Top Down vs. Bottom Up for Occupatoinal Therapy

Rethink OT Podcast

Transcript of Episode

Today’s topic is Top-Down vs. Bottom-up. We will define the terms, identify where occupational therapy falls in this paradigm according to education, and then talk about the actual reality of the profession and we can use this reality to foster growth in the community-based place of service. 

In school, we learn that occupational therapy is top-down while the medical model is bottom-up. That’s true. Occupational therapists approach rehabilitation with a top-down vantage point and this sets us apart in the allied health field. But, let’s back up and define the terms according to a rehab professional.

Bottom-up is objective. It is ‘parts of the whole’. 

Top-down is subjective. It is the ‘sum of its parts’. 

Let me give you an example, 

Let’s pretend we are mechanics. A bottom-up mechanic does not take into account the make and model of the car. How is this car marketed? What did the makers intend this car to be? Who were they designing this car to move? A business person? An athlete? A mom? An outdoorsy person? A construction worker? No – he may know about those things and write them down…. But, he sees all the individual parts that make up the car and treats the exact part that is having the malfunction. 

A top-down mechanic sees the beauty of the entire car and embraces why the car was made. Before he goes messing around with ordering parts, tinkering, or sliding under the car to get to work, he is going to take the time to appreciate the model of the vehicle. What it is being used for. Why it has to be in functioning condition once again. Who the driver is and the primary reason the vehicle is driven. All of these things are important to the driver before he gets to work. It’s not that he doesn’t know just as much about the parts of the whole vehicle as to the bottom-up mechanic. Nor does it mean that he is going to use a lesser, more non-traditional, or less-informed approach to fixing the malfunction. No, he just is taking time to appreciate the car’s identity so he can treat it most effectively. 

Now, I have absolutely NO IDEA if mechanics are top-down or bottom-up. But I do know a lot of people who appreciate the various qualities and attributes of vehicles as if they were actual people!! I hope this example helps to define these approaches. 

We are taught OT is top-down. If you heard the call about the history of occupational therapy, you know we made a massive shift during the second world war in order to fit within the medical model. How do we cope with this? The answer?


Accept it. Work with it. 


It is actually a testament to the profession that we can exist in a top-down and bottom-up world. Our vantage point never needs to change. We have and maintain a top-down vantage point, always promoting independence and maximizing function in ADLs, IADLs, and occupations…..but we document bottom-up. In order to justify our services, occupational therapy practitioners have grown accustomed to using activity analysis to break down each therapeutic element into its functions, structures, and skills. We adapt to the world we live in. What we miss is that our patients are also living in a bottom-up world. They have been taught to value medical knowledge, cookie-cutter activity, rote exercise, and science. That’s just a fact. Why force an occupation-based activity on our clients when they don’t understand the purpose? Why not provide a transitional relationship between bottom-up and top-down? 

In my outpatient OT practice, we use a hybrid model. We start in the clinic working on body structures, body functions, and performance skills while providing education to the patient regarding how this will impact the specific occupation we are working towards. Once we achieve appropriate measures, we transition into the home to focus on the actual occupation so that there is carry over into their everyday life. This hybrid approach also leaves room for occupational therapy advocacy among all players in the game.