point to my own head. I then go on to explain how the brain works. The stress response starts at the base of the brain, and when it’s triggered, it shuts down the higher parts—bye bye executive functioning (hand wave emoji). It also slows down digestion… and this is why hot people have gut issues (/j).

This psychoeducation often leads to those “aha” moments—like understanding why it can be so difficult to think clearly or start tasks, and how Autism, trauma, and chronic health issues are all connected.

Having this knowledge can be incredibly empowering. It fosters a sense of agency, which is especially important in a culture that often infantilizes Autistic individuals.

Why Autistic People Benefit from a Bottom-Up Approach

Since the brain processes in a bottom-up manner, addressing challenges that require higher brain functions means one needs to know how to first regulate their nervous system (which is responsible for the stress response). Some of these higher brain functions include things like executive functions, managing complex emotions, imagination and creativity, interpreting sensory information, and abstract thinking, to name a few.

Access to these higher brain functions allows people to move from simply surviving to truly thriving. To summarize, and to throw in a few extra benefits, here’s why this approach is especially helpful for Autistic individuals:

• Supports Sensory Processing Needs
• Reduces Cognitive Overload & Enhances Grounding
• Bypasses Verbal Challenges
• Improves Emotional Regulation
• Addresses Trauma Stored in the Body
• Builds a Foundation of Safety
• Enhances Self-Awareness through Interoception
• Encourages Autonomy and Self-Regulation

Therapy Needs: Finding What Works for You

There are a variety of bottom-up approaches that therapists can use with their clients, as well as therapies that can be introduced once clients have a solid understanding of how to regulate their nervous system. What’s important for therapists to remember is that there’s no single approach that’s universally “better” than the rest. What matters is selecting therapies and approaches that are best suited to meet your client’s needs. For therapy seekers, it’s important to know that you can always request a shift in approach as you gain a better understanding of what works for you and what doesn’t.

To give you an idea of what therapy needs might look like, I’ll share some personal examples from my own therapy experiences. One of my biggest needs is understanding the “why.” Why is this thing you’re suggesting supposed to be helpful? If I don’t understand the purpose behind something, I struggle to find the motivation to actually do it. I’ve even asked my therapists to explain things to me as though I don’t work in the mental health field, so I can fully grasp why it’s being suggested—and why it’s being suggested to me specifically. Another big need I have in therapy is structure. For me, that looks like having a flexible agenda to follow and my therapist asking follow-up questions/providing prompts to help me explore my feelings, thoughts, and any ways I might be getting in my own way (because me and avoidance are like a moth to a flame).

How to Know if You Could Benefit from a Bottom-Up Approach

If you’re in therapy or a therapist and aren’t seeing progress, here are some signs that a bottom-up approach might be helpful. These are things clients might say or experience that could signal the need for a shift:

• “I’m too self-aware, therapy doesn’t work for me.”
• Feeling so overwhelmed by competing needs that it leads to a functional freeze state—like doom scrolling for hours and being unable to do much else.
• Making a plan in session to tackle tasks but continuously failing to follow through outside of session.
• Using sessions, over an extended period, to put out little fires (e.g., talking about recent frustrations/annoyances) without addressing the underlying patterns, themes, or common factors.
• Avoiding emotions. Like, all the time. (I see you because I am you. /hj³)
• Feeling like nothing is working. Nothing.

When Therapy Isn’t Enough

Speaking of nothing working, it’s crucial to mention that no amount of nervous system regulation tools will create a sense of safety for someone who lacks stable housing, reliable access to food and water, or basic healthcare. The fight-or-flight response is designed to help us survive, and those basic needs are essential for survival. So, if someone’s body feels unsafe, it’s doing exactly what it’s supposed to do. In that case, it would be counterproductive for us therapists to try and override that response.

Making Progress, One Step at a Time

And there you have it—hopefully a clearer understanding of how a bottom-up approach can make a huge difference for Autists in therapy. This approach is not just about regulating the nervous system; it’s about creating safety, fostering autonomy, and empowering individuals to make meaningful changes. Whether you’re a therapist or someone in therapy, remember that what works for one person might not work for another. Therapy is about discovering what fits, adapting along the way, and finding what best supports each individual’s distinct needs. Now you’re armed with a little more knowledge to make it work for you. The important thing is that you’re making movement, however that looks for you. Progress doesn’t always have to be forward—after all, change often starts from the bottom up.

1. A tone indicator is a brief symbol or notation added to a message to clarify the intended tone or emotion behind the text. These indicators help prevent misunderstandings, especially in written communication where vocal tone and body language are missing. For example, “/s” signals sarcasm, while “/j” shows that a comment is a joke. Tone indicators are especially helpful in online communication and for Autistic individuals, adding clarity and ensuring the message lands as intended. In this case, “suffers” is a playful exaggeration—hence the “/j.”
2. I just need everyone who reads footnotes to know that I almost added, “not to be confused with a call to finish one’s drink,” behind these words, but I exhibited some self-control and put it here instead.
3.  Only half-joking, because while I’m not literally just like whoever is reading this and relates, I have (and sometimes still do) feel this way.