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March 10, 2021

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

Author Affiliations
  • 1Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
  • 2IRCCS Mondino Foundation, Pavia, Italy
  • 3Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
JAMA Psychiatry. 2021;78(6):593-594. doi:10.1001/jamapsychiatry.2020.4793

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 mechanistic1 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.

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