One of the most frustrating experiences in therapy is doing everything you’re supposed to do and still not feeling better.

You show up.

You talk.

You reflect.

You understand yourself more clearly.

And something still isn’t moving.

When that happens, people tend to assume they’re resistant, broken, or just bad at therapy. But most of the time, that isn’t what’s happening at all.

More often, the kind of support being offered doesn’t match the problem the nervous system is actually trying to solve.

Therapy tends to work in a few different ways. None of them are wrong. They just do different jobs.

Very broadly, most approaches fall into three categories.

Bottom up.

Top down.

Temporal relational.

Once you understand what each one is designed to help with, it becomes easier to see why something that helped a little might not have helped all the way.

Bottom up work starts with the body.

This approach assumes that something important is happening before words, thoughts, or insight arrive. Sensation, breath, muscle tension, activation, collapse. The body reacts first.

Bottom up support is often helpful when the nervous system is overwhelmed or hijacked. Panic. Chronic anxiety. Freeze. Dissociation. Moments when thinking feels impossible because the body is already in motion.

This might sound familiar.

My heart races out of nowhere.

I shut down and go blank.

My body reacts before I know what I’m reacting to.

This kind of work can be deeply grounding. It helps the nervous system settle enough to function again.

And sometimes, that’s exactly what’s needed.

But many people do a lot of body-based work and still feel stuck. Their system is calmer, yet the same emotional or relational patterns keep repeating. Regulation improves, but something underneath hasn’t shifted.

That’s often when people start wondering why the relief feels incomplete.

Top down work comes from the other direction.

These approaches focus on thoughts, beliefs, meaning, and understanding. They help name patterns, challenge assumptions, and build a coherent story about what’s happening.

Top down support can be incredibly helpful when confusion, shame, or distorted thinking is driving distress. When you need language. Perspective. Tools.

This might sound familiar.

I don’t understand why I feel this way.

I keep blaming myself and can’t stop.

I need help making sense of what’s happening.

Insight can be clarifying and empowering. It can help people feel less lost inside their experience.

And yet many people eventually hit a wall here too.

They understand everything.

They can explain their patterns in detail.

They know where it came from.

But their body still reacts as if the danger is happening now.

That’s usually when someone says, “I know this already, but it doesn’t change anything.”

This is where the third category matters.

Temporal relational work is not primarily about calming the body or changing thoughts. It’s about time.

More specifically, it helps the nervous system recognize the difference between then and now.

This kind of work is often helpful when the event is over, the threat is gone, but the system didn’t update. The body, emotions, or relational patterns are still responding as if the past is happening in the present.

This might sound familiar.

I know I’m safe, but my body doesn’t believe it.

This reaction feels younger than me.

I’m responding to something that isn’t actually happening.

In this work, the goal isn’t to force regulation or override experience with logic. It’s to bring present-day awareness into contact with past experience so the system can reorganize around time.

Not to relive it.

Not to fix it.

To orient.

When the nervous system truly recognizes that something belongs to then, movement often happens without being pushed.

So which approach is better?

None of them.

And all of them.

A more useful question is this.

What is your nervous system struggling to do right now?

If it can’t settle, bottom up support may help.

If it can’t make sense of what’s happening, top down support may help.

If it can’t tell that the danger is over, temporal relational work may help.

Many people need more than one over time. Sometimes in sequence. Sometimes gently layered together.

The problem isn’t choosing the wrong approach. The problem is expecting one approach to solve every kind of stuck.

If therapy has ever felt like too much, not enough, or strangely beside the point, it may not be you.

Your system isn’t broken.

It’s doing exactly what it learned to do.

The work isn’t about finding the perfect label.

It’s about finding support that meets you where you actually are.

And if you’re not sure what you need yet, that’s okay too.

Not knowing is often where something new begins.

And sometimes, the next step isn’t figuring it out on your own.

If something isn’t working in therapy, it’s okay to say that out loud.

Naming misalignment, confusion, or disappointment with your therapist isn’t a step backward. It’s often the work itself.

Learning to stay present and honest in that moment is practice for every other relationship that matters.

What changes things is rarely more effort. It’s alignment.

Embracing Shadows, Illuminating Hope,
Chelsey Fjeldheim, LCSW
Empowering Souls on the Path of Healing

Copyright © 2025 Chelsey Fjeldheim, Courage Speaks Counseling